| 140000105 |
Lone Tree Convalescent Hospital |
020009082 |
B |
06-Mar-12 |
PUKB11 |
5560 |
T22 DIV5 CH3 ART3-72311(a)(1)(A) Nursing Service--General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessment shall commence at the time of admission of the patient and be completed within seven days after admission. The facility violated the aforementioned regulation by failing to ensure staff identified the care needs of Resident 1 through continuing assessment of resident's surgical wound when Resident 1 complained of nausea and weakness, and exhibited an increase in body temperature. This failure caused delay in treatment for Resident 1. Record review on 9/1/11, during an onsite visit, showed the facility admitted Resident 1 on 7/26/11 for rehabilitation after right hip replacement surgery on 7/21/11. The "Discharge Summary" from the hospital showed Resident 1 had diagnoses including diabetes, anemia, and obstructive lung disease, which put her at greater risk for post-operative infection. She had also experienced, while in the hospital, an increase in the count of white blood cells (count increases in the presence of an infection) and was treated prophylactically with antibiotics. Upon transfer from the acute care hospital, the physician ordered, "Monitor surgical hip wound for s/s (signs/symptoms) of infection QD (every day) until healed." To monitor is, "To observe and evaluate a function of the body closely and constantly." (Mosby's Medical, Nursing and Allied Health Dictionary). The assessment of a surgical wound is defined in the Medical-Surgical Nursing Manual, Fifth Edition, Ingativius and Workman, 2006: "A general description of the color of the wound and surrounding area helps determine the wound's present phase of healing. Gently palpate (press) the edges of the wound for swelling. Document the amount, color, location, odor and consistency of any drainage. Pain: document and notify the physician of any pain or tenderness at the wound site. Pain may indicate infection of bleeding. It is normal to experience pain at the incision site of a surgical wound for approximately 3 days." According to the American Academy of Orthopaedic Surgeons, signs of infection after hip replacement surgery include fever, chills, increased pain and tenderness at the surgical site, drainage and swelling.Review of the 'Skin Condition Record (Non-Pressure Skin Conditions)' showed the nursing staff documented on 8/3/11 that Resident 1's surgical incision presented with minimal amount of serosanguineous (containing both blood and serous fluid) drainage, the staples were intact, the surrounding tissue was pink, and there were no signs of infection. On 8/5/11 (no time noted) the physical therapy aide (PTA) documented on the 'Physical Therapy Daily Documentation' record that Resident 1 stated, "I feel lousy today. I have nausea."The occupational therapist (OT) stated in an interview on 9/1/11 that on the morning of 8/5/11, Resident 1 had complained of having, "Chills and fever," and that the resident continued therapy with difficulty. The OT said that she took Resident 1's temperature, which was 100.1 degrees and then reported it to "the charge nurse." Record review showed OT documented about Resident 1's condition on 8/5/11 in a late entry note, dated 9/1/11 (after the interview). The a.m. shift (7 a.m. to 3 p.m.) nurse documented that Resident 1's surgical site on 8/5/11 had redness and swelling, and serosanguineous discharge was noted.Further review showed no evidence of an assessment of Resident 1's condition during the night shift on 8/5/11.At 12:30 p.m. on 8/6/11, a licensed nurse documented that the physician was notified of Resident 1's complaints of nausea and vomiting. There was no assessment of the resident's surgical wound. There was no evidence that the physician was informed of the wound's condition. The physician ordered Zofran, an antiemetic medication, which was administered at 1 p.m. According to the nurses' notes, at 1:30 p.m., Resident 1 had no further complaints of nausea and vomiting. According to the nurses' documentation, Resident 1 had no further complaints during the p.m. shift on 8/6/11. There was no documented assessment of Resident 1's overall condition during the night shift. The surgical wound was not assessed on p.m. or night shift. The next morning, on 8/7/11 at 9 a.m., Resident 1 was found to have redness, swelling, warmth, and pain with light palpation at the surgical site. The resident also complained of being lightheaded, and had a low blood pressure of 80/42 (indicator of decline in overall condition). Resident 1 was transferred to the hospital where she required intensive care for septic shock as her surgical wound was infected. On 1/27/12 at 10:05 a.m. in an interview with the surgeon, he stated that he had taken (Resident 1) to the operating room, cleaned out the wound surgically and started IV antibiotics. The surgeon stated in response to a question of whether he should have been notified earlier of Resident 1's change in condition, he said, "The surgery should be done right away, as soon as possible."Therefore, the facility failed to provide a continuing assessment of Resident 1's surgical wound, causing a delay in treatment. The above violation had direct or immediate relationship to the health and safety of Resident 1. |
| 140000105 |
Lone Tree Convalescent Hospital |
020010913 |
B |
06-Aug-14 |
IY8211 |
7590 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: The facility must ensure that: 1. The resident environment remains as free from accident hazards as is possible; and2. Each resident receives adequate supervision and assistance devices to prevent accidents. The facility is in violation of the above regulation by its failure to: 1. Ensure the necessary staff assistance to prevent a fall. 2. Implement the patient's care plan for prevention of injury due to fall. The facility admitted Resident 1 on 4/24/14 with multiple medical diagnoses that included dizziness. The Physical Therapy (PT) notes, dated 4/25/14, showed that Resident 1 was admitted and referred to physical therapy for the following reasons: 1. Muscle weakness. 2. Difficulty in walking. 3. Decrease in strength and functional mobility. 4. Decrease in ability to safely walk. 5. Increased need for assistance from others. The same PT notes reflected that Resident 1 needed PT to increase independence with walking, promote safety awareness, increase lower extremity strength and minimize falls. According to the PT evaluation, Resident 1 was at risk for falls and needed staff assistance when walking with a front-wheeled walker. In an interview on 5/20/14 at 2:55 p.m., Certified Nursing Assistant (CNA) 1 said that on 5/8/14 at around 2 a.m., Resident 1's room had the call light on so she went to answer the call light. She said that when she went into the room, she saw Resident 1 standing by Resident 2's (roommate's) bed. CNA 1 further stated Resident 1 had told her that she wanted to go to the bathroom so she helped Resident 1 go to the bathroom and back to bed afterwards. CNA 1 said that while Resident 1 was sitting on her bed, she noted Resident 1 rubbing the back of her head. CNA 1 quickly examined Resident 1's head and saw a baseball-sized bump on the back of her head. CNA 1 said that as she checked Resident 1's head, Resident 2 told her that Resident 1 had fallen. CNA 1 then went to call Registered Nurse (RN) 1 to report the fall and get CNA 2. CNA 1 said she had reminded Resident 1 in the past to use the call button if she needed help like going to the bathroom, but sometimes Resident 1, "Just does it by herself". During an interview on 5/20/14 at 3:15 p.m., RN 1 said that she noted a baseball-sized bump on Resident 1's right side of the back of her head. She said that even though Resident 1 had remained alert after the fall, she was particularly concerned about the unusual size of the bump.In an interview on 5/20/14 at 3:20 p.m., Resident 3 stated that she was awakened that night by, "What sounded like a crash", heard some moaning, so she turned on her call button to ask for help. Resident 3 further stated she had seen Resident 1 walk around in the room in the past few days and that "she was definitely handicapped, you can tell." During an interview on 5/20/14 at 3:50 p.m., Resident 2 said that she also was asleep when she heard a sound; she woke up and saw Resident 1 standing by the foot of her bed. Resident 2 added that it was Resident 3 who had turned her call light on so staff could come and help Resident 1. In an interview on 5/21/14 at 4:13 p.m., CNA 2 stated that Resident 1 had told her she walked to the bathroom by herself and in the process fell and hit her head on the floor. CNA 2 said that Resident 1 was the kind of resident who would follow reminders to use the call light to ask for help, but would forget it after some time. In an interview on 5/27/14 at 10:30 a.m., Physical Therapist (PT) 1 stated that Resident 1 could no longer walk on her own because she crisscrossed her legs and that she had dizziness when she walked, which made her unsteady and prone to lose her balance. PT 1 further added that Resident 1 had multiple falls at home before admission to the facility. PT 1 also said that this information was clearly communicated to the nursing staff because there was a white board at Resident 1's bedside where Resident 1's ability to walk and the level of assistance needed were written for the nursing staff to know. PT 1 confirmed that a staff had to be at Resident 1's back to assist while she walked. PT 1 added that Resident 1 had been considered a fall risk from the time she was admitted to the facility until the actual fall on 5/8/14. Review of the facility's assessment dated 5/1/14 showed that Resident 1 needed one person providing physical assistance while walking in her room. The same assessment also showed that Resident 1 had a risk of falling. The facility's plan of care titled "Fall Risk Care Plan," dated 4/24/14, showed that Resident 1 was at risk for fall and injury because of dizziness and being forgetful at times. Resident 1 was also receiving a medication that would make her go to the bathroom for frequent urination. One of the approaches to minimize Resident 1's risk for injury as a result of a fall was for the facility to provide a bed alarm. In an interview on 5/23/14 at 1:46 p.m., CNA 1 stated that she did not hear an alarm go off when she went into Resident 1's room and what prompted her to go into that room was the call light being on. CNA 1 said that she could not remember Resident 1 having a bed alarm while she was in the facility. She also said that Resident 1 sometimes did not follow directions of using the call light when she needed assistance. Review of the facility's nurses' notes dated 5/5/14, 5/6/14 and 5/7/14 showed that for safety, Resident 1 had the "Call Light in Reach" listed as the only intervention to keep her safe. The nurses' notes did not show that sensors/alarms were provided. In an interview on 5/27/14 at 11:15 a.m., Registered Nurse Supervisor stated that for residents who were newly admitted to the facility especially those who were at risk to fall and those who did not wait for assistance, bed alarms were very important because nurses have to be alerted if they needed to provide help for the residents. She confirmed that the care plan for Resident 1 included providing a bed alarm, but said that she could not find any documentation in Resident 1's clinical record that a bed alarm was provided for Resident 1. She added, "Alarm would have helped"..."We're even running out of alarms, I keep ordering." Resident 1 was sent to the hospital immediately on 5/8/14 at 2:27 a.m. Review of the emergency department notes dated 5/8/14 showed that Resident 1 had a large hematoma (a localized collection of blood outside the blood vessel) on the back right side of her head and complained of constant, throbbing posterior head pain. The ED notes also showed that Resident 1 was diagnosed with coagulopathy (a condition where the ability of the blood to clot is impaired) and subarachnoid hemorrhage (bleeding in the area between the brain and the tissues that cover the brain) that required blood transfusion. "Patient required multiple interventions and frequent reassessments..." and was treated to prevent further deterioration of central nervous system failure or compromise. Resident 1 was transferred to another hospital for a higher level of care. Therefore the facility failed to:1. Ensure the necessary staff assistance to prevent a fall. 2. Implement the patient's care plan for prevention of injury due to fall. The above violations had a direct or immediate relationship to the health and safety of Resident 1. |
| 140000113 |
Lafayette Care Center |
020013061 |
B |
22-Mar-17 |
TQAC11 |
6267 |
483.90(h)(4) MAINTAINS EFFECTIVE PEST CONTROL PROGRAM (h)(4)
Maintain an effective pest control program so that the facility is free of pests and rodents.
The facility failed to follow the aforementioned regulation by failing to prevent rodent and insect infestation from 4 of 21 resident rooms affecting five sampled residents (Resident 1, 2, 3, 4, and 5). Residents 1 and 2 saw rodents in their rooms, Resident 3 was bitten by an insect, and Residents 4 and 5 had a dead rodent removed from their room. This failure to maintain an effective pest control program resulted, in Resident 1 being scared in her room, Resident 2 not feeling well in her room, Resident 3 suffering pain from an insect bite that required antibiotic treatment to prevent infection, and Residents' 4 and 5 being exposed to a dead rodent in their room. There was also evidence of rodents in the kitchen, which had the potential to contaminate the food source for all 39 residents who resided in the facility. There was further evidence of rodents in the laundry room where Residents' linens were processed and had the potential to be contaminated.
During an interview with Resident 1 on 3/1/17, at 6:30 a.m., Resident 1 stated "There's a mouse in my room over by the corner, it runs back and forth. I feel scared, it's scary."
During an interview with Resident 2 on 3/1/17, at 6:35 a.m. Resident 2 stated, "There was a mouse yesterday. I saw it run across the floor - they are all over the place. It doesn't make me feel well."
During an observation and concurrent interview with Resident 3 on 3/1/17, at 6:40 a.m., Resident 3 stated he was bitten by "...a deadly spider..." Resident 3 stated it was on 12/25/16 and he had a picture of his arm that he took on his cell phone after it happened. Observation of the picture showed the back of Resident 3's upper arm, with distinctive tattoos, had a large reddened area that was round and had smaller reddened areas spreading outward from the center. Resident 3 stated his doctor prescribed antibiotics for the bite. Resident 3's bed was against the wall, directly next to long drapery that covered a sliding glass door that opened to a patio in the center of the building. Underneath Resident 3's bed there were numerous wires and cords and other debris with a heavy buildup of dust.
Review of Resident 3's "Nurse's Notes," dated 12/23/16, indicated "...Resident noted (with) reddened, raised, hardened...area in his R (right) upper arm. c/o (complained of) burning pain..."
Review of Resident 3's "Physician Orders," dated 12/23/16, indicated an order for Keflex (antibiotic used to treat infection) 500 mg three times a day times ten days for insect bites.
During an interview with Licensed Vocational Nurse (LVN 1) on 3/1/17, at 10:10 a.m., LVN 1 stated she wrote the nurses note regarding Resident 3's bug bite, called the nurse practitioner, and received an order for Keflex. LVN 1 also stated she told the Maintenance Director (MD) to clean under the bed and she thought he sprayed some bug spray.
During an interview with the MD on 3/1/17, at 10:20 a.m., the MD stated he did not know about the insects in Resident 3's room, but he did know about the dead rodent in Residents 4 and 5's room three weeks ago. The MD stated the dead rodent was in a glue trap in Residents 4 and 5's room, and he disposed of it.
During an observation in the kitchen on 3/1/17, at 7:25 a.m., there was evidence of fresh marks on the wooden threshold between the dry food storage room and the kitchen. The Dietary Manager (DM) stated they were rodent bite marks. Observation of the kitchen the back door was noted to have a gap at the bottom and top, and there were areas underneath the sink and dishwasher that were grimy, with missing tiles and orange foam material that was bulging from around the drain pipes.
During an observation and concurrent interview with the DM on 3/1/17, at 9:30 a.m., the DM stated that he found evidence where a rat ate through the plastic bag of a cake mix. The DM pointed at a bag with white powder and there was a quarter sized opening at the end of the bag. DM stated "How can I keep any food here the rodents keep coming in here and getting into everything?!"
During an interview with the Laundry Worker (LW) on 3/1/17, at 7:15 a.m., the LW stated she saw a large rat on the laundry room floor about 5:45 a.m. on 2/24/17. The LW pointed to a hole in the wall under a cabinet where the wall meets the floor and stated that was where the rat ran to exit the laundry room.
During an interview and concurrent record review with the ADM on 3/1/17, at 7:51 a.m., the ADM stated the facility had a plan from their Commercial Pest Control Company, who had been out the previous day. The ADM stated he could not access the plan at the present time.
According to the Centers for Disease Control and Prevention website, https://www.cdc.gov/rodents/ "...Worldwide, rats and mice spread over 35 diseases. These diseases can be spread to humans directly, through handling of rodents, through contact with rodent feces, urine, or saliva, or through rodent bites. Diseases carried by rodents can also be spread to humans indirectly, through ticks, mites or fleas that have fed on an infected rodent..."
Therefore the facility failed to prevent rodent and insect infestation from 4 of 21 resident rooms affecting five sampled residents (Resident 1, 2, 3, 4, and 5). Residents 1 and 2 saw rodents in their rooms, Resident 3 was bitten by an insect, and Residents 4 and 5 had a dead rodent removed from their room. This failure to maintain an effective pest control program resulted, in Resident 1 being scared in her room, Resident 2 not feeling well in her room, Resident 3 suffering pain from an insect bite that required antibiotic treatment to prevent infection, and Residents' 4 and 5 being exposed to a dead rodent in their room. There was also evidence of rodents in the kitchen, which had the potential to contaminate the food source for all 39 residents who resided in the facility. There was further evidence of rodents in the laundry room where Residents' linens were processed and had the potential to be contaminated.
The above violation has a direct relationship to the health, safety or security of patients. |
| 140000113 |
Lafayette Care Center |
020013062 |
B |
22-Mar-17 |
SJPD11 |
7696 |
483.25(b)(1) TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES
(b) Skin Integrity - (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
The facility failed to follow the aforementioned regulation by failing to implement interventions to prevent the development of pressure ulcers (localized injury to the skin and underlying tissue caused by pressure usually over a bony prominence) for one of three sampled residents (Resident 1), and failed to identify and provide timely assessment for a newly developed pressure ulcers. These failures resulted in the worsening of unstageable pressure ulcers (full thickness tissue loss in which the ulcer is covered by dead tissue and the depth of ulcer cannot be determined) on the right hip and right fifth toe (smallest toe) and development of a new Stage II pressure ulcers (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough [dead tissue]. May also present as an intact or open/ruptured blister) on the right and left heels.
Review of admission record indicated Resident 1 was admitted on XXXXXXX16 with diagnoses that included paraplegia (paralysis of lower part of body due to spinal cord injury).
Review of the Minimum Data Set (MDS-a resident assessment tool used to guide care), dated 12/1/16, indicated Resident 1 had no memory problems. Resident 1's skin condition assessment, dated 12/1/16, indicated Resident 1 did not have a pressure ulcer upon admission.
Review of the "Care Plan- Pressure Ulcer", dated 11/18/16, indicated Resident 1 had the potential to develop pressure ulcers due to sensory perception, decreased activity, and impaired mobility. Further review of the care plan indicated a goal of, "Pressure risk will be minimized with reduction interventions". The approaches included, "Apply pressure reduction cushion to chair or wheelchair...Complete full body check weekly during ADL [activities of daily living] care or as needed."
Review of Resident 1's Nurses Notes, dated 2/16/17 at 3 p.m., showed, "During rounds at 2 pm; Resident naked and noticed that resident has a wound/pressure ulcer unstageable on his right hip. Asked him why his not telling his CNA/Nurse. Resident verbalized "I don't feel anything and I can't see" gave him a mirror and showed it to him. Measure 6 centimeters [2.4 inches] x 5 [2.1 inches] cm. wound bed 100% necrotic (dead tissue)."
Review of Resident 1's "Weekly pressure Ulcer Healing Assessment" form, dated 2/16/17, indicated Resident 1's right hip pressure ulcer was identified on 2/16/17 as an unstageable pressure ulcer measuring 2.4 inches by 1.9 inches, and the wound color was describe as "black" with no exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury). Further review of the form indicated another skin assessment, dated 2/21/17 indicating the wound size increased to 2.4 inches by 2.1 inches, with presence of scant serous (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage) exudate and "yellow" wound color.
Review of Resident 1's "Care Plan - Skin Treatment", dated 2/16/17, showed Resident 1 had a pressure ulcer on the right hip. The approach included, "Turn and reposition resident every 2 hours... body check q [every] shift. Skin protectant at least qd [once daily]. Check for incontinent [having no or insufficient voluntary control over urination or defecation] needs at every 2 hours."
Review of Resident 1's "Weekly pressure Ulcer Healing Assessment" form, dated 2/19/17 indicated Resident 1's right fifth toe pressure ulcer was identified on 2/19/17 as an unstageable pressure ulcer measuring 0.7 inches by 0.8 inches, and had a "black" wound color.
Review of Resident 1's "Physician Orders", dated 2/16/17, indicated an order for a low air loss mattress (pressure reducing mattress).
During a concurrent observation and interview on 2/21/17 at 1:15 p.m., Resident 1 was sitting on the edge of his bed, the bed was a low air loss mattress (pressure reducing), and next to Resident 1's bedside was a wheelchair that had no pressure-reducing cushion. Resident 1 stated he got his low air loss bed the night before. Resident 1 further stated he put his call light on and the staff does not answer his call light and would take up to one hour for the staff to answer his call light and especially during the afternoon shift, they were always shorthanded.
During an interview on 2/21/17 at 2:45 p.m., Licensed Vocational Nurse (LVN) 1 stated the low air loss mattress was not in placed for Resident 1 until 2/19/17 (three days after the pressure ulcer was discovered).
During a wound care treatment observation and concurrent interview on 2/21/17 at 12:50 p.m., LVN 1 while in the presence of Registered Nurse 1 (RN 1), LVN 1 stated Resident 1 had two pressure ulcers, an unstageable pressure ulcer on the right hip and a black eschar (thick, leathery, frequently black or brown in color, dead or devitalized tissue) on his right fifth toe. LVN 1 removed Resident 1's booties and observed a brownish-black dried blister on the left and right heel. LVN 1 measured the right heel blister and it was 1.5 inches x 1.3 inches (in.), and the left heel blister measured 0.63 in. x 0.98 in. LVN 1 stated the blisters on the left and right heel were newly discovered.
Review of Resident 1's clinical record revealed no documentation of a weekly complete full body check as indicated in the care plan.
During an interview on 2/21/17 at 2:00 p.m., the Director of Nursing (DON) confirmed that they do not have evidence a weekly body check and body check every shift was done as indicated on the 2/16/17 care plan.
Review of undated policy and procedure titled, "Prevention of Pressure Ulcers" indicated "If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected ... Pressure ulcers are a serious skin condition for the resident. Routinely assess the resident's skin at least once a shift for any signs and symptoms of irritation or breakdown Immediately report any signs of a developing pressure ulcer to the staff/charge nurse.
Therefore the facility failed to implement interventions to prevent the development of pressure ulcers (localized injury to the skin and underlying tissue caused by pressure usually over a bony prominence) for one of three sampled residents (Resident 1), and failed to identify and provide timely assessment for a newly developed pressure ulcers. These failures resulted in the worsening of unstageable pressure ulcers (full thickness tissue loss in which the ulcer is covered by dead tissue and the depth of ulcer cannot be determined) on the right hip and right fifth toe (smallest toe) and development of a new Stage II pressure ulcers (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough (dead tissue). May also present as an intact or open/ruptured blister) on the right and left heels.
The above violation has a direct relationship to the health, safety or security of patients. |
| 140000113 |
Lafayette Care Center |
020013063 |
B |
22-Mar-17 |
7EGO11 |
11170 |
483.12 FREE FROM ABUSE/INVOLUNTARY SECLUSION
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms.
The facility failed to follow the aforementioned regulation by failing to provide goods and services for four of four sampled Residents (Resident 1, 6, 7, and 8) that were necessary to attain or maintain physical, mental, and psychosocial wellbeing. The facility neglected the needs of the residents when they did not pay wages to facility staff, or make payments to food, nursing, and cleaning supply vendors, and utilities. These failed practices resulted in the needs of four sampled residents not receiving basic nursing care and Resident (1) who only received two showers and three bed baths in one month. All of the residents were not served recommended 8 ounces of milk with their meals. Prescribed physical therapy services for three residents (6, 7, 8) were not provided. There was no non-emergency transportation to the hospital available. In addition, there were unsanitary conditions in the kitchen with no sanitizer for the dishwashing machine and no alternative method used to sanitize the dishes and utensils for use by the residents. There was overflowing garbage in the dumpster, and evidence of rodent infestation in the kitchen and laundry room. These failed practices had the potential to result in substandard quality of care which affected 43 residents residing in the facility.
During an interview with Resident 1 on 2/9/17, at 11:30 a.m., Resident 1 stated the facility was short of nurses and he did not have a shower for more than a month. A review of the "Resident Bathing...Chart" dated 1/22/17 to 2/20/17 showed he had received three bed baths on 2/1/17, 2/13/17 and 2/20/17, and two showers on 2/12/17 and 2/21/17. According to the shower schedule for Resident 1 date 10/4/2016, he was to receive a shower on Sundays, Tuesdays, Fridays and Saturdays.
During an interview with Certified Nursing Assistant (CNA 2) on 2/9/17, at 11:25 a.m., CNA 2 stated they were supposed to get paid on 1/25/17 but did not. CNA 2 stated "...Sometimes it's only two or three of us to provide care. Lot's of time we do not have towels. Sometimes we have to use pillow cases for towels."
During an interview with CNA 4 on 2/9/17, at 11:40 a.m., CNA 4 stated pay had been late, and "...Sometime supplies are short like today. They need to order diapers..."
During an interview with Licensed Vocational Nurse (LVN 1) on 2/17/17, at 6:58 a.m., LVN 1 stated "CNAs don't have enough time to provide quality of care...worse for the nonverbal (residents)." LVN 1 stated the last few weeks they had a shortage of supplies, like diapers, gloves, and food
During an interview with the Customer Service Representative (CSR) on 2/17/17, at 8:20 a.m., the CSR stated, the facility only had enough diapers to last for 24 hours.
During an interview with the Director of Nurses (DON) on 2/17/17, at 11:30 a.m., the DON stated the medical supply vendor was suspended and no longer provided supplies to the facility due to non-payment.
During an interview with CNA 6 on 2/17/17, at 6:27 a.m., CNA 6 stated "...pretty tough on night when short getting care done..."
During an interview with Medical Records Director/Certified Nursing Assistant (MRD/CNA) on 2/17/17, at 6:54 a.m., MRD/CNA stated "I help (as a CNA) when short (nursing staff) always short, don't get residents up...keep in bed."
During an interview with CNA 5 on 2/16/17, at 10:35 a.m., CNA 5 stated she did not get paid yet (last payday). She is thinking of looking for another job.
During an interview with CNA 4 on 2/16/17, at 10:40 a.m. CNA 4 stated that if there is no paycheck next week, she is thinking of leaving.
During an interview with MRD/CNA on 2/16/17, at 11:45 a.m., MRD/CNA stated that she was going to quit next month, if she did not get paid.
During an interview with the Dietary Aide (DA) on 2/16/17, at 11:48 a.m., DA stated that she was new to the company, but if not getting paid, she is thinking of leaving the place.
During an interview with Licensed Vocational Nurse (LVN 1) on 2/16/17, at 11:50 a.m., LVN 1 stated "I've been working here for one and half years...Receiving paychecks is a problem...after Christmas not get paid at all. I am planning to look for a job..."
During an interview with the Housekeeper (HK) on 2/9/17, at 11:20 a.m., HK stated she had not received her paycheck at the last payday.
During an interview with Licensed Vocational Nurse (LVN 1) on 2/9/17 at 11:55 a.m., LVN 1 stated, "We have a problem with payment. It started in late December. They are supposed to give us extra fifty dollars a day if we do not receive our money on time."
During an interview with the Maintenance (Maint) on 2/16/17 at 10:20 a.m., Maint stated two housekeepers, HK 3 and 4, had resigned in the past month.
A review of a facility Memo dated January 25, 2017 titled, "Paychecks," indicated "...The company is fully aware of the delayed in cashing some of employee's paychecks dated 1/10/17...The employees who have been affected will be paid $290. per work week or $58 per day (based on 5 days of work schedule). We are anticipating to distribute the paycheck date 1/25/2017 on or before 1/31/2017 and the same rule mentioned above will apply for the delay in cashing your paychecks..."
During an interview with Resident 1 on 2/9/17, at 11:30 a.m., Resident 1 stated that the facility did not have eggs or milk sometimes (for the resident meals).
During an interview with the Cook (CK) on 2/17/17, at 6:42 a.m., CK stated the facility had no milk for two days, and were giving the residents four ounces of milk (with meals) rather than the planned eight ounces of milk. CK stated that rats have eaten cookies and chips in the emergency food supplies, and she saw torn bags and crumbs on the floor of the emergency food supply this morning. Additionally CK stated the garbage had not been picked up for five days.
During an interview with the DON on 2/16/17, at 11:45 a.m., the DON stated management of the facility was aware there were no physical therapy services since 1/20/17. The DON stated there were three residents with physical therapy orders (Residents 6, 7 and 8). The DON stated there was a facility policy to have physical therapy and Occupational therapy (A service provided to assess and assist residents to with activities of daily living (ADLs) such as bathing and dressing) evaluations for all newly admitted residents to check functional ability and ADLs.
A review of the "Record of Admission" dated 1/16/17, showed Resident 6 was admitted to the facility on 1/16/17 and a review of the Physician's Orders dated 1/16/17 for physical therapy evaluation. As of 2/16/17 there had been no physical therapy evaluation for Resident 6.
A review of the "Record of Admission" dated 1/14/17 showed Resident 7, was admitted to the facility on 1/14/17 and review of the Physician's Orders dated 1/14/17 indicated a physician's order for physical therapy evaluation. As of 2/16/17 there was no physical therapy evaluation for Resident 7.
A review of the "Record of Admission" indicated Resident 8 was admitted to the facility on XXXXXXX17, with a diagnosis of fracture (break in the bone) of the left ileum (pelvis). Upon Resident 8's admission to the facility there was a Physician's Order dated 2/3/17 for physical therapy and occupational therapy evaluations. As of 2/16/17 there was no physical therapy or occupational therapy evaluation for Resident 8.
During an interview with the DON on 2/17/17, at 7 a.m., the DON stated the facility could not provide for non-emergency transportation to the hospital for residents.
During an concurrent observation and interview with Laundry Aide (LA) on 2/17/17, at 6:40 a.m., LA stated there was no delivery of laundry/housekeeping supplies for two months. LA stated her husband was a cook at the facility for 12 years and quit yesterday because of no pay checks. LA stated there were rats in the Laundry Room and there was a dead rodent in the laundry room garbage bin.
During an interview with CNA 1 on 2/17/17 at 6:45 a.m., CNA 1 stated she killed a mouse in the laundry room when it startled her and ran across her foot, she jumped in the air and landed on the mouse.
During a telephone interview with the pest control company representative (PCR) on 2/17/17, at 10:30 a.m., PCR stated the pest control service was canceled and the next service for 3/7/17 was suspended pending collection of past due payment.
During an observation on 2/9/17, on 10:45 a.m., two male staff members were loading large trash bags onto a pickup truck.
During an interview with Maint. on 2/9/17 at 11:35 a.m., Maint. stated he was loading garbage with the facility's CSR.
The ADM stated during an interview on 2/9/17, at 12:25 p.m., the ADM stated the CSR was loading his truck with trash because the trash was overflowing and he thought they were late with the garbage payment.
During an observation and concurrent interview with the Dietary Manager (DM) on 2/17/17, at 9:05 a.m., the DM stated the dish washing machine did not have hot water or sanitizer. During an observation of the dish washing machine the water temperature was 102 degrees Fahrenheit. The chlorine level did not register at all on the sanitizer strips used to test the level of chlorine sanitizer. The DM stated the water was not hot enough and they were out of sanitizer for a few days.
Record review of the Facility's Dish Machine Temperature Log had instructions that wash temperatures must be least 120 degrees Fahrenheit. Chlorine should be 50-100 parts per million (ppm).
Therefore the facility failed to provide goods and services for four of four sampled Residents (Resident 1, 6, 7, and 8) that were necessary to attain or maintain physical, mental, and psychosocial wellbeing. The facility neglected the needs of the residents when they did not pay wages to facility staff, or make payments to food, nursing, and cleaning supply vendors, and utilities. These failed practices resulted in the needs of four sampled residents not receiving basic nursing care and Resident (1) who only received two showers and three bed baths in one month. All of the residents were not served recommended 8 ounces of milk with their meals. Prescribed physical therapy services for three residents (6, 7, 8) were not provided. There was no non-emergency transportation to the hospital available. In addition, there were unsanitary conditions in the kitchen with no sanitizer for the dishwashing machine and no alternative method used to sanitize the dishes and utensils for use by the residents. There was overflowing garbage in the dumpster, and evidence of rodent infestation in the kitchen and laundry room.
The above violation has a direct relationship to the health, safety or security of patients. |
| 020000110 |
Lake Merritt Healthcare Center LLC |
020013386 |
B |
1-Aug-17 |
GPGO11 |
3808 |
72355(a)(1)(B)
Pharmaceutical Service - Requirements.
(a) Pharmaceutical service shall include, but is not limited to, the following:
(1) Obtaining necessary drugs including the availability of 24-hour prescription service on a prompt and timely basis as follows:
(B) Anti-infectives and drugs used to treat severe pain, nausea, agitation, diarrhea or other severe discomfort shall be available and administered within four hours of the time ordered.
The facility failed to follow the aforementioned regulation by failing to ensure anti-infectives were available and administered within four hours of the time ordered for Resident 4. Resident 4 was not administered intravenous (IV - delivered through a vein and into the blood) anti-infective on 2/14/17 and 2/15/17 and the medication was delivered 17 hours after it was ordered.
Review of Resident 4's hospital record titled, "Most Recent After Visit Summary", admission date XXXXXXX17, indicated Resident 4 had diagnoses that included sepsis (a life threatening condition caused by the body's response to an infection in the blood). The physician orders, dated 2/10/17, were to give 300 milligrams of Amikacin (anti-infective medication) intravenously every 12 hours through 2/19/17.
Review of Resident 4's hospital Medication Administration Record (MAR), dated 2/13/17, indicated Resident 4 had started the Amikacin IV antibiotics on 2/10/17 and received it every 12 hours (at 7:00 a.m. and 7 p.m.) while in the hospital.
Review of Resident 4's nursing notes, dated 2/14/17, at 9 p.m., indicated Resident 4 was admitted to the facility on XXXXXXX17 at 5:30 p.m. The nursing notes did not indicate an assessment of the condition of Resident 4's IV insertion site or documentation of the plan to begin administration of the IV antibiotics. The Nurse's notes also indicated "...Faxed all resident medications to pharmacy. Per pharmacy all her (Resident 4's) medications will receive tonight...."
Review of the facility pharmacy "Delivery Manifest," dated 2/15/17, at 10:53 a.m., indicated the facility received Resident 4's Amikacin antibiotic on 2/15/17 at 10:50 a.m.
In an interview with the Director of Staff Development (DSD) on 3/9/17, at 1 p.m., the DSD stated she could not locate Resident 4's MAR that reflected her stay at the facility from XXXXXXX17 at 5:30 p.m. until XXXXXXX17 at 5:30 p.m. (when Resident 4 returned to the hospital).
In an interview with Licensed Vocational Nurse (LVN) 1 on 5/4/17, at 9:15 a.m., LVN 1 stated she did not give any antibiotics to Resident 4 on the evening of 2/14/17 because she was not certified or licensed to give IV medications. LVN 1 stated she informed the Registered Nurse (RN) on the same shift that she (LVN 1) was not able give the antibiotics to Resident 4 and only an RN could administer the IV medication. LVN 1 stated Resident 4 did not receive any antibiotics while in the facility. LVN 1 worked with Resident 4 the next evening (2/15/17) and was told to transfer Resident 4 to the hospital emergency room so she could receive the antibiotics.
Review of the discharge nursing note on 2/15/17, at 6 p.m., indicated Resident 4 returned to the hospital to receive her antibiotic treatment.
Review of Resident 4's "Emergency Department Progress," dated 2/15/17, indicated Resident 4 was admitted to the hospital for IV antibiotics because the facility was "Unable to give IV antibiotics or check labs..." The Emergency Department Progress notes also indicated on admission to the emergency room , Resident 4 had a body temperature of 100.8 degrees Fahrenheit (øF) that rose to 101.1 (øF) (normal is 98.6 øF).
Therefore the facility failed to ensure anti-infectives were available and administered within four hours of the time ordered for Resident 4. |
| 020000110 |
Lake Merritt Healthcare Center LLC |
020013393 |
B |
1-Aug-17 |
FBUO11 |
5221 |
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 failed to follow the aforementioned regulation by failing to ensure resident safety during transfer for Resident 1, when the resident was transferred from wheelchair to bed without an assistive device.
Review of Resident 1's "Minimum Data Set," (MDS - an assessment tool used to direct resident care), dated 2/16/17, indicated Resident 1 was a able clearly think, reason, remember, and make his needs known. The MDS also indicated Resident 1 was totally dependent (full staff performance of activity) on two staff persons for transfers from the bed to wheelchair.
During an observation and concurrent interview with Resident 1 on 5/3/17 at 1:03 p.m., Resident 1 had purplish discoloration under the right eye and yellowish-blue discoloration on the side of the right eye. Resident 1 stated, "I fell in my room, hit the table."
During an interview with Certified Nursing Assistant (CNA) 1 on 5/3/17 at 2:53 p.m., CNA 1 stated Resident 1 was in his room getting ready to go back to bed on the afternoon of 4/9/17. CNA 1 stated, since everybody else (other staff) was busy; she decided to transfer Resident 1 by herself. CNA 1 stated while Resident 1 was in a standing position, and ready to pivot to sit on the bed, Resident 1 started to lean to the right side. CNA 1 stated she was standing behind Resident 1 to assist with transfer, but was not able to hold Resident 1's weight. CNA 1 stated she fell on the floor with Resident 1 and the wheelchair on top of her. According to CNA 1, Resident 1's right eye hit the over bed table in the process. CNA 1 stated she never used a mechanical lift to transfer Resident 1 and only requested help from other CNAs when they were available. Otherwise, CNA 1 stated she had to do transfers by herself. CNA 1 further stated she was 4 feet and 11 inches tall while Resident 1 was 5 feet and 10 and a half inches tall and weighed 180 pounds.
Review of Resident 1's "Nurse's Notes," dated 4/9/17, indicated Resident 1 and CNA 1 were found on the floor on 4/9/17 at 4:30 p.m. The Nurse's Notes also indicated Resident 1 was noted with an abrasion to the side of his right eye that measured 1 cm (centimeter) by 0.2 cm.
During an interview with the Director of Nursing (DON) on 5/3/17 at 1:30 p.m., the DON stated Resident 1 required two staff persons to assist with transfers.
Review of Resident 1's "Fall Risk Assessment," dated 5/18/16, indicated a score of 15 (score of 10 or higher represents high risk for falls) and a higher fall risk score of 19 on 8/16/16.
Review of the facility's policy and procedure titled, "Falls and Fall Risk, Managing" last revised December 2007, indicated "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling."
During an interview with the DON and concurrent record review on 5/3/17 at 2:10 p.m., the DON confirmed there was no care plan developed to address Resident 1's high risk for falls. There was no care plan to show how much staff assistance or how many staff were needed to transfer Resident 1 from bed to wheelchair and back.
Review of Resident 1's "Hospitalist Discharge Summary," dated 1/12/17, indicated Resident 1 was transferred to the hospital on XXXXXXX17 for right side weakness and leaning to the right side. While at the hospital, Resident 1 underwent imaging of the brain to evaluate for stroke. Resident 1 was evaluated by physical therapy (PT) while in the hospital and was given the following recommendation upon discharge; "Recommend [patient] return to [facility] and staff at SNF (skilled nursing facility) to use lift for transfers for safety." The hospital PT evaluation also indicated Resident 1 was not able to walk, was dependent on staff for transfers, and was on falls precautions (a variety of actions to help reduce the number of accidental falls).
During an interview with CNA 2 on 5/3/17 at 2:46 p.m., CNA 2 stated he transferred Resident 1 from the bed and onto the wheelchair every morning with extensive assist (staff provides weight bearing support, resident helps) and a licensed nurse never told him to use a mechanical lift (with Resident 1).
During an interview with Licensed Vocational Nurse (LVN) 1 on 5/3/17 at 3:26 p.m., LVN 1 stated Resident 1 was never transferred from wheelchair to bed with a mechanical lift. LVN 1 also stated CNAs who had a heavier build were able to transfer Resident 1 with one person assist because Resident 1 was able follow instructions.
Therefore the facility failed to ensure resident safety during transfer for Resident 1, when the resident was transferred from wheelchair to bed without an assistive device |
| 020000110 |
Lake Merritt Healthcare Center LLC |
020013395 |
B |
1-Aug-17 |
M8I311 |
4875 |
THIS CITATION IS AMENDED TO CORRECT THE CITATION NUMBER ON THE SECTION 1424 NOTICE, THE CIVIL MONEY PENALTY ASSESSMENT AND ON THE CONFIDENTIAL NAMES LIST. ALL OTHER ITEMS OF THE CITATION REMAIN UNCHANGED AND EFFECTIVE.
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 failed to follow the aforementioned regulation by failing to provide an environment free from accident hazards for Resident 5 when an electrical wire below Resident 5's bed sparked and caused a burn on the floor as a result of faulty and exposed wiring.
During an interview on 5/18/17 at 10:05 a.m., the DON stated a certified nursing assistant had unplugged a bed which created a spark and caused a power outage.
In another interview with the DON on 5/18/17, at 11:10 a.m., the DON stated Certified Nursing Assistant 1 (CNA 1), had unplugged a resident's bed from an electrical outlet and there was a spark. As a result, Room 19, 20 and 21 had lost electrical power.
In a concurrent observation and interview with CNA 1 on 5/18/17, at 11:15 a.m., CNA 1 stated Resident 5 was a total care resident (total care: requires full assistance with bathing, eating, toileting, moving in bed, and getting out of bed). CNA 1 stated Resident 5's bed brakes did not work. When he would turn Resident 5 in bed with the brakes engaged, the bed moved, and the wheels had been rolling side to side over electrical cords on the floor below the bed. CNA 1 stated at approximately 10 a.m., on 5/18/17, as he was repositioning Resident 5 in her bed, he noticed sparks shoot up from under the bed. At the time of the incident, Resident 5 was laying on an inflated air mattress (an air-filled mattress intended to prevent skin breakdown or wounds). The air mattress control device box (electrical device used to inflate the air mattress), was located at the foot of the bed. The electrical cord attached to the control device box was below the bed, on the floor, running from the bottom of the bed to the top and then plugged into an electrical outlet. CNA 1 showed the electrical cord which was the source of the spark. The cord was worn through in three spots and bare wire was exposed. There was an approximately 5-6 inch burn mark noted on the floor below the bed. CNA 1 stated he had written the faulty brakes on the maintenance log several times (maintenance log- list of items/equipment which needed to be repaired with a column for check off and date completed by the maintenance director)
Review of the document titled, "Maintenance Log," showed an entry dated 2/17/17. The work request showed, the "bed weels [sic] won't lock". Further review of the Maintenance log indicated another work request entry dated 2/21/17 to "Change the bed completely." The Maintenance Log entry dated 2/17/17 and 2/21/17, was dated and signed indicating it was repaired on 3/8/17.
During a concurrent observation and interview on 5/18/17 at 12:10 p.m., CNA 1 stated Resident 5's bed continued to roll when locked even after the bed had been changed. CNA 1 demonstrated how Resident 5's bed continued to roll when the bed wheels were locked.
During a concurrent observation and interview with a licensed electrician (LE), who had been called by the facility, on 5/18/17 at 2:22 p.m., the LE stated, if the exposed, sparked wiring had been lying next to combustible materials, (for example sheets and blankets), the incident could have started a fire.
Review of the facility's policy and procedure titled, "Maintenance Service," dated 12/2009, indicated, "Maintenance services shall be provided to all areas of the building, grounds, and equipment...Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times..Functions of maintenance personnel include, but are not limited to: Maintaining the building in good repair and free from hazards."
During a concurrent observation and interview with the DON, on 5/18/17, at 3:45 p.m., the DON stated the immediate plan of correction was the LE had ensured the electrical system was safe and Resident 5's air mattress and power equipment had been replaced.
The DON was notified verbally the IJ was lifted on 5/18/17 at 3:45 p.m. The Administrator was not available in the facility for notification.
Therefore the facility failed to provide an environment free from accident hazards for Resident 5 when an electrical wire below Resident 5's bed sparked and caused a burn on the floor as a result of faulty and exposed wiring.
The above violation had a direct relationship to the health, safety or security of patients. |
| 140000105 |
Lone Tree Convalescent Hospital |
020013450 |
B |
25-Aug-17 |
9QFC11 |
5585 |
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 failed to follow the aforementioned regulation by failing to ensure Certified Nurse Assistant (CNA) 1 transferred Resident 1 to the wheelchair with assistance, resulting in Resident 1 falling and sustaining fractures of both thigh bones.
A review of the clinical record on 8/19/16 showed Resident 1 was admitted on XXXXXXX15 with diagnoses including dementia (problems with memory, thinking and behavior). The Minimum Data Set Assessment (MDS, an assessment tool), dated 5/5/16, showed Resident 1 required extensive assistance of two or more persons to transfer to and from the bed and the wheelchair. Resident 1's care plan, updated on 8/5/16, showed a risk for falls due to a heart condition, arthritis, receiving a medication (Metropol) with risks for side effects, such as dizziness, a history of falls; attempted unsafe self-transfers poor vision and resistance to care at times. The facility's approach to decrease Resident 1's risk for falls included transfers should be done with extensive assistance. Resident 1's care plan also indicated she had previous falls on 8/27/15 and 12/15/15. A Post Fall Observation (nurse assessment form completed after a fall), dated 8/11/16 at 2:30 p.m., indicated Resident 1 started to fall during a transfer to the wheelchair and was assisted to the floor by CNA 1. Facility progress notes, dated 8/13/16 at 7:00 a.m., almost two days after the fall, indicated Resident 1 had pain in her right leg with swelling of the thigh and knee. Resident 1 was transferred to the hospital on XXXXXXX16.
During an interview on 8/19/16 at 11:15 a.m., CNA 1 stated she was assisting Resident 1 to the wheelchair at 2:10 p.m. on 8/11/16. CNA 1 stated she sat Resident 1 up on the side of the bed and lifted her by holding her around the waist. CNA 1 told Resident 1 to hold onto her. Resident 1 reached to grab the arm of the wheelchair. The wheelchair tilted and CNA 1 and Resident 1 went to the floor. CNA 1 stated most staff do not want to put Resident 1 in the wheelchair because it is not easy. CNA 1 stated, "She puts up a fuss."
During an interview on 9/7/16 at 11:27 a.m., CNA 2 stated she cared for Resident 1 on 8/11/16. CNA 2 said she placed Resident 1 back in bed from the wheelchair with the assistance of another CNA 3 at about 3:10 p.m. CNA 2 stated Resident 1 was yelling and holding her right side when she put her back in bed. CNA 2 stated she always used two people to transfer Resident 1 from the wheelchair, because she was not comfortable moving Resident 1 by herself.
During an interview on 9/7/16 at 11:35 a.m., Licensed Vocational Nurse 1 (LVN 1) said she cared for Resident 1 on the night shift on 8/11/16. LVN 1 stated she was told that Resident 1 had almost fallen, but had been caught by the CNA 1. LVN 1 did not document any after-fall assessment, or observations of Resident 1 that night.
A review of the facility's policy and procedure titled, "Assessing Falls, Their Causes, Definition", dated 10/2010, indicated, "The definition of a fall is an unintentional change in position coming to rest on the ground or floor. Nursing staff will observe for delayed complications of a fall for approximately seventy-two hours after an observed or suspected fall, and will document findings in the medical record." The policy and procedure also indicated, "Documentation will include any observed signs of pain, swelling, bruising, deformity and/or decreased mobility; and any change in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings."
During an interview on 8/19/16 at 9:40 a.m., Registered Nurse 1 (RN 1) stated she provided care for Resident 1 on 8/13/16. RN 1 stated CNA 3 told her Resident 1 had bruising and swelling of her right leg. RN 1 stated she examined Resident 1 and noted a sharp piece of bone just under the skin of her right thigh, her right knee was rotated inwardly, and her right knee and ankle were bruised. 911 was called and Resident 1 was transferred to the hospital. RN 1 stated she was not aware of the fall Resident 1 had on 8/11/16.
During an interview on 9/22/16 at 3:04 p.m. the facility's Director of Nursing, stated Resident 1 did not get out of bed again after the fall on 8/11/16.
A review of the hospital discharge summary dated XXXXXXX16 showed Resident 1 was admitted to the hospital on 8/13/16. She was treated at the hospital for a right femoral shaft stress fracture (break in the thigh bone caused by a twisting force) and a left femur comminuted fracture (break in the thigh bone when the bone has broken into three or more pieces). Resident 1 had surgery to repair the right femur fracture and a cast was placed on the right leg. Resident 1 was discharged from the hospital to have hospice care (end of life care).
During a telephone interview on 9/27/16 at 9:46 a.m., the physician (MDI), who treated Resident 1 in the emergency room, stated the fracture to Resident 1's right leg was a high energy fracture, meaning a direct fall onto her right knee.
Therefore the facility failed to ensure Certified Nurse Assistant (CNA) 1 transferred Resident 1 to the wheelchair with assistance, resulting in Resident 1 falling and sustaining fractures of both thigh bones. |
| 030000589 |
Lincoln Meadows Care Center |
030009792 |
AA |
21-Mar-13 |
OZ5J11 |
14635 |
F279483.20 Develop Comprehensive Care Plan (d) 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 section 483.25; and any services that would otherwise be required under section 483.25 but are not provided due to the resident's exercise of rights under section 483.10, including the right to refuse treatment under section 483.10(b)(4). F329 483.25 Drug Regimen is Free from Unnecessary Drugs (l) Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. An unannounced visit was made on 7/11/11 to initiate an investigation of Complaint #CA00274673 concerning quality of care and treatment. The reports identified allegations Resident 1 had fallen, sustained a head injury and died. As a result of the investigation, it was determined that the facility failed to: 1. Ensure the resident was free from unnecessary drugs when Coumadin/warfarin was ordered and administered for 17 days without monitoring which contributed to his death from bleeding in the brain and coagulopathy (bleeding disorder). 2. Revise a care plan for anticoagulant treatment when Coumadin was ordered.Resident 1 was originally admitted to the facility on 12/12/06 with diagnoses which included a prior stroke with paralysis of his right arm and leg, atrial fibrillation (irregular heart rhythm), hematuria (presence of blood in the urine) and recurrent urinary tract infection. Resident 1's most recent readmission was 5/7/11, following treatment of recurring urinary tract infections. In the event of a cardio-pulmonary arrest (loss of heart and/or lung function), Resident 1 was to be fully resuscitated (Full Code). The last full MDS (minimum data set, an assessment tool) dated 10/6/10, described Resident 1 as being non-English speaking, but he used signs and gestures to enable staff to understand his needs. Resident 1 was described as having short term memory problems and modified cognitive skills. The resident was not able to walk, but used a wheelchair to move himself around the facility. Review of the clinical record initiated on 7/11/11 for Resident 1 revealed the following: Readmission physician's orders dated 5/7/11 included "PT/INR (bleeding time studies. PT stands for Prothrombin Time. INR stands for International Normalized Ratio, a test which measures blood clotting time) monitor for Coumadin." (Coumadin is a medication to prevent clot formation), "Coumadin, start when bleeding stops - review by PCP" (primary care physician). A laboratory report dated 5/12/11 at 1:30 p.m. documented INR level of 1.2 and indicated the level was normal for someone not receiving anti-coagulation therapy. The INR lab report dated 5/12/11 contained a hand written note "Resident currently not on any dosage of Coumadin, please decide dosage." To the right of this note, in different handwriting was "D/C [discontinue] I&R (INR) if not on Coumadin 5/12/11 per [MD name] at 1345 (1:45 p.m.)." A third written note was below the first and it documented: "Resident new admit from hospital. Came with order for Coumadin but no dosage. PT/INR done to set parameter. Please advice (sic)!! "A physician's order dated 5/13/11 for "Verbal order from NP (nurse practitioner) to start Coumadin 3 mg. (milligrams, a unit of measure for medications) orally every evening for prophylaxis (prevention measure)." The order was written at 4 p.m. The Medication Administration Record (MAR) for May 2011 included an entry for Coumadin 3 mg orally, at bed time each day. The medication was documented as given daily starting 5/13/11. The MAR also had an entry for PT/INR every Monday and Thursday. There were no signatures on any dates indicating a lab test result was available or checked. The clinical record contained no other laboratory reports documenting PT/INR values after 5/12/11. Review of LexiComp.com, an on-line drug information source revealed the following information (in part) about warfarin, the generic name for Coumadin: "Warfarin is used for chronic oral anticoagulation in a variety of clinical settings. Monitoring warfarin therapy by adjusting the INR to lie within the recommended range for the disorder treated (e.g., 2.0-3.0) is recommended. Dosing warfarin is more complex than with many drugs. High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant resident harm when used in error. Geriatric Considerations: Before committing an elderly resident to long-term anticoagulation therapy, the risk for bleeding complications secondary to falls, drug interactions, living situation, and cognitive status should be considered. A risk of bleeding complications has been associated with increased age. Adverse Reactions - Bleeding is the major adverse effect of warfarin. Hemorrhage may occur at virtually any site. Risk is dependent on multiple variables, including the intensity of anticoagulation and resident susceptibility.Warnings/Precautions Hemorrhage: Possible massive hemorrhage involving the GI (gastrointestinal) tract, spinal cord, GU (genitourinary tract), cerebral, pericardial, pulmonary, adrenal, or hepatic (liver) sites. Hemorrhagic (bleeding) complications may be manifested by signs or symptoms that do not indicate obvious bleeding, such as paralysis; headache; pain in the chest, abdomen, joints, muscles, or other areas; dizziness; shortness of breath; difficulty breathing or swallowing; unexplained swelling; weakness; hypotension (low blood pressure); or unexplained shock. Results principally from overdosage. Careful clinical management, including frequent PT or INR determinations, is required." The Coumadin product information provided by the manufacturer with the medication validated the above reference. In the section titled, Highlights of Prescribing Information, (in part) stated: "WARNING: BLEEDING RISK.Coumadin can cause major or fatal bleeding. Perform regular monitoring of INR in all treated patients...Monitoring: Obtain daily INR determinations until stable in the therapeutic range...Most common adverse reactions to COUMADIN are fatal and nonfatal hemorrhage from any tissue or organ...An INR of greater than 4 appears to provide no additional therapeutic benefit in most patients and is associated with a higher risk of bleeding...Patients 60 years or older appear to exhibit greater than expected INR response to the anticoagulant effects of warfarin...Therefore, as patient age increases, a lower dose is usually required to produce a therapeutic level of anticoagulation..." The product insert also included specific guidelines for monitoring.On 5/19/11(Day #7 of his anticoagulation therapy), Resident 1 fell from his wheelchair without apparent injury. Neurological assessments were done but there was no documented evidence that a bleeding risk was considered or anticoagulation monitoring ordered.A Fax Notification Form dated 5/26/11 at 3:30 p.m. (Day #14 of his anticoagulation therapy) documented, "Resident had an unwitnessed and unassisted fall at 1530 (military time for 3:30 p.m.). Resident was sitting in w/c (wheelchair) and fell to floor. Bleeding to upper right forehead and to right cheek bone due to rug burn, no S/T (skin tear) observed. Right eye swollen and purple discoloration. Observed VS (vital signs) 126/72, 82 (pulse), 18 (respirations), 102.0 (temperature in Fahrenheit). [Complains] to right leg. No swelling or discoloration noted to legs/knees. Will continue to observe." The physician documented "noted" and signed the form and returned it to the facility on 5/27/11. There was no acknowledgement of an elevated temperature, and no orders were given. This note was signed by a Licensed Vocational Nurse (LVN). There was no documented evidence that anticoagulation monitoring was considered or ordered.A Nurse's Note dated 5/26/11 at 9:30 p.m. included, "DON (Director of Nursing) notified and will do an assessment tomorrow." A Nurse's Note dated 5/27/11 at 2:53 a.m. documented the resident had a temperature of 100.9 Fahrenheit. "Skin excoriations to right side of face, right eye blackened." The note was not signed. A Nurse's Note dated 5/27/11 at 1:58 a.m. included "Right is purple and swollen. Right side of face has two abrasions upper and lower." The note was not signed. On that same day at 6 p.m. the notes indicated "forehead bleeding, refused to get out of bed, swollen bruised eye, generalized pain."There was no documentation in the record that Resident 1 was assessed by a Registered Nurse (RN) following his fall. During an interview with the DON on 7/13/11 at 3:30 p.m. she stated "I came in on the night shift and assessed [Resident 1]...I have no note...I was concerned his cheek bone was fractured." The DON stated there was not an x-ray done of the resident's facial bones. The DON was not able to locate an RN assessment of Resident 1 following the fall.On 5/29/11 at 1:35 p.m., there was an indication that the family member "wanted to speak to Hospice to decide if that is the next step..." An untimed and unsigned order for a Hospice Consult was in the clinical record.On 5/30/11 Resident 1 was transferred to the emergency room of a General Acute Care Hospital (GACH) following a change in condition. The resident's condition was described in a 5/30/11 Nurse's Note at 5:56 p.m. as "Alert and responsive...rapid respirations and low BP (blood pressure)." The resident's blood pressure was "50/36" (normal range was 100/60 to 140/90) and his respiratory rate was "36" per minute (normal range was 16-20 per minute). Review of the GACH clinical record for Resident 1's admission on 5/30/11 revealed: A History and Physical report dated 5/30/11 which included: "Assessment (1) septic (infection) shock with multiorgan failure... (2) Intracranial (inside the skull) hemorrhage with subarachnoid bleed. This is probably secondary to his fall and his coagulopathy. (3)"Iatrogenic coagulopathy (clotting disorder due to medical treatment). The resident probably is on Coumadin, and his INR is more than 18...I do not think the resident is going to survive this episode." A laboratory report dated 5/30/11 included an INR result of "18.2" (18 times normal). On 06/03/11, Resident 1 was transferred from the GACH to another skilled nursing facility for comfort care. He died there on 06/04/11 at 5:10 a.m.The Death Certificate for Resident 1 listed the following diagnoses: 1. Cardiopulmonary arrest (heart beat and breathing stopped); 2. Subdural hematoma (blood accumulation between the brain and the dura covering); 3. Probably secondary to Coumadin." Review of undated facility policy titled "INR Coumadin Protocol" included (in part) "Notify the attending physician of PT/INR results of 3.0 or greater... 3. If INR is greater than 3.0 a. hold Coumadin..." During an interview with LN 4 on 9/16/11 at 3:25 p.m. LN 4 stated "Before giving Coumadin I want to know the INR results. Monday and Thursday INRs are routine for our residents. All Coumadin is given on PM shift; PM nurses know to get the INR every Monday and Thursday." During an interview with the Director of Nursing (DON) on 7/13/11 at 3:30 p.m. she stated they had reviewed the record and were unable to locate the lab tests following the 5/12/11 test. The DON stated "We're following up with the lab, they didn't come and draw blood, they received the order but never came out." The DON stated "The evening shift nurse is responsible for ensuring the INR is done when they give the medication." The DON verified the PT/INR tests ordered twice weekly on Mondays and Thursdays after Coumadin was started were not done for Resident 1 on the following scheduled days: 5/16/11, 5/19/11, 5/23/11, 5/26/11 and 5/30/11. Resident 1 had received Coumadin 3 mg. daily for 17 days without any laboratory monitoring. An INR of 18.2 was six times the therapeutic range for prevention of blood clots. Further review of the clinical record revealed for Resident 1 revealed:A 9/23/10 Care Plan for Risk for bruising and/or abnormal bleeding referenced the use of Plavix, a blood thinner which was no longer administered to the resident after his discharge on 5/3/11. The care plan included a goal of "will have therapeutic levels of medications [without signs and symptoms] of abnormal bleeding and excessive bruising daily [through] 7/6/11." No other blood thinner care plan was in the record and no revision was documented when the Coumadin was ordered.In an interview with the DON on 10/18/11 starting at 1:15 p.m. she stated the anticoagulant care plan "should have been changed when he went on Coumadin." As a result of the investigation, it was determined that the facility failed to: 1. Ensure the resident was free from unnecessary drugs when Coumadin/warfarin was ordered and administered for 17 days without monitoring which contributed to his death from bleeding in the brain. 2. Revise a care plan for anticoagulant treatment when Coumadin was ordered. These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom and were a direct proximate cause of death of the patient or resident. |
| 030001825 |
Lodi Nursing & Rehabilitation |
030009898 |
B |
20-May-13 |
GEDJ11 |
3775 |
1418.91 - Health & Safety Code (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 12/15/10 at 9:35 a.m. an unannounced visit was made to the facility to investigate an entity reported incident regarding an allegation of neglect for intake CA00228786. The Department determined the facility failed to: 1. Notify the Department of an allegation of neglect of Patient A immediately or within 24 hours as required. Patient A was an 83 year old admitted to the facility on 4/17/10 with diagnoses that included chronic airway obstruction, and congestive heart failure. The 4/30/10 Minimum Data Set (an assessment tool used in nursing facilities) indicated Patient A had no memory loss, no behavior problems, and required extensive assistance to get to the toilet. The Minimum Data Set also indicated Patient A was continent of bowel.On 5/13/10 the facility provided the Department with a "Report of Suspected Dependent Adult/Elder Abuse." The report indicated the facility had become aware of an allegation of neglect when a family member completed a grievance form. The report indicated the incident occurred on 4/26/10. Review of the facility "Grievance/Complaint Report" dated 4/28/10, indicated the Director of Social Service received the complaint on 4/28/10. The grievance noted, "The worker [CNA 1] was mean to [Patient A] on Apr. 26th. She told [Patient A] she didn't have time to take her to the bathroom and left her sitting in diarrhea. Then when she came to change [Patient A] she talked mean to her and was very rough with her. I do not want her with [Patient A]. She has also been mean in the past." Further review of the grievance included a section titled, "Documentation of Facility Follow-Up." This portion of the document indicated a licensed nurse was assigned to follow up on 5/3/10, and was to have the concern resolved by 5/7/10. A hand written note indicated the CNA was suspended pending an investigation. The grievance form was left blank where the staff was to note the "Results of the action taken:" The entire portion of the form which noted, "Resolution of the grievance/Complaint" was also left blank. The facility "Abuse Training and Reporting Policy" revised in January 2003, included the following information: "Neglect is defined as 1. The negligent failure of any person having the care of the elderly or a dependent adult to exercise that degree of care that a reasonable person in a like position would exercise...Neglect includes...failure to assist in personal hygiene..." Further review of the abuse policy indicated for "Investigation" the Abuse Coordinator will notify the Department that an investigation is in progress within 24 hours of the alleged abuse and that a letter would be sent to the Department within five working days with the results of the investigation. The employee file of Certified Nursing Assistant (CNA 1) contained a form titled, "Change in relationship Notice to Employee" dated 5/18/10. The form indicated CNA 1's employment status had changed due to a "substantiated abuse allegation." In an interview with Social Services Staff (SS) on 12/15/10 at 10:25 a.m. she verified she had received the grievance on 4/28/10, but could not explain why the Department was not notified, as required, until 5/13/10. Therefore, the facility failed to notify the Department of an allegation of neglect of Patient A immediately or within 24 hours as required. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000589 |
Lincoln Meadows Care Center |
030009989 |
B |
19-Jul-13 |
U0RG11 |
2581 |
72527 Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. An unannounced visit was made on 10/14/10 to initiate an investigation of an Entity Reported Incident (CA00222965) concerning an allegation that a patient was given medication against her wishes.As a result of the investigation, it was determined that the facility failed to protect Patient 1 from physical abuse. Patient 1 was admitted to the facility on 1/27/10 with diagnoses including an infection on her leg. A Minimum Data Set (MDS, an assessment tool) dated 2/4/10 described the patient as having no cognitive impairment and no memory problems. Patient 1 was discharged from the facility on 9/28/10. Review of the clinical record for Patient 1 revealed: 1. Physician's Order dated 1/27/10 for Dulcolax (a laxative) suppository, 10 milligrams rectal suppository, as needed every 3 days for constipation, if the milk of magnesia was ineffective. 2. Medication Administration Record dated March 2010 included an entry for administration of Milk of Magnesia on 3/23/10. Review of the facility investigation file included documentation of an interview with LN (Licensed Nurse) 1 dated 3/24/10. LN 1 stated she administered a rectal suppository to Patient 1 after the patient "stated she didn't want the suppository." In an interview with LN 2 on 10/14/10 at 10:45 a.m. she stated Patient 1 had reported to her on 3/25/10 that she had been given medication by rectal suppository the prior evening, after Patient 1 had refused the medicine. LN 2 stated refusals of care were common for Patient 1 and they were "honored normally." In an interview with the Director of Nursing (DON) on 10/14/10 at 11:30 a.m., she stated her investigation revealed the patient had been given a suppository, after refusing it and the staff "made a mistake" by giving the medicine. The DON stated, "It was abuse." Therefore, the facility failed to protect Patient 1 from physical abuse when medication was administered rectally after the patient refused the medication.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030001825 |
Lodi Nursing & Rehabilitation |
030010006 |
B |
19-Jul-13 |
LRZ311 |
5744 |
F323 - Free Of Accident Hazards/supervision/devices - 42 CFR 483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. An unannounced visit was made on 10/26/10 to initiate an investigation regarding an Entity Reported Incident (CAOO247050) concerning the abduction of Resident 1 by her son. The report identified allegations of Resident 1's son, who was not the responsible party, removing her from the facility without permission from the lawful responsible party.As a result of the investigation, it was determined that on 10/22/10, the facility failed to provide adequate supervision to protect Resident 1 from abduction when 2 building exits were observed without alarming equipment which would have alerted staff when Resident 1 approached an exit. Staff was not aware Resident 1 had left the building for approximately 20 minutes resulting in delayed actions to locate her. Resident 1 was re-admitted to the facility on 8/20/10 with diagnoses which included adult failure to thrive and late effects of a stroke. A Minimum Data Set (MDS, an assessment tool) dated 9/3/10 described Resident 1 as having long term and short term memory problems, with moderate independence in decision making skills. Resident 1 was unable to walk, required assistance to transfer from a wheelchair to bed, and she had bladder incontinence. In an interview with the DON (Director of Nursing) on 10/26/10 at 2:35 p.m., she stated Family Member (FM) 1 had been visiting his mother the evening of 10/22/10 between 7:30 p.m. and 9:15 p.m. and had been wheeling Resident 1 around the halls wearing his coat. The DON stated at 9 p.m. Resident 1 was observed wearing a sweatshirt. DON stated Resident 1 always wore an alarm band which would trigger a loud audible alarm to alert staff when the Resident was near an exit door because she was "an elopement risk." The DON stated FM 1 had taken Resident 1 out of the building through a sliding glass door in the dining room, which DON stated was not equipped with exit alarms. The DON stated Resident 1 had last been seen on 10/22/10 around 9:15 p.m. and staff had determined she was no longer in the facility at approximately 9:35 p.m. During an observation on 10/26/10 at 2:50 p.m. with the DON, two sliding glass doors were observed in the dining room across from Room 31, the sliding glass doors were observed to be in a common area and were not under direct observation by staff. The sliding glass doors were observed to have 3 signs on the doors and the wall, which read "This is not an exit." There were no exit alarms on the sliding doors. The doors opened onto a patio which was surrounded by the building on 3 sides, and a wood fence, approximately 6 feet tall, with a gate on the 4th side. The gate was not locked. The gate was observed to exit to a side driveway for the facility. One other resident in the facility was determined to be an elopement risk and wore an exit alarm, according to the DON. On 10/27/10 at 8:20 a.m. the facility was notified the situation constituted Immediate Jeopardy (IJ) to resident health and safety. The IJ status was changed within 4 hours of that determination since an immediate plan of correction to prevent elopement was submitted and approved by the Department. Review of the clinical record for Resident 1 revealed: 1. A Physician's order dated 8/20/10 "Wander guard [exit alarm] on at all times to alert staff of unwanted elopement." 2. A care plan titled Restraints-Risk for Injury Care Plan dated 8/27/10 which listed under Problem "Wandering" and "Verbalizes wanting to leave the facility". 3. A care plan titled Risk for Injury Care Plan which listed under Problem, "Hx [history] of attempts to leave facility." 4. A care plan titled Elopement Risk dated 8/27/10 which listed under Approach "Personal alarm in place on wheelchair." 5. An Elopement Risk Assessment dated 8/27/10 which described the resident as being mobile by wheelchair and having the desire to exit the facility. The described the resident as "confused at times." Under Plan the following had been checked off "Monitoring plan, add specifications to care plan; Wanderguard [exit alarm]; ID bracelet." 6. A Nursing Weekly Summary dated 10/22/10, "Resident taken by son tonight despite warning not to go out door. Police informed." In an interview with the DON on 10/26/10 at 3:30 p.m. she stated the patio gate had not been locked in the last year "because the Fire Marshall told us we couldn't lock it." During an observation on 11/2/10 at 5:25 p.m. the exit door located between Rooms 6 and 7 was observed from outside the building to be unlocked. Upon entry there was no audible alarm and facility staff was unaware of entry. There were no exit alarm strips next to the door. In an interview with DON on 11/2/10 at 5:28 p.m. she observed the exit door between Rooms 6 and 7 and verified it was not locked, did not have an exit alarm system on it and did not audibly notify staff the exit had been opened. Therefore, the facility failed to provide adequate supervision to protect Resident 1 from exiting the building when 2 exit doors were observed without alarming mechanisms to notify staff of the Resident's exit. Resident 1 was removed from the facility by a family member without medical approval, facility awareness and without required medications. She was transported by car to an acute care hospital in Marin County and admitted there approximately 8 hours after her exit from the facility.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility residents or patients. |
| 030001825 |
Lodi Nursing & Rehabilitation |
030010281 |
A |
27-Nov-13 |
HEV911 |
14103 |
72315 - Nursing Service - Patient Care (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. An unannounced visit was made on 6/15/11 to investigate complaint #CA00272052 regarding Patient 1 whose medical condition deteriorated while in the facility. The complaint alleged the patient developed Clostridium difficile (a bowel infection commonly referred to as "C-diff," a bacteria which produces a toxin that causes diarrhea, nausea, vomiting, and abdominal pain) which led to unrelenting diarrhea for 18 days, in addition to vomiting for 4 days in a row, she also suffered from intermittent nausea during the 18 day period, all of which resulted in the patient not being able to keep food and fluids in her system to maintain fluid and electrolyte (essential minerals in the blood) balance. The patient complained of getting sicker over the course of this infection. As a result of the investigation the Department determined the facility failed to ensure Patient 1 received necessary care and services to ensure adequate hydration to prevent dehydration when facility staff did not recognize deficits from prolonged fluid losses caused by nausea, vomiting and diarrhea, while continuing to administer a diuretic (water pill), further reducing her fluid volume. This resulted in severe dehydration and dangerously low sodium levels that required transfer to the General Acute Care Hospital (GACH) for emergent treatment to restore hydration and correct kidney failure. Patient 1 was a 56 year old admitted to the facility on 11/23/10 with diagnoses which included generalized muscle weakness, urinary tract infection, diabetes, and hypertension (high blood pressure). A GACH "Dismissal Summary", dated 11/23/10 described Patient 1's transfer to the facility for completion of antibiotics and for physical therapy for spine and knee disorders. An admission MDS (Minimum Data Set- an assessment tool used in nursing facilities) dated 12/3/10 described the patient as having no memory impairment or cognitive loss. The assessment described Patient 1 as requiring extensive assistance with dressing and toilet use, and, as being continent of urine and bowel. Review of the clinical record for Patient 1 revealed: A physicians order, dated 11/23/10 for "Maxzide 1 tab[let] by mouth [every day]." Maxzide is a diuretic [water pill] containing two diuretics, hydrochlorothiazide and Triamterene, in combination. Review of LexiComp On-line, a professional drug resource, accessed on 9/19/13, described Maxzide as a combination of hydrochlorothiazide and Triamterene. The section titled, "Warnings/Precautions" included: "Concerns related to adverse effects: Electrolyte disturbances...hyponatremia [low sodium in the blood] can occur with hydrochlorothiazide. [U.S. Boxed Warning]: Hyperkalemia (elevated potassium levels in the blood serum) can occur with triamterene; patients at risk include those with renal [kidney] dysfunction, diabetes mellitus, the elderly, and the severely ill. Serum potassium levels must be monitored at frequent intervals especially when dosages are changed or with any illness that may cause renal dysfunction. Avoid potassium supplements (except in severe cases of hypokalemia), potassium-containing salt substitutes, a diet rich in potassium, or other drugs that can cause hyperkalemia. Discontinue if hyperkalemia develops. Patients who are severely ill may develop respiratory or metabolic acidosis which may be associated with rapid elevations in serum potassium concentrations; avoid use in these patients." A laboratory report dated 12/1/10 confirmed Patient 1 had clostridium difficile (C. diff) toxin in her stool. Review of "Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) dated May 2012, found on the Centers for Disease Control (CDC) website at Http://www.cdc.gov/hai/organisms/cdiff/Cdiff_shd.html included: "The clinical manifestations of infection with toxin-producing strains of C. difficile range from symptomless carriage, to mild or moderate diarrhea, to fulminant and sometimes fatal pseudomembranous colitis....Complications of severe C. difficile colitis include dehydration, electrolyte disturbances, hypoalbuminemia [low albumin in the blood serum], toxic megacolon [distended or dilated colon], bowel perforation, hypotension [low blood pressure], renal failure [kidney failure], systemic inflammatory response syndrome, sepsis, and death." Review of a physician's order, dated 12/3/10, for Flagyl 500 milligrams, three times per day. Flagyl was an antibiotic for the treatment of C-Diff diarrhea. A Hypertension care plan for Patient 1, dated 12/3/10, listed under the heading Problem/Need: "Potential for fluid volume deficit [related to] diuretics." The "approaches" listed on the care plan related to assessing mental functions and "encouraging independence." There was no mention of the diuretic medication the resident was receiving (Maxzide), and there were no instructions in the care plan to hold the medication for low blood pressure. A short term care plan, dated 12/3/10, for "Risk of Dehydration due to episodes of loose stools/diarrhea, C-diff" listed "Monitor frequency and consistency of stools; Monitor for [signs/symptoms] of dehydration or electrolyte imbalance; Dizziness, lethargy, confusion, decreased urinary output, including temperature or change in vital signs, report any noted changes to MD."Review of a short term care plan, dated 12/4/10, for "Nausea/Vomiting, Risk for Dehydration" included under Approach "Monitor and encourage fluids and notify MD if inadequate fluids taken; staff to encourage intake each shift...notify MD if vomiting persists, staff to monitor medications, diet, environment, and labs as possible cause." Review of "Nursing Assistant Daily Flow Sheet" for November and December 2010 revealed Patient 1 developed diarrhea on 11/29/10 and had multiple episodes of diarrhea every day after that, for 18 days, except on 12/4/10. The flow sheet also documented the patient vomited 5 times on 12/4/10, and 1-3 times daily through 12/6/10.A "Total Intake and Output Record" dated 12/1/10 included documentation of the amount of fluid consumed by the patient (intake) daily through 12/7/10, for 7 days. The record included documentation of urine output as the number of times the patient urinated. The output column titled "diarrhea" was blank for all 7 days which contradicted the nursing assistant daily flow sheet. There was only 1 episode of output classified as emesis [vomiting] recorded, which occurred on 12/6/10. The report was signed on 12/8/13 by a nurse who wrote the patient's skin turgor (skin texture that correlates with hydration) was "fair" and that she had edema [swelling caused by water retention] in her legs. There was no evidence the patient's fluid intake or output were recorded after 12/7/10, despite her continued diarrhea and recent vomiting (12/4/10 through 12/6/10). The signing nurse wrote, "Off I&O [intake and output]." No further measurements of fluid intake were documented. Review of a note faxed to the physician on 12/8/10 notified the physician the patient had rashes on her legs, arms and face. The physician responded with "Hold Flagyl." There was no evidence the physician substituted another antibiotic to facilitate resolution of diarrhea caused by C-diff. A "Nursing Assistant Daily Flow Sheet" for December 2010 indicated the patient continued to have 4-8 diarrhea stools daily between 12/10/10, and her transfer out to the GACH on 12/17/10. A note faxed to the physician on 12/12/10 notified the physician that Patient 1 continued to have diarrhea and was not on an antibiotic. The note included, "Also, husband expressed frustration she is not making good progress. Requesting you to come and see patient." The physician directed nurses to restart the Flagyl. The physician did not see Patient 1 until four days after the request. A fax note to the physician, dated 12/14/10, reflected that nurses were unable to obtain a urine specimen due to contamination by liquid stool, indicating she was having loose stool each time she urinated. A physical therapy note, dated 12/14/10, indicated "Pt. [patient] had a decline this week due to some problems medically. Pt. had several bouts of diarrhea...had become very weak." Review of the Medication Administration Record (MAR) for December 2010 indicated the resident was given her dose of Maxzide [a water pill for high blood pressure] daily through 12/15/10, despite having difficulty keeping fluids in her system due to vomiting and diarrhea. The nurses notes for December 2010 did not include an assessment of the patient's fluid volume, such as testing skin turgor (tenting), dryness of mucous membranes of the mouth, dizziness when standing up, etc., nor was there evidence the nurses considered holding the diuretic medication for low blood pressure readings on 12/10/10 when the blood pressure was 94/63 and on 12/16/10 when her blood pressure was noted to be 97/56. A physician progress note, dated 12/16/10, indicated "Feeling weak. No appetite, too weak to walk...generalized weakness secondary to diarrhea, (decreased) nutrition." Prolonged diarrhea can result in loss of water from the body, which can reduce the essential balance of electrolytes (minerals such as sodium) required for cell and organ function. A Laboratory report, dated 12/17/10 at 6:05 a.m., included the following values, marked with 6 asterisks and titled, "CRITICAL VALUE" Sodium 116 (normal range 135-146); Potassium 6.1 (normal range 3.5-5.2). A low sodium value can be life-threatening. The following additional abnormal lab values were also included on the report dated 12/17/10: BUN 64 (normal range 8-22); Creatinine 1.89 (normal range 0.35-1.18). Elevation of these values are consistent with abnormal kidney function due to fluid losses with low blood flow to the kidneys.Review of the U.S. National Library of Medicine medical encyclopedia, accessed on-line on 9/19/13 described Hyponatremia as, "Can be caused by: Diarrhea...Diuretic medicines, which increase urine output...Vomiting...Common symptoms include:...fatigue, irritability, loss of appetite...muscle weakness, nausea...vomiting...In severe cases, hyponatremia can lead to: decreased consciousness, hallucinations or coma, brain herniation, death...hyponatremia can be a life-threatening emergency."Review of Nurse's Notes, dated 12/17/10, indicated, "I'm sending resident to [GACH] ER [Emergency Room] for evaluation, per DON [Director of Nurses]...need to send her out re [regarding] labs critical values." Review of the GACH clinical record for Patient 1's 12/17/10 admission included: Laboratory test results dated 12/17/10 revealed Patient 1 was positive for C. diff in her stool. The "Admission History & Physical" report dated 12/17/10 included, "The patient was found with acute renal [kidney] failure with a creatinine of 2.3 [creatinine measures kidney function. Normal levels are 0.44-1.03]...hyperkalemia [elevated potassium]...with a blood pressure of 89/57...severe dehydration...severe low blood pressure..." The report further documented, "Hypotension [low blood pressure]...could be due to dehydration...will hold off [anti-hypertensive medications]...will hold off atenolol [a beta blocking blood pressure medication], hydrochlorothiazide [a diuretic]..."During an interview with the Director of Nurses on 7/1/11 at 10:20 a.m. she stated there were, "No hold parameters for [the diuretic and hypertension medications]...they [nurses] followed orders." There was no evidence the facility considered the safety of continued administration of the diuretic in the context of Patient 1's clinical condition. In an interview with Certified Nursing Assistant (CNA) 2 on 7/12/11 at 4:45 p.m. CNA 2 stated Patient 1 "was supposed to be doing rehab... she was exhausted [from the diarrhea] and kept saying 'I just don't feel good' for 5 days. She couldn't pinpoint why, except she had diarrhea and was not eating." In an interview with Physical Therapist (PT) 1 on 11/2/11 at 8:40 a.m. she reviewed the patient's clinical record and stated, "Initially she was only able to roll in bed, but could not stand without the help of 2-3 people." PT 1 stated the patient made some progress in her ability to transfer herself during the second week of therapy. PT 1 stated, "The third week, starting 12/14/10, she declined [therapy] due to her medical condition." During an interview with Patient 1 on 6/15/11 at 8:35 a.m. she stated that after having terrible diarrhea from C-diff for a long time, "I was too sick and weak to do therapy." She stated, "I told my husband I was dying. I kept asking for a doctor, nobody listened to me, I was frustrated." The patient also stated she told a night nurse, "I was trying to survive.'" In addition, Patient 1 stated she recently returned home, finally after six months, recovering from the effects of the illness. Patient 1 stated, "I missed Christmas and lost all that time with my grandchildren." Review of the GACH "Dismissal Summary" dated 12/29/10 indicated the date of discharge from the GACH was 12/29/10. This represented a 12 day hospital stay for Patient 1. Therefore, the Department determined the facility failed to ensure Patient 1 received necessary care and services to ensure adequate hydration to prevent dehydration when facility staff did not recognize deficits from prolonged fluid losses caused by nausea, vomiting and diarrhea, while continuing to administer a diuretic, further reducing her fluid volume, resulting in severe dehydration and dangerously low sodium levels. These violations presented either 1) imminent danger that death or serious harm to the patients or the residents of the long-term care health care facility would result therefrom; or, 2) substantial probability that death or serious physical harm to patients or residents of the long-term care facility would result therefrom. |
| 030001819 |
La Salette Health and Rehabilitation Center |
030010445 |
A |
12-Feb-14 |
LU9V11 |
14134 |
7231 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. 72311 Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. 72313(a)(1) Nursing Service -Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. An unannounced visit was made to the facility to investigate entity reported incident CA00286139 on 2/24/12. The report identified allegations of the declining respiratory condition of Patient 1 on 10/1/11 and her unexpected death that afternoon. As a result of the investigation the Department determined the facility failed to: 1. Conduct a comprehensive assessment of Patient 1's respiratory system with input from qualified health professionals, when the patient had a significant change in condition. Two Licensed Vocational Nurses did not consult with an available Registered Nurse to perform the patient assessment; 2. Notify the physician promptly of significant changes in respiratory symptoms for Patient 1 that presented potential for emergency treatment interventions; and 3. Obtain a physician's order before administering an increased dose of oxygen for a prolonged time when Patient 1 showed signs of respiratory system failure.These failures placed Patient 1 at risk for life threatening conditions, without the opportunity for medical interventions to stabilize her respiratory condition. Patient 1 was admitted to the facility on 9/22/11 with diagnoses which included pneumonia (inflammation of the lungs usually due to infection) and emphysema (disease of the lungs resulting in difficulty exhaling air). Review of the clinical record for Patient 1 included: An "Admission H&P" [history and physical] dated 9/23/11 documented the resident had a history of "severe COPD" [chronic obstructive pulmonary disease] and removal of her left lung 25 years earlier for cancer. The H&P described Patient 1's hospitalization from 9/13/11 to 9/22/11, for pneumonia and respiratory failure which included the use of a breathing tube to enable the patient to breathe effectively from 9/14/11 to 9/16/11. The H&P concluded "May [discharge] home this Friday if condition continues to improve." Physician's orders for admission to the facility, dated 9/22/11 indicated Patient 1 "has mental capacity to understand and make health care decisions" and orders included "oxygen at 2 liters (L) via NC [nasal cannula] for respiratory failure." "Physician Orders for Life-Sustaining Treatment (POLST)" dated 9/22/11 and signed by the physician on 9/23/11, directed staff to follow these life sustaining orders and then notify the physician. A box in Section B was checked for Full Treatment. Full Treatment included advanced airway interventions and transfer to a hospital when indicated, and/or patient comfort could not be achieved.Review of Nurse's Notes, dated 10/1/11 at 11:50 a.m., indicated "Medicated with Ativan [anti-anxiety sedative medication that can suppress breathing function] for [increased] anxiety. O2 [Oxygen] sat[uration] is 85-87%. Placed on re-breather mask at 10L/min. [liters per minute] O2 sat[uration] went up to 98%." This note was signed by Licensed Vocational Nurse 1 (LVN 1). Review of Nurse's Notes, dated 10/1/11 at 12:10 p.m., indicated "...Left the re-breather mask to maintain [oxygen saturation] [above] 90%..." Further review of Nurse's Notes, dated 10/1/11 at 2:30 p.m., indicated "Resident is trying to do self- transfer. Sitting on the edge of the bed [and] wants to get out of the bed. Explained to her the importance of the [oxygen]. Resident kept on trying to remove the mask. [Oxygen saturation] 96-98% [with] the mask on." Nurse's Notes written at 12:10 p.m., 12:30 p.m., 1 p.m.; 2:15 p.m. and 2:30 p.m. did not include documentation that a registered nurse, or any nurse, listened to the lungs/breath sounds of Patient 1 during any time while the patient was having difficulty breathing. Review of Lippincott Manual of Nursing Practice, ninth edition, regarding Respiratory Disorders on page 284 indicated, "Nursing Assessment...1. Note changes suggesting increased work of breathing...2. Assess breath sounds...3. Assess level of consciousness." There was no documented evidence a Registered Nurse (RN) assessed Patient 1's respiratory status when she showed signs of respiratory distress, between 10:50 a.m. and 3:10 p.m. on 10/1/11, that required extraordinary amounts of oxygen to maintain normal blood oxygen levels. There was no documented evidence Patient 1's physician was notified of her change in condition and no documented evidence of a physician's order to administer 10L [liters per minute] of oxygen via a re-breather mask to Patient 1.Review of facility policy titled "Oxygen Applications," dated 1/1/07, and revised on 10/18/11 included, "Non-Rebreather Masks (NRB) are also used in emergency situations when a patient is in significant respiratory distress and shows evidence of significant hypoxia [low oxygen levels]...A Non-Rebreather Mask delivers a higher level of oxygen in the range of 80-100% depending on fit, at flow rates from 10-15 L/min [liters per minute]." Review of the "Nursing Staffing Assignment and Sign-In Sheet" dated 10/1/11 indicated the East Station, where Patient 1's room was located, was staffed by LVN 1, and LVN 2 on the day shift. The schedule indicated 2 RNs were working the day shift and both were working on the West Station. Review of facility policy titled, "Resident Condition Changes that Require Physician Notification Guidelines," dated as revised on 12/19/12 indicated, "Categories of Condition Change Notifications: Emergent: A situation/condition that would warrant immediate physician notification and intervention (if the physician response is not immediate, determine if resident should be sent to the emergency room". Such conditions include...Deviation of vital signs when intervention must be immediate." Vital signs are measurements of life-preserving body systems. Oxygen saturation is a type of vital sign that measures the level of oxygen carried by blood cells to and from vital organs. Oxygen saturation levels below 90% are associated with life-threatening conditions. In an interview with the Administrator on 1/19/13 at 7:40 a.m. the Administrator stated the Resident Condition Change policy did not have significant changes from the earlier policy. The policy included under the heading "Expectations," the following: "Licensed nurses...are expected to recognize resident situations/conditions that require physician notification. The nurse shall complete an assessment of the condition, including level of urgency...Documentation of the resident condition change and proper notification shall be the responsibility of the nurse who observes and assesses the change." The policy did not clearly define which licensed nurse (RN or LVN) was qualified to do such assessment. Review of a "Change of Condition Form" dated 10/1/11 included, "Received resident [with] O2 at 10L/rebreather at 1510 [3:10 p.m.]." The form, completed by LVN 3 indicated the patient stopped breathing 10 minutes later. The form indicated a physician was notified, however, the time of physician notification was not documented. Review of a "Continuing Care Telephone Contact Summary" dated 10/1/11 noted the facility's contact to the physician's office at 4:38 p.m. by LVN 3; "Received call from nurse [LVN 3]. Expired unexpectedly today 10/1/11 at 3:51 p.m. Was a full code." There was no documented evidence a physician was contacted prior to her death. Review of the physician's orders for Patient 1 for September 2011 and October 2011 revealed no order for Oxygen at 10 L per minute via mask. Review of the "Pre-Hospital Care Report" dated 10/1/11, completed by the ambulance crew revealed: "Time on Scene: 15:26 [3:26 p.m.]...The staff said they found the patient in cardiac arrest at 1515. They put a non-rebreather on the patient and started chest compressions." Review of the Lippincott Manual of Nursing Practice, Ninth Edition, Chapter 11, Respiratory Disorders, included on page 283 a section titled, "Nursing Alert" in red text: "Avoid administration of....oxygen...of 100% for COPD patients because you may depress the respiratory center drive. For COPD patients, the drive to breathe may be hypoxemia [low blood oxygen levels]." The chapter also included a section on page 316, titled, "Nursing Alert" in red text: "Normally, CO2 [carbon dioxide] levels in the blood provide a stimulus for respiration. However, in patients with COPD, chronically elevated CO2 may impair this mechanism and low oxygen levels act as stimulus for respiration. Giving high concentration of supplemental oxygen to people who retain CO2 may suppress the hypoxic drive, leading to worsening hypoventilation [slow breathing], respiratory decompensation, and the development of a worsening respiratory acidosis [a life-threatening condition that occurs when the lungs cannot remove all of the carbon dioxide the body produces]." Review of the facility "Disciplinary Action Record" dated 10/18/11 for LVN 1 included "provided the patient with high flow O2 of 10L non-rebreather mask without doctor's orders. [LVN 1] displayed poor clinical judgment of giving O2 with high concentration instead of sending the patient to the hospital...this inappropriate action contributed to the patient's worsening condition." Review of the facility "Disciplinary Action Record" dated 10/20/11, for LVN 2 included "...Recommended to the charge nurse [LVN 1's name] to provide nursing measures only by giving high flow O2 instead of sending the patient to the hospital...[LVN 2's ] action contributed to the severity of the patient's worsening condition." During an interview with the Director of Nurses (DON) on 2/24/12 at 10:05 a.m. the DON stated LVN 1 and LVN 2 had no orders from the physician to increase the oxygen. The DON stated, "They didn't call the MD that was our problem...they did everything on their own." The DON verified there were no physician orders for 10 liters of oxygen by mask. In an interview with RN 1 on 2/24/12 at 12:35 p.m., she verified she worked on the West Station on 10/1/11 during the day shift. RN 1 stated, "There was not an expectation the RNs were to supervise the East Station also." RN 1 stated, "I was not asked to look at [Patient 1] that day." In an interview with CNA 2 on 2/24/12 at 1:12 p.m. CNA 2 stated Patient 1 "Was desperate to breathe, I called the nurse...the nurse put an oxygen mask on [Patient 1's] face...she kept taking the oxygen off...I called the nurse again and she gave a breathing treatment. I checked on her a lot that day." CNA 2 stated, "Sometimes I think I should have called 911 that day. The way I saw her, she needed help." CNA 2 indicated the resident did not eat any food at lunch, and was "Breathing hard the whole time from lunch to the end of the shift." In an interview with LVN 1, on 2/28/12 at 11 a.m., LVN 1 stated, after lunch Patient 1 "had SOB [shortness of breath] so I reported it to the desk nurse, my supervisor. Since oxygen was ordered anyway we increased the oxygen...using the face mask at 5 liters or more." LVN 1 further stated there was "No MD order to increase the oxygen." In an interview with LVN 2 on 2/28/12 at 1:10 p.m. LVN 2 verified he had been the desk nurse on 10/1/11 during the day shift. LVN 2 stated, "I thought [LVN 1] called the doctor, it was her responsibility...she didn't call the doctor, I learned later." In an interview with the Assistant Director of Nurses (ADON) on 2/29/12 at 2 p.m. the ADON stated "An RN has to back up the assessments of an LVN...RNs have a wider scope [of practice]...and more education." The ADON also stated "2 LVNs still have to consult the RN" on duty. The ADON described the basic respiratory system assessment as including "Starting with the nares [nasal openings], the full system, the chest movements, lung sounds, vital signs, oxygen use...these are the basics, RNs and LVNs should assess." During an interview with Medical Doctor 1 (MD 1) on 3/1/12 at 9:42 a.m. MD 1 stated the increased oxygen rate administered was "not for them [the nurses] to decide to administer, they should have notified the provider [MD]." MD 1 confirmed that no physician, who was in the position to direct immediate life-saving interventions for this patient's respiratory distress, was notified by facility nurses prior to the 4:38 p.m. contact on 10/1/11. Therefore, the facility failed to: 1. Conduct a comprehensive assessment of Patient 1's respiratory system with input from health professionals, when the patient had a significant change in condition and two Licensed Vocational Nurses did not consult an available Registered Nurse to perform a patient assessment; 2. Notify the physician promptly of significant changes in respiratory symptoms for Patient 1 that presented potential for emergency treatment interventions; and 3. Obtain a physician's order before administering an increased dose of oxygen for a prolonged time when Patient 1 showed signs of respiratory system failure. These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. |
| 030001825 |
Lodi Nursing & Rehabilitation |
030012302 |
B |
16-Jun-16 |
MBB811 |
9402 |
F223 Free from Abuse/Involuntary Seclusion The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The following citation is written as a result of entity reported incident #CA00482872. Unannounced visits were made to the facility on 4/8/16, 4/11/16, and 4/14/16 to investigate an allegation of non-consensual sexual abuse. The Department determined the facility failed to ensure one of two sampled Residents (Resident 2) was free from sexual abuse when: Escalation of Resident 1's monitored inappropriate sexual behavior was not addressed or reported to the consulting psychiatrist (MD 2); and an anti-psychotic medication (a drug used to alter behavior) was reduced and then discontinued without input from MD 2. These failures resulted in Resident 1's engagement in non-consensual oral sex on 4/4/16 with Resident 2. Clinical record review revealed Resident 1 had resided at the Facility for almost two years. Review of a Minimum Data Set (MDS-an assessment tool) dated 2/8/16 revealed Resident 1 had a Brief Interview for Mental Status (BIMS-a cognition test with a score of 15 being the highest cognitive level) of 15. Resident 1 was under the care of a primary doctor (MD 1) and a consultant Psychiatrist (MD 2) since 2014. Further clinical record review of past history, revealed Resident 1 was diagnosed with, and prescribed multiple psychotropic medications for, schizophrenia (a mental disorder that leads to faulty perception and inappropriate actions and feelings among other symptoms) which manifested for Resident 1 as inappropriate sexual behavior and aggression that first occurred on 7/17/14 and again on 4/4/16. Resident 1's psychotropic medication history included Seroquel, Geodon, Haldol as well as Depakote, and an antidepressant. The psychotropic medications were discontinued and restarted at different times since July 2014 through the present. On 7/22/14, Resident 1 was also prescribed Premarin (a female hormone) for sexual aggression. Review of "Psychotropic Drug Summary" sheets from July 2014 through the present, revealed the following: Resident 1's behavioral medications: Depakote, Seroquel, and Geodon, were all discontinued in 2014. Risperdal (an antipsychotic) 0.5 milligrams, one tablet daily replaced the Geodon for the treatment of Resident 1's schizophrenia with combativeness (this order did not link sexual aggression to the Risperdal as a behavior to monitor). A fax, dated 3/3/16, sent to the MD 1, read: "Currently on Risperdal 0.5 ml [milliliters-a unit of measurement] QD [every day] for schizophrenia m/b [manifested by] combativeness. Resident has had a reduction in behaviors and we would like to try a GDR [gradual dose reduction] to Risperdal 0.25 ml QD X [times] 1 week & [and] D/C [discontinue]." MD 1's response was "Ok" and dated 3/3/16. The Risperdal was discontinued on 3/31/16. An interview was conducted with the Director of Nurses (DON) on 4/8/16 at 2:45 p.m. The DON stated she "Didn't see the earlier diagnosis of schizophrenia so she asked for a dose reduction of Risperdal on 3/3/16." An interview conducted with the DON on 4/11/16 at 2:35 p.m. disclosed, the monitoring of sexually inappropriate behavior should be linked to a medication. Review of the March 2016 MAR (medication administration record) revealed 27 episodes of "sexually inappropriate behavior" occurred between 3/13/16, through 3/31/16 (the day the medication was discontinued). There was no documented evidence in the clinical record that either MD 1 or MD 2 were notified of the continued and escalating episodes of Resident 1's documented sexually inappropriate behavior. In an interview with the DON on 4/11/16 at 2:35 p.m., the DON stated she "Was told the sexual comments and episodes had stopped." Clinical record review revealed Resident 2 was diagnosed with advanced dementia (decline in reasoning/thinking) and did not have the ability to make decisions. On 4/4/16 Resident 2 was sexually abused by Resident 1. Resident 1's clinical record had a "Behavior Note" dated 4/4/16 and timed at 1:00 p.m., which read "...Resident was witnessed at 0400 [4 a.m.] at roommates bedside performing fellatio [oral sex]" on Resident 2, who was diagnosed with advanced dementia. Review of a fax document dated 4/4/16, disclosed "Resident found naked beside another's [sic] Resident bed while giving oral sex. Resident [Resident 1] noted with increased sexual aggression even to CNA [Certified Nurses' Assistant] taking care of him. Please Advise..." MD 1's response dated 4/4/16 was "Please ask [MD 2] to eval [evaluate] pt [patient]." Resident 1's room was changed to a room with an alert and oriented male resident. The "Behavior Note" dated 4/4/16, disclosed that during a discussion with Resident 1, he was aware of what he had done, and stated, "What I did was an abomination [something that causes disgust or hatred]." Resident 1 "stated how sorry he was." A care plan for "behavior problem r/t [related to] poor impulse control m/b [manifested by] sexual inappropriate verbalizations," and "Resident had episode with sexual act" was initiated on 2/2/16 (prior to the discontinuation of the Risperdal on 3/31/16). Interventions included administration of medications as ordered, provided opportunities for positive interaction, attention, and to stop and talk with him as passing by, discussion of Resident 1's behavior, explain/reinforce why behavior is inappropriate and/or unacceptable, monitoring of behavior episodes, document behavior and potential causes, and monitor episodes of aggressive behavior every shift tally by hash marks in the MAR. The March 2016 MAR revealed 27 episodes of "sexually inappropriate behavior" which occurred in the time frame of 3/13/16 through 3/31/16. The care plan had no intervention to notify either MD 1 or MD 2 of any escalation in sexually inappropriate behavior and was not updated until 4/4/16; the date Resident 1 sexually abused Resident 2. There was no documented evidence the facility updated the care plan interventions after Resident 1's increase in sexually inappropriate behavior between 3/13/16 and 3/31/16. A "Behavioral Note" dated 4/4/16 at 11:57 p.m. disclosed Resident 1 was on every 15 minute monitoring by facility staff. The note indicated Resident 1 stated in part, "...That was just a one time thing...all guys are going to mess up a few times in there [sic] life..." Review of "Physician's Progress Notes" dated 4/5/16 disclosed MD 2's note which read in pertinent part, "Concern: oral sex with peer...Probably due to pharmacist request for decrease psychotropic....Restart Risperdal...please stop bothering [primary care physician] send pharmacy rec [request] to me." Review of physician orders dated 4/5/16 disclosed Resident 1 was again prescribed Risperdal, 0.5 ml twice daily for schizophrenia manifested by sexually aggressive behavior and Premarin, (a female hormone which decreases sexual drives/urges in males), 0.5 milligrams once daily for schizophrenia manifested by sexually aggressive behavior. Review of a facility policy and procedure dated 2/13 titled, "Psychotherapeutic Drug Management," read in pertinent part, "Procedure...d) The physician shall review the monthly psychotherapeutic summary and determine if the resident should remain on the same dose or an adjustment should be made..." There was no documented evidence that the monthly behavioral data for Resident 1 was gathered, which resulted in MD 1 not being able to review the data for sexually inappropriate behavior, as it was not attached to a medication, or sent on the fax with the request for a gradual dose reduction. Continued record review of a "Psychopharmacologic Drug Summary" sheet for the Risperdal prescribed for "schizophrenia manifested by combativeness" showed no monthly totals of the aggressive or sexual inappropriate behaviors were completed by the facility staff; therefore, data was not available to MD 1 or MD 2, since January of 2016 to the present. An interview was conducted with the consultant psychiatrist (MD 2) on 4/14/16 at 1:05 p.m. MD 2 stated that the monitoring data for aggression and sexually inappropriate behavior were both linked to the schizophrenic diagnosis, and should have been monitored as such. MD 2 stated the fact that the gradual dose reduction requests go to the primary care doctor (MD 1) rather than the consultant "Remains a problem" as it excluded any input from the consultant. MD 2 also stated, "I probably would not have done a dose reduction given knowledge of [Resident 1's] history." He concluded, "I feel it [the sexual abuse toward Resident 2] was preventable." Therefore, The Department determined the facility failed to ensure one of two sampled Residents (Resident 2) was free from sexual abuse when: Escalation of Resident 1's monitored inappropriate sexual behavior was not addressed or reported to the consulting psychiatrist (MD 2); and an anti-psychotic medication (a drug used to alter behavior) was reduced and then discontinued without input from MD 2. These failures resulted in Resident 1's engagement in non-consensual oral sex on 4/4/16 with Resident 2. The above violations had a direct relationship to the health, safety, or security of patients. |
| 030000589 |
Lincoln Meadows Care Center |
030013118 |
B |
13-Apr-17 |
3X3J11 |
6453 |
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 a complaint investigation for #CA00519088, #CA00519715, and #CA00519761. An unannounced visit was made to the facility on 1/24/17 to initiate the investigation of an allegation of sexual abuse first received from an acute care hospital on January 23, 2017.
The Department determined the facility failed to report an allegation of abuse within 24 hours as required, when facility staff members were informed of an allegation of sexual abuse in May 2016 and again in August 2016. There was no subsequent report filed with the Department by the facility for either allegation. This violation potentially placed facility residents at risk for continued abuse.
Patient 1 was an 82 year old. Patient 1's Minimum Data Set (MDS, a standardized assessment tool), dated 6/5/16, revealed Patient 1 had a Brief Interview for Mental Status (BIMS, an assessment screening tool used to assess cognition) score of 15. This score indicated Patient 1 was cognitively intact.
During an interview with Patient 1, on 1/24/17 at 8:52 a.m., P1 stated "[I] saw my roommate get raped. He just came in and got in bed with her ...it was during the day...in room [room number provided]...only remember the one incident." When P1 was asked if she had told anyone about what she saw she stated "yes, I turned it in... all the girls came in... he still works here..." P1 stated her roommate (Patient 2) was not capable of speaking for herself stating "...that's why I felt bad about it..."
Patient 2 was an 80 year old admitted to the facility with diagnoses which included dementia with behavioral disturbances, major depressive disorder, and anxiety disorder. The MDS dated 1/15/17 revealed Patient 2 had a BIMS score of 00. This score indicated severe cognitive impairment and problems with memory.
During an interview with Licensed Nurse (LN) 2, on 1/24/17, at 11:27 a.m., LN 2 stated he first heard about allegations of abuse that were sexual in nature from Patient 1"one time" and recalls the conversation was "last year" but could not recall the date or time of the year. LN 2 stated "I feel like I may have told someone, like social services or someone..."
During an interview with Certified Nursing Assistant (CNA) 1, on 1/24/17 at 12:32 p.m., he recalled "at least eight months ago" he heard of an allegation of a sexual abuse that Patient 1 had reported to various staff. CNA 1 recalled the Administrator had a conversation with him around this time regarding the sexual abuse allegation.
During a review of the clinical record for Patient 1, a Social Services progress note dated 5/30/16 at 1:03 p.m., indicated "Patient was interviewed in regards to accusations she made to several CNAs about a CNA being in bed with her roommate..."
In an interview on 1/24/17, at 10:03 a.m., with LN 1, LN 1 stated she had a "strange conversation" with Patient 1 on 8/24/16. LN 1 stated she notified her upper management, via email, about what Patient 1 told her during a treatment that day. The observed email, composed on 8/24/16, was sent to the Director of Nursing (DON), Administrator, and Social Services Director (SSD). LN 1 read aloud, from a printed copy of the e-mail, explaining that Patient 1 alleged she saw a guy (first name of CNA 1 provided) in bed with her roommate (Patient 2) a while ago and that she (Patient 1) also told the night nurse. LN 1 then read an email reply sent from the Administrator indicating he was aware and that Patient 1 had reported allegations of rape multiple times.
In an interview on 1/24/17 at 10:03 a.m., with CNA 2, CNA 2 recalled that she was "in the room with social services talking to the patient [Patient 1] with the first accusation of a CNA raping her roommate..." CNA 2 was unable to recall the date or time of this conversation.
During an interview with the SSD, on 1/24/17, at 10:20 a.m., the SSD recalled Patient 1 had a history of making false accusations and remembered in May 2016 a report that mentioned someone was lying on the roommate's bed. It was around that time that Patient 1 started saying her roommate (Patient 2) was raped by a staff member. The SSD described her investigative process upon learning of an allegation of abuse. The SSD said she interviewed those involved and reported her findings to the Administrator; then the Administrator decided the next steps. The SSD stated CNA 1 remained employed by the facility and Patient 1 had accused CNA 1 of inappropriate sexual behavior before.
During an interview with the Administrator on 1/24/17, at 10:31 a.m., the Administrator confirmed he was aware of the history of sexual abuse allegations made by Patient 1 and was unable to produce an official investigative file for Patient 1's allegation(s) nor any documentation or evidence that the allegation had been investigated. There was no indication that an allegation of sexual abuse had been filed with the Department for either of the allegations brought to his attention in May 2016 or August 2016. The Administrator acknowledged that Patient 1 had a history of making multiple allegations of a sexual nature between CNA 1 and Patient 2. The Administrator explained that he had determined the allegations were false and if the allegations had been substantiated he would have filed a report.
The facility policy and procedure titled "Reporting Abuse to State Agencies and Other Entities/Individuals" revised August 2011, indicated "...All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law."
Therefore, the Department determined the facility failed to report an allegation of abuse within 24 hours as required, when facility staff members were informed of an allegation of sexual abuse in May 2016 and again in August 2016. There was no subsequent report filed with the Department by the facility for either allegation.
This violation had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 040000920 |
LOYD'S LIBERTY HOMES, INC. - NORTH KNOLL |
040011050 |
B |
07-Oct-14 |
SYOP11 |
12163 |
W 149483.420 (d)(1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. On 9/4/14 at 7:15 a.m., an unannounced visit was made to the facility to investigate complaint allegations of neglect for failure to provide appropriate and timely medical care and services.The facility failed to implement written policies and procedures that prohibited mistreatment or neglect, when Registered Nurse (RN) 1 failed to provide appropriate nursing care for documented changes in health, weight, and nutritional status for two of two sampled clients (Client 1 and Client 2) as follows: 1a. Registered Nurse (RN) 1 failed to assess, monitor, and take appropriate action when Client 1 experienced severe weight (33 pounds [lb] = 18.75 percent [%] of total body weight) loss in six months. 1b. RN 1 failed to monitor for three months, the status of a physician ordered colonoscopy (a visualization of the lower intestines with a camera to identify abnormalities) for Client 1's severe weight loss. 2a. RN 1 failed to assess, monitor, and take action when Client 2 experienced severe weight (22 lb [17.5 %] of total body weight) loss in six months. 2b. RN 1 failed to assess, monitor, and take appropriate action for Client 2's worsening skin condition when physician orders for dermatology (specializing in skin conditions) follow-up appointments were missed.1a. Client 1 was 67 years old, admitted to the facility on 10/06, with a diagnosis of seizure disorder and cerebral palsy (affects body movement and muscle coordination). Client 1was non-verbal, followed simple commands, and was dependent on staff for all care and activities of daily living. On 9/4/14 at 7:30 a.m., Client 1 appeared thin and unsteady as he was assisted to sit at the dining table.On 9/4/14, Client 1's physician's report dated:1/22/14 = weight of 176 pounds (lb) 3/19/14 = weight of 156 lb 5/15/14 = weight of 156 lb 7/15/14 = weight of 143 lb.From 1/22/14 (176 lb) to 7/15/14 (143 lb), there had been a loss of 33 lb (18.75%) weight loss in six months, a severe weight loss.Client 1's "Monthly Vital Signs" log dated:7/26/14 =141 lb 8/10/14 =140 lb 8/30/14 =130 lb.From 8/10/14 (140 lb) to 8/30/14 (130 lb), there had been a 10 lb (7.14%) weight loss in almost three weeks, which constituted a severe weight loss. From 5/15/14 (156 lb) to 8/30/14 (130 lb), there had been a 26 lb (16.66%) weight loss in three months, which constituted a severe weight loss. Client 1's "Nurses Notes" dated 1/8/14 through 8/22/14 (seven months), were reviewed. On 6/23/14, RN 1's nursing note indicated "Medical Director (MD) made aware of [Client 1's increased weakness and 25 # (lb) weight loss over past year..." On 9/4/14 at 10:30 a.m., RN 1 stated she was unable to provide documented evidence she assessed, monitored, or contacted Client 1's physician regarding the continued weight loss after the 6/23/14 nursing note. RN 1 stated she should have monitored the weight loss more closely.Client 1's RN "Quarterly Nursing Assessments (QNA)" dated 2/5/14, indicated a weight of 173 lb. Client 1's QNA dated 5/5/14, indicated "He has lost 21 pounds in the last three months. [MD] order Glucerna (nutritional supplement) one can with each meal. Dietician [Facility's Registered Dietician=RD] recommends mech (mechanical) soft healthy low concentrated sweets, low fried food, large portions with low fat milk, and snacks between meals..."On 9/4/14 at 10:30 a.m., RN 1 stated she was unable to provide documented evidence she questioned or clarified the appropriateness of the RD's recommendation for low concentrated sweets, low fried food, or low-fat milk, when he continued to lose weight. On 9/10/14 at 11:45 a.m., the Program Manager (PM) stated everybody failed Client 1 when he continued to lose weight monthly and steps were not taken to identify the cause. The facility policy titled "Weight and Height Record" dated 3/09, indicated "...A weight change of five pounds is reported to the physician and explained by the Nurse Consultant in the monthly health summary." Federal Code of Regulations 483.420 (d) (1) on "Neglect...means failure to provide goods or services to avoid physical or psychological harm." Center of Medicare and Medicaid Services "Insidious Weight Loss" dated 6/20/08, website downloaded 9/10/14, indicated "...parameters for evaluating significance of unplanned and undesired weight loss are: 1 month=Significant Loss 5% Severe Loss 5% 3 months=Signif. Loss 7.5% Severe Loss 7.5% 6 months=Signif. Loss 10% Severe Loss10% 1b. Client 1's physician's report dated 1/22/14 through 5/15/14, indicated there was a total weight loss of 20 lb (11.36%), which indicated a severe weight loss.Client 1's physician's note dated 5/15/14, indicated an order for a "...GI [gastroenterology) referral (referenced by physician during '60 day evaluation') for weight loss, colonoscopy." Client 1's "Nurse's Note" dated 8/20/14, indicated "...Colonoscopy yesterday..." Client 1's Colonoscopy for his severe weight loss was performed three months after the physician's order was received.On 9/4/14 at 10:30 a.m., RN 1 stated she was not able to provide justification or rationale for the delayed implementation of the colonoscopy order or evidence she monitored the status of the colonoscopy order to ensure the test was scheduled after 5/15/14. On 9/10/14 at 11:45 a.m., the PM stated it was the RN's responsibility to ensure client's medical follow-up had been done. 2a. Client 2 was 29 years old, admitted to the facility on 6/13, with a diagnoses that included Cerebral Palsy. Client 2 was verbal, able to communicate basic needs, and capable of performing basic hygiene independently. Client 2 required supervision for community outings and health care needs.The "Monthly Vital Signs" log indicated Client 2's weight as follows: 1/14 = 126 lb 2/14 = 124.5 lb 3/14 = 121.3 lb 4/14 = 118 lb 5/14 = 115 lb 6/14 = 108 lb 7/14 = 104 lb From 1/14 (126 lb) through 7/14 (104 lb), there was a total of 22 lb (17.5%) weight loss in six months, which indicated a severe weight loss. Client 1's physician's progress note dated 9/2/14, indicated a weight of 103 lb (a 27 lb [21%] total body weight loss, which indicated a severe weight loss.From 2/14 (124.5) through 9/14 (103 lb), there was a 21.5 lb (17.27%) total weight loss in six months, which indicated a severe weight loss. On 9/4/14 at 10:30 a.m., RN 1 stated she had not noticed or identified any concerns with Client 2's weight. She stated he always wore baggy clothes and his clothes did not appear to fit him any differently. RN 1 stated she was not able to provide documented evidence of notification to the physician about Client 2's progressive weight loss from 1/14 through 8/22/14.On 9/5/14 at 1:35 p.m., during a telephone interview, Family Member (FM) 1 stated on 5/14, she shared concerns about [Client 2's] weight loss. FM 1 stated she contacted the Regional Center (RC) on 6/14, about the weight loss and again on 7/14.The facility policy titled, "Weight and Height Record" dated 3/09, indicated, "...A weight change of five pounds is reported to the physician and explained by the Nurse Consultant in the monthly health summary." The Federal Code of Regulations 483.420 (d) (1) indicated, "Neglect...means failure to provide goods or services to avoid physical or psychological harm."The facility policy titled, "Individual's Rights" dated 8/12, indicated, "To be free from harm ... abuse or neglect."Center of Medicare and Medicaid Services, "Insidious Weight Loss" dated 6/20/08, website downloaded 9/10/14, indicated, "...parameters for evaluating significance of unplanned and undesired weight loss are: 1 month=Significant Loss 5% Severe Loss 5% 3 months=Signif. Loss 7.5% Severe Loss 7.5% 6 months=Signif .Loss 10% Severe Loss 10%."2b. Client 2's Dermatologist Note dated 2/12/14, indicated, "Assessment: Dermatitis, Seborrheic (inflamed skin glands) ...Worse...Patient to return in 3 months."Client 2's Dermatologist Note dated 7/30/14., indicated "...on history lesions were widespread over lower extremities, face, upper extremities and hands...Progress report shows worsening of this condition...Associated symptoms included itching, dryness, and scaling ... Dermatitis Eczematous-Worse (itchy red rash that initially weeps or oozes...may become crusted or scaly) ... return in 4 weeks."The clinical record reflected Client 2 was not seen by a dermatologist for five plus months (2/12/14 to 7/30/14), for the recommended three month follow-up (due on 5/12/14), and the four week follow-up (due 8/27/14) on 9/10/14. On 9/4/14 at 8:10 a.m., DCS 2 encouraged Client 2 to remove his hooded sweatshirt. Client 2's skin was observed to have numerous red raised bumps, scabs, and scratch marks covering his arms, neck, and face. Client 2's "Nurses Notes" dated 9/3/14 at 1:45 p.m., indicated, "Received call ... that [Client 2] is scratching so much has caused R (right) arm to bleed 'there's blood all over the wall.' Here at this time to medicate with Benadryl, no longer scratching at this time has some smeared blood on R (right) arm." There was no documentation of references to Client 2's skin condition in the nurse's notes from 5/9/14 through 9/2/14.On 9/4/14 at 10:45 a.m., RN 1 stated she could not provide documented evidence she assessed or monitored Client 2's worsening skin condition from 5/9/14 through 9/2/14.On 9/5/14 at 1:35 p.m., Family Member (FM) 1 stated on 5/14, she shared concerns about Client 2's worsening skin condition with facility staff. FM 1 stated Client 2 had missed three follow up appointments with the Dermatologist (physician who specialized on skin disorders) due to conflicting appointments for other clients. FM 1 stated Client 2's skin condition usually flared up in the summer, but his skin "has never looked this bad, for so long." On 9/8/14 at 4:30 p.m., Client 2's Regional Center Case Manager (RCCM) stated she met and discussed care concerns (weight loss and worsening skin condition) with the facility's Interdisciplinary Team on 7/14. The RCCM stated during the 7/14 meeting, Client 2 verbalized he wanted something done about his skin condition. The RCCM stated Client 2 indicated he was embarrassed by his skin appearance (multiple visible scabs, scratches, and scaling). The RCCM stated this may have contributed to his increased resistance to attend day program. Copies of photographs of Client 2 taken 7/11/14, and provided during the investigation, reflected multiple marked skin irritation with extensive red, raised, open sores. The left arm appeared slightly swollen and inflamed with oozing areas consistent with scratch marks and frank blood, numerous scabbed, flaky, and crusted lesions were noted over the entire upper half of his body. On 9/9/14, the California Department of Public Health's Medical Consultant (CDPH-MC) reviewed the photographs of Client 2's skin. The CDPH-MC indicated "Round, linear (along a straight or nearly straight line) and irregularly shaped open sores and sores in various stages ... over entire body surface measuring up to 1/4 inch in their greatest dimension. The sores are associated with visible chafing (injuring by rubbing and friction), peeling and sloughing (dead tissue from a non-healing sore) of the skin which is also distributed over the entire body surface." The facility failed to implement written policies and procedures that prohibited mistreatment or neglect, when Registered Nurse (RN) 1 failed to provide appropriate nursing care for documented changes in health, weight, and nutritional status for two of two sampled clients (Client 1 and Client 2), and failed to ensure Client 2 had a follow up appointment with the Dermatologist, timely. These failures of the RN to assess, monitor, and take appropriate and timely action led to Clients 1 and 2 suffering unplanned and undesired severe weight loss. Client 2 suffered worsening painful, itchy, dry, and disfiguring skin conditions due to missed dermatology follow-ups.These violations placed Clients 1 and 2 at potential for harm to health and well-being, and constitutes a Class B Citation. |
| 040000584 |
Loyd's Liberty Homes, Inc. - San Jose Street |
040011234 |
B |
15-Jan-15 |
42YI11 |
8493 |
Title 17 50510 (a)(8)50510 Each person with a developmental disability, as defined by this subchapter, is entitled to the same rights, protections, and responsibilities as all other persons under the laws and Constitution of the State of California, and under the laws and the Constitution of the United States. Unless otherwise restricted by law, these rights may be exercised at will by any person with a developmental disability. These rights include, but are not limited to the following:a) Access Rights (8) A right to be free from harm, including unnecessary physical restraint, or isolation excessive medication, abuse or neglect. Medication shall not be used as punishment, for convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program. The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident: CA00422738. The facility failed to ensure Client B was free from harm when the Program Coordinator (PC) purchased a pair of shoes, size 3 for the client when he required a size 5. As a result, Client B sustained two Stage II pressure ulcers to the 4th and 5th toes of his left foot and required debridement (the removal of unhealthy tissue from a wound to promote healing), wound treatments, dressing changes, and pain medication. Client B's Individual Service Plan (ISP) dated 6/25/14, contained documentation he was admitted to the facility on 10/06, he had vision impairment, and he required staff's assistance with his activities of daily living (ADLs - including grooming). The ISP contained a Health Care Objective to keep Client B "free of skin problems; skin will remain intact with no problems..."On 12/17/14 at 7:15 a.m., Client B was observed wearing a disposable blue surgical shoe cover over the sock on his left foot when staff wheeled Client B into the kitchen. On 12/17/14 at 9:15 a.m., during an interview, the Program Director (PD) stated Client B had sustained an injury to the 4th and 5th toes of his left foot on 12/6/14. The PD stated Client B wore his new shoes to the day program on Friday morning (12/5/14) and they were not removed from his feet until 6 p.m., that evening. She stated the next morning (12/6/14), staff noted the injury to his toes. The PD stated an Incident Report had been completed regarding this incident.The "Incident Report" dated 12/9/14, indicated on 12/6/14, Client B was observed with "two grape size blisters on his R (right) [sic] foot on the 4th and 5th toe." Client B was taken to the emergency room for evaluation. The report contained documentation, "The physician lanced (pricked or cut open) the blisters and sent (Client B) home with a diagnosis of injury as a result of trauma most likely caused by pressure or crushing. The physician ordered Cephalexin (antibiotic) 500 mg (milligrams) 3x day (three times per day), triple antibiotic and a gauze (sic) dressing change TID (three times a day)." On 12/9/14 Qualified Intellectual Disabilities Professional (QIDP) 1 took Client B to urgent care for a follow up visit. The urgent care physician diagnosed the injury as a burned area and ordered Silver Sulfadizin [sic] 1% cream (a sulfa drug, used to prevent and treat infections of second- and third-degree burns) to be applied to the 4th and 5th toes of his left foot twice daily and referred Client B to a wound clinic for further treatment. Client B was taken to the wound clinic on 12/9/14 at 1 p.m., and was diagnosed with a Stage II pressure ulcer (partial thickness skin loss involving outer layer, inner layer, or both) due to friction from his shoe. Client B required at least five follow up visits to the wound clinic for continued treatment of his wounds between 12/8/14 and 12/19/14. Client B's "Consent to Special Procedure" notes (from the acute hospital) dated 12/6/14, in the section titled, "Operation or Procedure to be Performed," contained documentation, "... Incision and Drainage of Blisters on Left Foot." Client B's "Physician's Orders," dated 12/6/14, contained an order to: "Change dressing to (L) (left) toes 3x a day (with) simple gauze LVN (Licensed Vocational Nurse) RN (Registered Nurse) only. There were also orders for: "Cephalexin Monohy (Monohydrate - antibiotic) 500 mg (milligrams) cap (capsule) po (by mouth) Tid (three times a day) x 7 days (for 7 days) (L) foot wound (infection prevention). An additional physician's order written on 12/8/14 contained documentation, "Silver Sulfadiazin 1% cream Apply to entire burn area topical route (outer skin) BID (twice daily) qd (everyday) Dx (diagnosis): Burn area per (physician name) RN/LVN D/C (discontinue) until Thursday follow up with (physician) wound clinic." Client B's "Medication Administration Record" (MAR) dated, "2014 -December," contained documentation Client B received Motrin (anti-inflammatory, pain medication) 200 mg per tablet (2 tablets - 400 mg) for pain to his left foot: twice on 12/6/14 and 12/7/14; and once on 12/9/14, 12/11/14, 12/13/14, 12/14/14 and 12/17/14. The MAR contained documentation staff changed the gauze dressing to Client B's left foot once (8 p.m.) on 12/6/14, three times (7 a.m., 4 p.m., and 8 p.m.) on 12/7/14, and once (7 a.m.) on 12/8/14; before the dressing change order was discontinued by the physician on 12/8/14. Client B had "Physician Referral Form"(s) dated 12/8/14, 12/9/14, and 12/15/14 for wound care follow up for the blisters on his left foot. The form dated 12/8/14, contained documentation, "Extensive debridement of 4th and 5th toe burns dressed with Silvadene. F.U. (follow up) with Wound Care tomorrow and for ongoing tx (treatment)." The form dated 12/9/14, contained documentation, "Pt (patient) has St. II (Stage II) Pressure Ulcer due to friction of the shoe (new tight shoes). It don't seems [sic] burn as there is no burned area on the top of the toes, which Indicate hot fluid..." The form dated 12/15/14, contained documentation, "Wound almost healed 4th toe. 5th toe is healed. Will continue same treatment..."Client B's "Physician Referral Form" dated "12-14-15-" [sic], contained documentation he had a podiatry evaluation scheduled for 12/16/14 at 12 p.m. The section titled, "Results of visit:" contained documentation Client B should wear a size "5 wide." On 12/17/14 at 11:40 a.m., during an interview, the Program Coordinator (PC) stated she took Client B to purchase new shoes on 11/11/14. She stated she tried the new shoes on Client B before purchasing them and stated, "They seemed to fit." She stated Client B did not indicate in any way (gestures, grimacing, making vocalizations, etc.-due to client being non-verbal) the shoes were uncomfortable when she tried them on the client. She stated she did not know the shoes did not fit Client B until he was taken to the doctor on 12/6/14. She stated she was contacted by the PD on 12/8/14, asking if the PC thought Client B's injury could have been caused by the new shoes. The PC stated since she was not at the facility at the time, she called the facility and asked Direct Support Professional (DSP) 8 to try the shoes on Client B while she waited on the phone. The PC stated DSP 8 replied the fit seemed "snug" and stated the toes of his right foot were right at the end of the shoe, stating, "he doesn't have any room." The PC stated on 12/9/14, DSP 8 told QIDP 1 "They (the shoes) were too small" when QIDP 1 came to the facility to take Client B to a follow up physician appointment. When the PC was asked if she knew what size shoes Client B wore, she stated it varied, depending on the shoe style. She stated the podiatrist recommended Client B wear a size 5. The PC stated since Client B was with her, she just tried the shoes on him and purchased a size 3 (pair of tennis shoes). The PC stated the shoes Client B wore when she took him shopping for shoes were a size 5 1/2 or 6. The facility failed to ensure Client B was free from harm when the PC purchased a pair of shoes, size 3 for Client B when he required a size 5. Client B was left in the size 3 shoes from the morning when he left for the day program until 6 p.m. As a result, Client B sustained two Stage II pressure ulcers to the 4th and 5th toes of his left foot, and required debridement wound treatments, dressing changes, and routine pain medication. The above violation had a direct or immediate relationship to the client's health, safety, or security, and therefore constitutes a Class 'B' Citation. |
| 040000224 |
LOYD'S LIBERTY HOMES, INC., - COLONIAL |
040011380 |
B |
14-Apr-15 |
RXZQ11 |
4588 |
Title 17 50510 (a)(8)50510 Each person with a developmental disability, as defined by this subchapter, is entitled to the same rights, protections, and responsibilities as all other persons under the laws and Constitution of the State of California, and under the laws and the Constitution of the United States. Unless otherwise restricted by law, these rights may be exercised at will by any person with a developmental disability. These rights include, but are not limited to the following:a) Access Rights (8) A right to be free from harm, including unnecessary physical restraint, or isolation excessive medication, abuse or neglect. Medication shall not be used as punishment, for convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program. The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident: CA00429626. On 2/17/15 at 8:00 a.m., an unannounced visit was made to the facility to investigate an entity reported event regarding a fractured right hip.The facility failed to ensure Client 1 was free from harm when: The Registered Nurse (RN) failed to identify and refer Client 1 for a medical evaluation of a fractured right hip for more than four days when Client 1 demonstrated a change in condition (resistive to care, refused to ambulate [walk] and grimaced in pain when repositioned).Client 1 was a 71 year old, admitted to the facility 7/97, with diagnoses that included seizure disorder, Parkinsonism (progressive disorder of the nervous system), osteoporosis (causes bones to be weak and brittle), and dysphasia (inability to speak). Client 1 followed simple commands, was non-verbal, unable to recognize or report illness, was dependent on staff for activities of daily living, and was ambulatory (able to walk).On 1/29/15, direct care staff (DCS) reported to the RN that Client 1 was resistive to care, and refusing to walk. RN assessment and plan indicated Client 1 was sleepy and had possible flu/cold symptoms, and instructed staff to keep the client home from day program on 1/29/15 and use a wheelchair as needed. On 1/30/15, DCS again notified the RN of Client 1's continued refusal and resistant to care, refusal to walk and requested permission to medicate Client 1 with Tylenol (used to treat mild to moderate pain). RN assessment and plan for 1/30/15 again indicated Client 1 had flu/cold symptoms. RN again instructed staff to keep Client 1 home from day program, monitor and medicate with Tylenol for generalized pain.Client 1's Physician's Progress Note dated 2/2/15 indicated "71 year old male is here for a 60 day evaluation and lab review. Patient stopped walking about 5 days ago...X-ray ordered: Bilateral hips, Bilateral knees to rule out fractures..."Client 1's "Emergency Room Report" dated 2/2/15, indicated "...was brought to the emergency department by caregiver. He is a nursing home resident. Reportedly he suffered a fall 2 days ago; this was unwitnessed by staff at nursing home. Since then he is barely able to get up and walk and is in obvious pain. He was taken to his primary care physician today and hip x-rays taken, showing fractured right hip..." Client 1's "[Hospital] Consultation" dated 2/2/15, indicated "X-rays: X-rays demonstrate a right hip displaced femoral neck fracture." On 2/4/15 Client 1 had surgery to repair the right hip fracture.On 2/17/15 at 10:00 a.m., during an interview the RN stated she assessed Client 1 on 1/29/15 while he was seated on the sofa. RN stated she assessed his range of motion from the knee down. She did not perform a full body assessment or check the range of motion to his hips since he was sitting on the sofa. RN stated she thought Client 1 had the flu and needed to rest. RN verified his vital signs were within normal limits. RN stated she did not follow-up or check on Client 1 over the weekend. RN stated Client 1 was seen on 2/2/15 for a routine examination by his primary care physician who identified the right hip fracture.The facility failed to ensure Client 1 was free from neglect when the RN failed to perform a thorough and complete assessment of Client 1's change in condition and behavior demonstrated by repeated resistance to care, refusal to walk and demonstrated pain symptoms. This failure resulted in Client 1 suffering unnecessary pain for five days prior to receiving medical treatment. The above violation had a direct or immediate relationship to the client's health, safety, or security, and therefore constitutes a Class 'B' Citation. |
| 040000605 |
Loyd's Liberty Homes, Inc. - Augusta |
040011545 |
B |
10-Jun-15 |
BJSI11 |
10972 |
50510 Each person with a developmental disability, as defined by this subchapter, is entitled to the same rights, protections, and responsibilities as all other persons under the laws and Constitution of the State of California, and under the laws and the Constitution of the United States. Unless otherwise restricted by law, these rights may be exercised at will by any person with a developmental disability. These rights include, but are not limited to the following: (a) Access Rights (8) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse or neglect. Medication shall not be used as punishment, for convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program. The facility failed to ensure Client A was free from harm including neglect when he was scalded during a shower and sustained second degree burns (partial thickness burns involving the 1st and 2nd layers of skin) to his left foot while temperature of the water in the shower reached 120 degrees Fahrenheit (F).The facility's Incident Report, dated 2/2/15 contained documentation, Client A had diagnoses which included: Degenerative Muscle Disorder (diseases cause progressive damage and loss of muscle cells with associated weakness), Paraplegia (impairment in motor or sensory function of the lower extremities), and venous stasis of lower legs (slow blood flow in the veins). The Incident Report also contained documentation Client A required set up assistance of staff during showers. The facility's Incident Report dated 2/2/15, indicated on 1/31/15 at approximately 7:00 a.m., the Program Coordinator (PC) contacted a Professional Water Heater Technician (Professional Technician) to check the water heater for safety due to an unusual black burn mark on the wall near the heater. At approximately 10:30 a.m., the Professional Technician reported no issues of concern. He said the burn mark appeared to be old. The technician then informed the PC he turned up the water temperature to an unspecified degree during his visit.The facility's Incident Report dated 2/2/15, indicated on 2/1/15 at approximately 3:15 p.m., Direct Care Staff (DCS) 1 notified the Program Director (PD) and Registered Nurse (RN) 1, that DCS 2 assisted Client A to the shower in the front bathroom (Bathroom 2). Immediately after the shower Client A had blisters to his left foot. DCS 1 reported the blisters, looked like they were caused by the temperature of the water in the shower. Client A was transferred to Acute Hospital 1's Emergency Room (ER) and from the ER to Acute Hospital 2's Burn Unit.On 2/4/15 at 2:15 p.m., Client A was observed (at Acute Hospital 2) in bed. During an interview Client A stated (on 2/1/15) he was seated in the shower alone, which he usually did. He tested the water with his hand and stated it felt ok, so he washed his hair. Client A stated he did not usually receive assistance with his shower or water adjustment because he liked privacy; however when he put his feet into the water (flow), the water felt suddenly hot. Client A stated he called for help and help came, but his left foot had blistered by that time.An "Incident Report Follow-up" dated 2/5/15 contained documentation that on 2/1/15 at approximately 12:35 p.m., Client A was in the shower, when he called for assistance (from DCS 2) because he was having trouble with the shampoo bottle. The report indicated Client A called for DCS 2 again at approximately 12:45 p.m., stating the water temperature was too hot. DCS 2 touched the water and stated the water did not seem that hot. DCS 2 stated she "adjusted the water temp." At approximately 12:55 p.m., Client A called for DCS 2 because he dropped the shower head nozzle again. At this time, DCS 2 reported noticing Client A's feet were "red." The report contained documentation that on 2/1/15, DCS 3 "checks water temp and says it is between 120 and 125 (degrees Fahrenheit)." The report also indicated, "On 2/4/2015, a new plumbing company replaced the water heater and tempering valve. Plumbing company also replaced shower water control valve as it was not properly installed..." 42 CFR (Code of Federal Regulations) 483.420 (d)(1) indicates, "Neglect means failure to provide goods or services necessary to avoid physical or psychological harm." Client A's Nursing Progress Notes dated 2/1/15 at 9:30 p.m., contained documentation, RN 1 was notified Client A "had blisters on (R) [sic] (right) foot which formed while in shower. RN (RN 1) advised cool cloth / water to tx (treat) prior to transport to Urgent Care. Images sent (1:53 p.m.) RN and Program Director agreed Cl (Client A) to go to ER via ambulance. RN advised staff to soak foot in bucket of cool water prior to EMS (Emergency Medical Service) arrival. Client seen at ER (at Acute Hospital 1) & (and) transferred to (Acute Hospital 2's) Burn Unit for care..." Acute Hospital 2's History Notes dated 2/1/15 contained documentation, Client A was "transferred here from (Acute Hospital 1) for scald burns to the L (left) heel. Pt (patient) was awaiting a bath and had L foot in tub with water running and staff returned to room and pt's foot was burning." The Physical Exam showed Client A's heart rate was elevated at 114 beats per minute (bpm). The Note contained documentation, "Involved burn service with care on arrival will give analgesia (pain relieving medications) as determined by vital signs." The Burn Service Notes dated, 2/2/15 contained documentation, "The patient has moderately tachycardic (rapid heartbeat) this afternoon running in the 120s... (normal adult heart rate 60 - 100) We will give him some pain medication and see if it this has an effect on his heart rate, this may be an autonomic response (fight or flight response) to his injury." The Assessment/Plan contained documentation, "Social work consult to evaluate for safety at (facility)."Acute Hospital 2's Discharge Summary - General form dated 2/4/15, contained documentation, Client A's admitting diagnosis was partial thickness burn (2nd degree burn - involving 1st layer and some of the 2nd layer of skin) to left foot. Client A required debridement (medical removal of dead or damaged tissues to improve the healing potential of the remaining healthy tissues) of the burn. Client A's electronic medical record (EMR) dated 2/1/15 contained physician's orders for pain medications: Fentanyl (a powerful pain relieving medication similar to, but more potent than morphine; typically used to treat patients with severe pain) 25 micrograms (mcg) intravenously (IV) every 15 minutes as needed for pain; Versed (a short-acting central nervous system depressant [causes sedation]) 0.5 milligrams given with Fentanyl every 15 minutes IV for procedural pain; and Norco (narcotic medication used to relieve moderate to severe pain) 5-325 mg one tablet by mouth every four hours as needed for pain. Client A remained hospitalized from 2/1/15 - 2/4/15. On 2/5/15 at 2:00 p.m., during an interview the Quality Assurance Coordinator (QAC) stated, there was no written policy for water temperatures (temp) but a verbal policy was "If water temp is not 105-110 (degrees) report to the QAC." The Maintenance Request Log was provided and contained documentation of four separate requests dated: 1/4/15 (thermostat temperature needed adjusting); 1/18/15 (check water pressure); 1/21/15 (water temperature adjustment); and 1/28/15 (water temperature needs adjusting). The QAC stated the facility had purchased a new water heater and had it installed on 2/4/15, (after the scalding incident of Client A's left foot on 2/1/15). 42 CFR (Code of Federal Regulations) 483.470 (d)(3) indicates, "In areas of the facility where clients who have not been trained to regulate water temperature are exposed to hot water, ensure that the temperature of the water does not exceed 110 degrees F."On 2/6/15 at 10:35 a.m., during a telephone interview, DCS 2 stated, she worked the evening of 2/1/15. She stated Client A was taking a shower when the water turned hot without him touching the control. DCS 2 stated, she went in the bathroom a couple of times when Client A needed her to get things. She stated Client A said the water was hot but it wasn't hot (when she felt it). DCS 2 stated, "I turned it up all the way and thought it was to his liking. I left and he called me back to open shampoo." She stated Client A washed his hair and "the water was fine." DCS 2 stated, " I left and he called me back because he dropped the nozzle again. When I picked up the nozzle, I saw his foot was red and bubbly. I wasn't sure what it was." DCS 2 stated "the other staff (DCS 1) came and said it was probably scalded." DCS 2 stated she called RN 1 and the Qualified Intellectual Disabilities Professional (QIDP), and also she and DCS 1 took pictures and sent them to the QIDP and RN 1. DCS 2 stated the RN 1 called her back and said it looked more serious on the picture than she had thought. RN 1 told DCS 1 to put cold compresses on Client A's feet and call the ambulance to transport him to the ER. DCS 2 stated, "We've had problems with water in the past."On 2/6/15 at 11:00 a.m., during a telephone interview, the Program Coordinator (PC) stated, on 2/1/15 before taking the clients on an outing she noticed the water was cold as she washed her hands so she "Turned the water temperature up just a little then left the house." She stated, "When we returned home the water was hot (to touch) so I turned it down. The PC stated, "I checked and it was in normal range I just cannot remember what it was. We have been having problems with the water temps and pressure for about two weeks. A couple of weeks ago [Client A] took a cold shower. There was no hot water." The facility's "Water Temperature Record" for the year 2015 contained documentation for both bathrooms (Bathroom 1 - girl's) and (Bathroom 2 -boy's). No temperatures were recorded on the log for dates: 1/22/15, 1/23/15, 1/26/15 and 1/27/15. For the boy's bathroom (Bathroom 2) no temperature was documented on 2/2/15. All other dates 1/1/15 - 2/4/15 failed to document any temperature readings at or above 110 degrees F for Bathrooms 1 and 2. A note at the top of this log indicated, "(Must be between 105 degrees and 110 degrees - *If out of range, you must make a note on the maintenance log)." There was no direction included to "report to the QAC." The facility failed to ensure Client A was free from harm including neglect when he was scalded during a shower and sustained second degree burns to his left foot while temperature of the water in the shower reached 120 degrees F. Client A required hospitalization (2/1/15 - 2/4/15) and treatment of the burns to his left foot which included debridement and pain management. The above violation had a direct or immediate relationship to the client's health, safety, or security, and therefore constitutes a Class 'B' Citation. |
| 040000584 |
Loyd's Liberty Homes, Inc. - San Jose Street |
040012132 |
B |
24-Mar-16 |
I0HM11 |
3673 |
Class B Citation - Patient Rights Title 17 50510 (a)(8)50510 Each person with a developmental disability, as defined by this subchapter, is entitled to the same rights, protections, and responsibilities as all other persons under the laws and Constitution of the State of California, and under the laws and the Constitution of the United States. Unless otherwise restricted by law, these rights may be exercised at will by any person with a developmental disability. These rights include, but are not limited to the following: a) Access Rights(8) A right to be free from harm, including unnecessary physical restraint, or isolation excessive medication, abuse or neglect. Medication shall not be used as punishment, for convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program. "Neglect" means failure to provide goods or services necessary to avoid physical or psychological harm. The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident: CA470728. On 1/11/16 at 7:00 a.m., an unannounced visit was made to the facility to investigate an entity reported incident which involved Client 1, who was left in urine soaked clothing and bedding throughout the night by a Direct Support Professional (DSP). The facility failed to ensure Client 1 was free from harm when: The Direct Support Professional (DSP) 1 failed to provide basic personal care to Client 1 for more than eight hours when she failed to remove or change his urine saturated clothing (adult briefs, pajamas) and bedding during her shift (night shift).Client 1 was a 55 year old, admitted to the facility in 10/06, with diagnoses that included seizure disorder (convulsions), hypoglycemia (low blood sugar), and dysphasia (inability to speak). Client 1 followed simple commands, was non-verbal, unable to recognize or report illness, was dependent on staff for activities of daily living, including all personal care (health, grooming, hygiene, and bowel and bladder needs), and was non-ambulatory (unable to walk). On 1/11/16 at 9:30 a.m., during an interview, the Qualified Intellectual Disabilities Professional (QIDP) stated she received a telephone call on 12/28/15 at approximately 6:35 a.m. The QIDP stated DSP 6 reported she arrived at work to find Client 1 lying in urine soaked clothing (adult briefs and pajamas) and bedding. The QIDP stated she was able to substantiate the report of Client 1 being left in urine soaked clothing and bedding for up to eight hours when DSP 1 admitted during an interview she did not provide incontinent care (brief changes) to Client 1 during her shift on 12/28/15. The QIDP reported that during her investigation, DSP 2 reported that DSP 1 commented in passing during a.m. rounds she was busy all night with Client 1. The QIDP stated the night shift documentation for 12/27/15-12/28/15 did not reflect DSP 1 had patient care concerns throughout her shift; and DSP 1 did not call to request assistance during her shift.Multiple attempts were made to contact DSP 1 and 2 for interviews without success.The facility failed to ensure Client 1 was free from neglect when DSP 1 failed to meet the basic personal care needs when Client 1's clothing and bedding was left saturated in urine for an extended length of time, placing him at risk for pressure sores and skin breakdown. This failure resulted in Client 1 not having his basic toileting needs met and being treated in an undignified manner.The above violation had direct or immediate relationship to the clients' health, safety, welfare, and therefore constitutes a Class 'B' Citation. |
| 040000584 |
Loyd's Liberty Homes, Inc. - San Jose Street |
040012134 |
B |
24-Mar-16 |
I0HM11 |
3848 |
Class B Citation - Patient Rights Title 17 50510 (a)(8)50510 Each person with a developmental disability, as defined by this subchapter, is entitled to the same rights, protections, and responsibilities as all other persons under the laws and Constitution of the State of California, and under the laws and the Constitution of the United States. Unless otherwise restricted by law, these rights may be exercised at will by any person with a developmental disability. These rights include, but are not limited to the following: a) Access Rights(8) A right to be free from harm, including unnecessary physical restraint, or isolation excessive medication, abuse or neglect. Medication shall not be used as punishment, for convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program. "Neglect" means failure to provide goods or services necessary to avoid physical or psychological harm. The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident: CA470728. On 1/11/16 at 7:00 a.m., an unannounced visit was made to the facility to investigate an entity reported incident which involved Client 2, who was left in urine soaked clothing and bedding throughout the night by a Direct Support Professional (DSP). The facility failed to ensure Client 2 was free from harm when: The Direct Support Professional (DSP) 1 failed to provide basic personal care to Client 2 for more than eight hours when she failed to remove or change his urine saturated clothing (adult briefs, pajamas) and bedding during her shift (night shift).Client 2 was an 80 year old, admitted to the facility in 10/06, with diagnoses that included legally blind (loss of eye sight), diabetes II (abnormal blood sugars), renal disease (loss of normal kidney function), osteoarthritis (inflammation of joints), Seizure disorder, anemia (decrease of red blood cells), angina (chest pain), hypothyroidism (decrease thyroid hormone level, edema (swelling), and renal failure (loss of kidney function). Client 2 followed simple commands, communicated verbally, required verbal and physical prompting for activities of daily living, including toileting needs, and was ambulatory (able to walk). On 1/11/16 at 9:30 a.m., during an interview, the Qualified Intellectual Disabilities Professional (QIDP) stated she received a telephone call on 12/28/15 at approximately 6:35 a.m. The QIDP stated DSP 6 reported she arrived at work to find Client 2 lying in urine soaked clothing (adult briefs and pajamas) and bedding. The QIDP stated she was able to substantiate the report of Client 2 being left in urine soaked clothing and bedding for up to eight hours when DSP 1 admitted during an interview she did not provide incontinent care (brief changes) to Client 2 during her shift on 12/28/15. The QIDP reported that during her investigation, DSP 2 reported that DSP 1 commented in passing during a.m. rounds she was busy all night with another client. The QIDP stated the night shift documentation for 12/27/15-12/28/15 did not reflect DSP 1 had patient care concerns throughout her shift; and DSP 1 did not call to request assistance during her shift.Multiple attempts were made to contact DSP 1 and 2 for interviews without success.The facility failed to ensure Client 2 was free from neglect when DSP 1 failed to meet the basic personal care needs when Client 1's clothing and bedding was left saturated in urine for an extended length of time, placing him at risk for pressure sores and skin breakdown. This failure resulted in Client 2 not having his basic toileting needs met and being treated in an undignified manner.The above violation had direct or immediate relationship to the clients' health, safety, welfare, and therefore constitutes a Class 'B' Citation. |
| 040000584 |
Loyd's Liberty Homes, Inc. - San Jose Street |
040012135 |
B |
24-Mar-16 |
I0HM11 |
3778 |
Class B Citation - Patient Rights Title 17 50510 (a)(8)50510 Each person with a developmental disability, as defined by this subchapter, is entitled to the same rights, protections, and responsibilities as all other persons under the laws and Constitution of the State of California, and under the laws and the Constitution of the United States. Unless otherwise restricted by law, these rights may be exercised at will by any person with a developmental disability. These rights include, but are not limited to the following: a) Access Rights(8) A right to be free from harm, including unnecessary physical restraint, or isolation excessive medication, abuse or neglect. Medication shall not be used as punishment, for convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program. "Neglect" means failure to provide goods or services necessary to avoid physical or psychological harm. The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident: CA470728. On 1/11/16 at 7:00 a.m., an unannounced visit was made to the facility to investigate an entity reported incident which involved Client 3, who was left in urine soaked clothing and bedding throughout the night by a Direct Support Professional (DSP). The facility failed to ensure Client 3 was free from harm when: The Direct Support Professional (DSP) 1 failed to provide basic personal care to Client 3 for more than eight hours when she failed to remove or change his urine saturated clothing (adult briefs, pajamas) and bedding during her shift (night shift).Client 3 was a 55 year old, admitted to the facility in 10/06, with diagnoses that included cerebral palsy (impaired muscle coordination), seizure disorder, impaired vision (vision loss), bowel and bladder incontinence (loss of bowel and bladder control), hypertension (high blood pressure), and history of pressure ulcers (sores from excess pressure) etc. Client 3 followed simple commands, communicated verbally; required verbal and physical prompting/assisting for activities of daily living, dependent on staff for all toileting needs, and was non-ambulatory.On 1/11/16 at 9:30 a.m., during an interview, the Qualified Intellectual Disabilities Professional (QIDP) stated she received a telephone call on 12/28/15 at approximately 6:35 a.m. The QIDP stated DSP 6 reported she arrived at work to find Client 3 lying in urine soaked clothing (adult briefs and pajamas) and bedding. The QIDP stated she was able to substantiate the report of Client 3 being left in urine soaked clothing and bedding for up to eight hours when DSP 1 admitted during an interview she did not provide incontinent care (brief changes) to Client 3 during her shift on 12/28/15. The QIDP reported that during her investigation, DSP 2 reported that DSP 1 commented in passing during a.m. rounds she was busy all night with another client. The QIDP stated the night shift documentation for 12/27/15-12/28/15 did not reflect DSP 1 had patient care concerns throughout her shift; and DSP 1 did not call to request assistance during her shift.Multiple attempts were made to contact DSP 1 and 2 for interviews without success.The facility failed to ensure Client 3 was free from neglect when DSP 1 failed to meet the basic personal care needs when Client 3's clothing and bedding was left saturated in urine for an extended length of time, placing him at risk for pressure sores and skin breakdown. This failure resulted in Client 3 not having his basic toileting needs met and being treated in an undignified manner.The above violation had direct or immediate relationship to the clients' health, safety, welfare, and therefore constitutes a Class 'B' Citation. |
| 040000584 |
Loyd's Liberty Homes, Inc. - San Jose Street |
040012136 |
B |
24-Mar-16 |
I0HM11 |
3603 |
Class B Citation - Patient Rights Title 17 50510 (a)(8)50510 Each person with a developmental disability, as defined by this subchapter, is entitled to the same rights, protections, and responsibilities as all other persons under the laws and Constitution of the State of California, and under the laws and the Constitution of the United States. Unless otherwise restricted by law, these rights may be exercised at will by any person with a developmental disability. These rights include, but are not limited to the following: a) Access Rights(8) A right to be free from harm, including unnecessary physical restraint, or isolation excessive medication, abuse or neglect. Medication shall not be used as punishment, for convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program. "Neglect" means failure to provide goods or services necessary to avoid physical or psychological harm. The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident: CA470728. On 1/11/16 at 7:00 a.m., an unannounced visit was made to the facility to investigate an entity reported incident which involved Client 4, who was left in urine soaked clothing and bedding throughout the night by a Direct Support Professional (DSP). The facility failed to ensure Client 4 was free from harm when: The Direct Support Professional (DSP) 1 failed to provide basic personal care to Client 4 for more than eight hours when she failed to remove or change his urine saturated clothing (adult briefs, pajamas) and bedding during her shift (night shift). Client 4 was a 43 year old, admitted to the facility in 10/07, with diagnoses that included cerebral palsy, blind, congenital scoliosis (abnormal curvature of the spine), micro cephalic (small head, caused by incomplete brain development), and incontinent of bowel and bladder. Client 4 was dependent of staff toileting needs and activities of daily living. Client 4 was non-ambulatory. On 1/11/16 at 9:30 a.m., during an interview, the Qualified Intellectual Disabilities Professional (QIDP) stated she received a telephone call on 12/28/15 at approximately 6:35 a.m. The QIDP stated DSP 6 reported she arrived at work to find Client 4 lying in urine soaked clothing (adult briefs and pajamas) and bedding. The QIDP stated she was able to substantiate the report of Client 4 being left in urine soaked clothing and bedding for up to eight hours when DSP 1 admitted during an interview she did not provide incontinent care (brief changes) to Client 4 during her shift on 12/28/15. The QIDP reported that during her investigation, DSP 2 reported that DSP 1 commented in passing during a.m. rounds she was busy all night with another client. The QIDP stated the night shift documentation for 12/27/15-12/28/15 did not reflect DSP 1 had patient care concerns throughout her shift; and DSP 1 did not call to request assistance during her shift.Multiple attempts were made to contact DSP 1 and 2 for interviews without success.The facility failed to ensure Client 4 was free from neglect when DSP 1 failed to meet the basic personal care needs when Client 4's clothing and bedding was left saturated in urine for an extended length of time, placing him at risk for pressure sores and skin breakdown. This failure resulted in Client 4 not having his basic toileting needs met and being treated in an undignified manner.The above violation had direct or immediate relationship to the clients' health, safety, welfare, and therefore constitutes a Class 'B' Citation. |
| 040000584 |
Loyd's Liberty Homes, Inc. - San Jose Street |
040012137 |
B |
24-Mar-16 |
I0HM11 |
3562 |
Class B Citation - Patient Rights Title 17 50510 (a)(8)50510 Each person with a developmental disability, as defined by this subchapter, is entitled to the same rights, protections, and responsibilities as all other persons under the laws and Constitution of the State of California, and under the laws and the Constitution of the United States. Unless otherwise restricted by law, these rights may be exercised at will by any person with a developmental disability. These rights include, but are not limited to the following:a) Access Rights (8) A right to be free from harm, including unnecessary physical restraint, or isolation excessive medication, abuse or neglect. Medication shall not be used as punishment, for convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program. "Neglect" means failure to provide goods or services necessary to avoid physical or psychological harm. The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident: CA470728. On 1/11/16 at 7:00 a.m., an unannounced visit was made to the facility to investigate an entity reported incident which involved Client 5, who was left in urine soaked clothing and bedding throughout the night by a Direct Support Professional (DSP). The facility failed to ensure Client 5 was free from harm when: The Direct Support Professional (DSP) 1 failed to provide basic personal care to Client 5 for more than eight hours when she failed to remove or change his urine saturated clothing (adult briefs, pajamas) and bedding during her shift (night shift).Client 5 was a 47 year old, admitted to the facility in 10/06, with diagnoses that included cerebral palsy, seizures, visual impairment, anemia, seizures, and hypertension. Client 5 followed simple commands, communicated with gestures, was dependent on staff for activities of daily living, including all toileting needs, and was non-ambulatory. On 1/11/16 at 9:30 a.m., during an interview, the Qualified Intellectual Disabilities Professional (QIDP) stated she received a telephone call on 12/28/15 at approximately 6:35 a.m. The QIDP stated DSP 6 reported she arrived at work to find Client 5 lying in urine soaked clothing (adult briefs and pajamas) and bedding. The QIDP stated she was able to substantiate the report of Client 5 being left in urine soaked clothing and bedding for up to eight hours when DSP 1 admitted during an interview she did not provide incontinent care (brief changes) to Client 5 during her shift on 12/28/15. The QIDP reported that during her investigation, DSP 2 reported that DSP 1 commented in passing during a.m. rounds she was busy all night with another client. The QIDP stated the night shift documentation for 12/27/15-12/28/15 did not reflect DSP 1 had patient care concerns throughout her shift; and DSP 1 did not call to request assistance during her shift. Multiple attempts were made to contact DSP 1 and 2 for interviews without success.The facility failed to ensure Client 5 was free from neglect when DSP 1 failed to meet the basic personal care needs when Client 5's clothing and bedding was left saturated in urine for an extended length of time, placing him at risk for pressure sores and skin breakdown. This failure resulted in Client 5 not having his basic toileting needs met and being treated in an undignified manner.The above violation had direct or immediate relationship to the clients' health, safety, welfare, and therefore constitutes a Class 'B' Citation. |
| 040000605 |
Loyd's Liberty Homes, Inc. - Augusta |
040012696 |
B |
28-Oct-16 |
IMZJ11 |
6738 |
Class 'B' Citation - Client Protections 483.420(a) (5) Ensures that clients are not subjected to physical, verbal, sexual or psychological abuse or punishment. The facility failed to ensure clients were not subjected to physical abuse when Direct Staff Professional (DSP) 1 and 3 were not able to effectively control and redirect the aggressive and self-injurious behavior (SIB) of Client A. Client A was observed to suffer actual physical injury such as biting himself, hitting his head on the floor and wall without the benefit of DSP effectively intervening to prevent injury. The Qualified Intellectual Disabilities Professional (QIDP) 1, who is in-charge of ensuring client safety in the home, did not provide an effective safety plan or training to DSPs to keep Client A from injuring himself. Client A's Face Sheet dated 8/2/16 indicated he is a 39 years old male admitted on XXXXXXX with multiple diagnoses including severe mental disabilities, Optic nerve Hypoplasia (underdevelopment or incomplete development of a the optic nerve), Blindness, Psychosis (mental disorder characterized by a disconnection from reality), Cerebral Palsy (congenital disorder of movement, muscle tone, or posture). Client A's "Nursing Progress Notes" dated 7/30/16 at 2:00 a.m., "...Significant scarring & scabs to the backs of his hands from SIB which he displayed when prompted to use toilet after soiling himself. When staff attempted to guide (Client A) through touch or verbal guidance he repeatedly dropped to the ground, clawed staff (sic) hands and hit head against floor & (and) walls. Area of scarring & scabs on forehead at start of hairline began bleeding but stopped (without) Tx (treatment)... Cl (Client A) guided to bedroom where he refused to sit on bed to dress/ (change). Instead Cl sat on floor and urinated... repeatedly attempted to hit head on hard surfaces. When pillow was used to cushion, he reached back + (and) threw it, then attempted to hit head again..." On 9/1/16 at 11:30 a.m., during an interview, DSP 1 stated, on 7/31/16 during the p.m.(evening) shift she was preparing to change Client A's brief. DSP 1 stated Client A began to reach out to scratch DSP 1. She stated things got worse; Client A began to hit his head on the floor making a loud, "thump" sound. DSP 1 stated she placed her hands a few inches away from Client A's forehead trying to make sure he did not hit his head on the floor. She stated Client A disrobed, pulled his brief off and began defecating and smearing the feces on the floor with his bottom. She stated, "(Client A) began walking around the house pooping where he stood." DSP 1 stated when the staff tried to put a brief on Client A would attempt to cause the DSPs to fall back by leaning back onto them. DSP 1 stated, "This went on for hours, we would get him (Client A) showered and cleaned up, he would disrobe, poop and pee on the floor, and scratch staff." DSP 1 stated it all started around 9 p.m. and lasted until 12 a.m. DSP 1 stated Registered Nurse (RN) 1 decided to call 911." When asked if DSP 1 was trained how to manage Client A's behaviors, DSP 1 stated, "we don't know much about him (Client A)... I'm afraid sometimes... I'm afraid that he might hurt himself really bad and I don't know how to take care of him if he does..." On 9/1/16 at 12:33 p.m., during an interview, Qualified Intellectual Disabilities Professional (QIDP) 1 stated Client A's aggressive and uncontrolled behaviors had worsened. QIDP 1 stated she called the Case Manager (CM - the assigned counselor for Client A from the Regional Center) on 8/26/16 for an "emergency meeting" to discuss the Client A's uncontrollable and aggressive behaviors. QIDP 1 stated she wanted to discuss an overall plan for Client A with the CM. QIDP 1 stated, "I felt the staff were being attacked" and "for the clients' safety..." When asked if the staff were afraid to work with Client A, QIDP 1 stated, "Yes, they are afraid that he might hurt himself (and) them too." On 9/1/16 at 8:20 p.m., when asked if QIDP 1 was afraid to work with Client A, QIDP 1 stated, "Yes, I'm afraid of him hurting himself, hurting another client or scratching me." When asked if QIDP 1 had safety plan to protect all of clients, QIDP 1 stated if Client A had behaviors and staff were scratched by Client A, staff were to contact her. No other components of a safety plan were provided by QIDP 1. On 9/1/16 at 2:14 p.m., during an interview when asked if there was any training how to manage Client A's behaviors, DSP 3 stated, "No, we were told he had slight behaviors..., very easy care." DSP 3 stated on 8/25/16 "He (Client A) was throwing himself on the floor, pooping everywhere, biting himself, hitting himself on the head, banging his head on the wall (and) floor, his hands were bleeding from biting himself." DSP 3 stated, "This night his (Client A's) behaviors escalated, it was really intense that night." DSP 3 stated, "When EMS (Emergency Medical Service) came out he (Client A) had blood from his hands (and) poop all over him from being on the floor (and) vomit from making himself throw up by sticking his hand down his throat (and) bowel movement (BM) all over his hands from sliding in the poop." DSP 3 stated, "...I felt really sad (and) exhausted because we could not help him." She stated "... we are not trained on how to manage his behaviors. Three other staff have quit because of having to work with him... When the Program Director (PD) asked her (DSP 3) to be Client A's 1:1 (staff directly assigned to a specific client for close monitoring), "I told her, 'No' because I'm afraid to work with him." A review of the facility's policy titled, "PREVENTION OF ABUSE, NEGLECT and MISTREATMENT" last reviewed 8/2012 indicated, the policy was "...intended to prevent and ensure prompt detection of abuse, neglect or mistreatment, provide direction for appropriate and thorough investigation, provide resolution for any occurrence of abuse, neglect or mistreatment..." The facility failed to ensure Client A was not subjected to physical abuse when they failed to prevent Client A's self-injurious behavior (self-abuse), which allowed the client to exhibit uncontrolled and aggressive behaviors: (head banging on hard objects, biting self which caused injuries, throwing self to the floor, fecal smearing, scratching self [and/or staff] with fecal contaminated hands, and urinating on floor). Within one month (8/1/16 - 9/1/16), Client A exhibited multiple incidents of self-injurious behaviors which, at times lasted several hours, and caused injuries to himself. The above violation had a direct or immediate relationship to the client's health, safety, or security, and therefore constitutes a Class 'B' Citation. |
| 050001416 |
LOMPOC SKILLED NURSING & REHABILITATION CENTER |
050005373 |
A |
25-Jul-12 |
4F8G11 |
8900 |
Title 22. 72315(f)(7) (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 facility did not comply with the above regulation when it failed to ensure Patient A's physician received notification when treatment for a decubitus ulcer was not effective. On 7/29/08, Patient A developed an unstageable decubitus ulcer on his coccyx. The physician was notified, examined the patient on 7/31/08, and on 8/1/08, orders for treatment of the decubitus ulcer were received. A weekly assessment of the decubitus ulcer performed on 8/5/08, demonstrated that the wound had progressed in size and developed drainage and an odor. Despite an increase in size and signs of a possible infection, indicating the treatment ordered was not effective, the physician was not notified. A nurse evaluated the decubitus ulcer again on 8/7/08, and a fax was sent to the physician notifying the physician of the assessment results and requesting direction. However, there was no response from the physician, no follow up by nursing, and no change in orders for treatment of the decubitus ulcer as of 8/11/08, when the patient was transferred and admitted to another skilled nursing facility.Patient A was an 80 year old male who was admitted to the facility on 7/21/08 with diagnoses including dementia with agitation and benign neoplasm of the prostate. The comprehensive admission assessment completed 8/3/08, indicated that Patient A's memory and his ability to make decisions were severely impaired, he had difficulty understanding others and communicating his needs, and was resistive to care. The assessment noted that Patient A was incontinent, did not ambulate, and required extensive assistance with daily living activities including personal hygiene, eating, getting dressed, changing positions in bed and transfers. A nutritional assessment completed by the dietician on 7/23/08, also noted that Patient A was below his ideal body weight, his serum albumin (indicator of protein adequacy and nutritional status) was below normal range, and he was at risk for unintended weight loss. Patient A was at high risk for developing pressure ulcers due to immobility, incontinence, compromised nutritional status and decreased functional ability, and a plan of care was developed upon admission to prevent skin breakdown. Care plan interventions included turning and repositioning the patient every 2 hours and as needed, providing pressure relieving devices, keeping the patient clean and dry, encouraging adequate nutrition and hydration, evaluating the patient's skin on a daily basis, reducing excessive moisture, and positioning the resident with pressure off of bony areas.On the morning of 7/29/08, however, nursing noted that Patient A had developed a 2.5 cm by 5 cm unstageable decubitus ulcer on his coccyx. Nursing documentation described the wound as necrotic looking, without drainage or an odor, and indicated that the skin surrounding the wound was red and hard, but still blanchable. The nurse documented that the wound was cleansed with normal saline, a foam dressing was applied, the patient was positioned on his side, and a fax was sent to notify the physician Patient A had developed a pressure sore and to request orders for treatment. A subsequent entry on 7/30/08, indicated the physician would be in to evaluate the patient on 7/31/08, and instructions to cleanse the pressure ulcer with normal saline daily, cover with a foam dressing, and position the patient on his sides while in bed, pending evaluation by the physician.On 7/31/08, Patient A's physician came to the facility, evaluated the patient and noted a stage II (superficial) sacral or gluteal 3 cm by 5 cm decubitus and a right heel bulla (fluid filled blister). The physician's plan was noted as turn off back, wound consult, and podiatry consult. Physician's orders written on 7/31/08 included an order for a Posey boot for the right foot and a nutritional supplement three times daily between meals, but no orders for a wound consult or treatment of the sacral decubitus.On 8/1/08 at 11:35 am, a physician's order for treatment of the coccyx ulcer was faxed to the facility. The order instructed nursing to cleanse the ulcer with normal saline, pat dry, fill the wound base with hydrogel, and cover with a foam dressing then with an abdominal pad. The treatment was to be completed every other day and as needed for 7 days, then nursing was to re-evaluate. In an interview on 9/3/08, RN 1stated that she completes an evaluation of all pressure sores in the facility that are Stage 2 and above each week on Tuesday, and documents the evaluation in the decubitus record. RN1 indicated that on 8/5/08, she evaluated the pressure ulcer on Patient A's coccyx and completed the treatment as ordered.The evaluation documented in Patient A's decubitus record on 8/5/08, noted that the pressure ulcer was unstageable, was 9 cm by 3.5 cm in size, was necrotic and red in color, and had drainage and an odor. Despite a progression in the size of the wound and the development of drainage and an odor, signs indicating a possible infection, there was no evidence the physician was notified regarding the status of the wound, and that treatment was not effective. RN 2 completed a treatment and an evaluation of the decubitus ulcer again on 8/7/08, and described the wound as a Stage 3 pressure ulcer (full thickness tissue loss with no bone, tendon or muscle exposed), 9 cm by 4 cm in size, black, brown and red in color, with an odor and a moderate amount of brown yellow drainage. A nursing progress entry at 8 am on 8/7/08, noted that a treatment was done, the wound was re-evaluated and the physician was notified via fax. A review of physicians' orders, nurses' notes, and treatment records, however, revealed no further orders for treatment of the decubitus ulcer were received.On 8/7/08, a nurse visited the facility at the family's request to assess Patient A for admission to another skilled nursing facility. The nurse noted that the patient was wearing a foam boot on his right foot and his right heel had a white mushy cap. She indicated that Patient A had a dressing on his coccyx and she could not assess his coccyx with the dressing in place. She also noted a strong odor, and that Patient A's family said he had a sore on his bottom. Following the visit, the patient's physician was called and arrangements were made for Patient A to be admitted to the new facility on 8/11/08. On 8/8/08, the physician was at the facility and saw the patient. There was no information, however, to indicate that nursing followed up with the physician to ensure he received the fax sent to his office on 8/7/08, was aware Patient A's pressure sore had progressed, and that he was consulted regarding treatment. Nursing notes on 8/8/08 at 11:22 am noted that the physician was in and wrote a new order for administration of a narcotic pain medication for treatment of leg pain, but no information regarding the pressure ulcer. The physician's progress documentation noted the patient's weight and blood pressure, that Patient A had pain with movement, and a plan to increase the patient's analgesic medication. There was no information, however, regarding the pressure ulcer on Patient A's coccyx.Patient A was discharged from the facility and admitted to the new skilled nursing facility under the care of the same attending physician on 8/11/08. A nursing assessment conducted upon admission to the facility noted that Patient A had a 15 cm by 7 cm full thickness pressure ulcer on his coccyx, that the wound bed was covered with thick black necrotic tissue, and that the areas around the pressure ulcer were red and irritated.The physician's admission history and physical examination on 8/11/08, noted that Patient A had developed a sacral decubitus prior to admission, and that nursing reported what sounded like progression of the wound. The physician indicated that Patient A had a large decubitus ulcer over the sacrum with a central ulceration, surrounding eschar and a foul odor. The noted he thought the wound was infected, and plans to start treatment with oral antibiotics and obtain a surgical consult for debridement of the wound.The facility violated the above regulation by failing to ensure Patient A's physician was notified when treatment for a decubitus ulcer on the patient's coccyx was not effective.The violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 050000054 |
LOMPOC VALLEY MEDICAL CENTER COMPREHENSIVE CARE CENTER D/P SNF |
050009766 |
B |
21-Nov-13 |
QHGB11 |
3396 |
483.25(m)(2)The Facility must ensure that Residents are free of any significant medication errors.The Department determined the facility failed to follow the manufacturer recommendations and adequately monitor medication administration when administering durgesic patches (Fentanyl-a highly concentrated narcotic used to control moderate to severe chronic pain through topical administration) to Resident A, which resulted in excessive dose administration for an excessive duration causing Resident A to become unresponsive and requiring acute hospital admission.Resident A was 62 years old admitted to the facility with diagnoses including left sided paralysis, difficulty swallowing, gastroparesis (delayed stomach emptying resulting in food remaining in stomach for a longer time than normal), and diabetes.Review of the facility Fentanyl Dosing Guidelines titled "Transdermal Fentanyl Order" form revealed "...Nursing Measures...Remove old patch prior to placing new patch..." Review of the manufacturer's recommendation regarding "Duragesic (Fentanyl Transdermal System) prescribing information indicated...Dosage and Administration...each transdermal system is intended to be worn for 72 hours...Warnings and Precautions...Fatal respiratory depression can occur with Duragesic...; ...each Duragesic patch may be worn continuously for 72 hours. The next patch is applied to a different skin site after removal of the previous transdermal system..."A physician ordered fentanyl 75 micrograms (mcg) patches, which carries a "Black Box Warning" (most serious labeling indicating significant risk of serious or life threatening adverse effects) indicating that each patch may be worn continuously for 72 hours. The next patch should be applied to a different skin site after removal of the previous patch.On 1/4/13 Resident A became unresponsive after being transferred to the hospital for tests. Resident A was found to have three Fentanyl patches affixed to various areas on his body and Narcan (a potent medication for reversal of side effects suspected with narcotic overdose) 0.4 milligram intravenous was administered to reverse Resident A's unresponsive state. After administration of Narcan, Resident A became more alert.During an interview on 1/11/13 at 10:45 a.m., the hospital Quality Improvement Nurse confirmed three fentanyl patches were found on Resident A located on the right anterior chest near the collarbone, on the right shoulder blade, and a third just below the right shoulder blade.During an interview on 1/11/13 at 3:45 p.m., a licensed nurse (LN 10) stated on 12/24/12 she administered a Duragesic Fentanyl patch on Resident A's upper left chest. LN 10 confirmed not having inspected Resident A's body for additional Duragesic patches to be removed. During an interview on 2/20/13 at 9:15 a.m. an emergency room (ED) physician confirmed Resident A suffered from Fentanyl overdose when the facility failed to remove prior patches before administering a new one, and stated "the three patches contributed to the resident's condition." The facility's failure to administer and monitor the duragesic patches according to the manufacturer's recommendations and facility guidelines resulted in Resident A becoming unresponsive and requiring acute care hospitalization. The violation of this regulation had a direct relationship to the health, safety or security of residents. |
| 050000054 |
LOMPOC VALLEY MEDICAL CENTER COMPREHENSIVE CARE CENTER D/P SNF |
050011804 |
B |
07-Apr-16 |
D68Y11 |
2194 |
CLASS B VIOLATION-HSC 1418.91 (a)(b)(a) A long-term care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class "B" violation.During an abbreviated survey, the Department determined the facility was in violation of the above statute by its failure to report an incident of alleged staff to resident abuse to the Department immediately or within 24 hours.Resident A was admitted to the facility with diagnoses including insomnia, high blood pressure, and depression. Resident A was alert and oriented, had the ability to express himself, and to understand others.The facility's nurses' notes indicated Resident A was heard yelling, "Abuse! She punched me! Help me! Help me!"Resident A said the nurse hit him hard on the arm and made anti-Semitic statements. The social service notes indicated Resident A was interviewed on 10/6/15 regarding his allegation of abuse as reported by the administrator. According to a Licensed Nurse (LN 1), Resident A became upset when he was told his physician had discontinued a sleeping medication the resident had taken for many years. The resident stated: "I've been taking my sleeping pill for 30 years. Why would he take it away from me without seeing me?" LN 1 stated the resident began to throw his trash, his trash can, and his urinal. LN 1 stated Resident A hit her (LN 1) right arm, right flank, and called her names. Resident A's treatment notes indicated on 10/5/15, thirty minutes after the alleged abuse, multiple new bruises were noted on the right forearm which were described as "red, purple, no sign of yellow, brown, or green discoloration to any of the areas at this time." The allegation of abuse was reported to the ombudsman on 10/6/15, however, was not reported to the Department.The facility was in violation of the above statute by its failure to report an incident of alleged staff to resident abuse to the Department immediately or within 24 hours. The violation of this regulation had a direct relationship to the health, safety, or security of the resident. |
| 050001416 |
LOMPOC SKILLED NURSING & REHABILITATION CENTER |
050011959 |
A |
01-Mar-16 |
IJOX11 |
2728 |
CFR 483.25 (h) ACCIDENTS- The facility must ensure that- (2) Each resident receives adequate supervision and assistance devices to prevent accidents.The Department determined the facility failed to ensure Resident A, who was identified by the facility as requiring two-person physical assistance with ambulation and transfer, received two - person assistance with ambulation. As a result of this failure, Resident A fell while being assisted with ambulation by one person, and sustained fractures of proximal tibia and fibula (just below the knee).Resident A was admitted to the facility with diagnoses including rheumatoid arthritis (erosion of bones and joints), Chronic Obstructive Pulmonary Disease (COPD- inflammation of the airway passage occluding air passage), and hypertension.The facility's comprehensive assessment, dated 8/28/15 indicated Resident A had impaired memory and required extensive assistance with two-person for transfers, ambulation and toileting.Resident A was assessed by the facility as a high risk for falls due to confusion, history of falls, ambulatory/incontinent status, and gait problems. These placed the resident at a higher risk for fall.The plan of care addressing Resident A's risk for falls and the need for help with activities of daily living (ADL) indicated the resident required two-person extensive assistance with transfer, walking, and toilet use. On 10/26/15 at 9:15 a.m., while coming back from a bathroom, Resident A lostbalance and fell to the floor while being assisted by one person. Resident A verbalized pain and swelling of the right leg.Upon evaluation at the hospital, Resident A was diagnosed with fractures of the proximal tibia and fibula head.During an interview on 11/10/15 at 12:30 p.m., CNA 1 indicated she was assisting the resident back to bed from the bathroom by herself with a front wheeled walker when the resident's knees gave in (buckled). She (CNA) was not able to stop the fall because the resident was too heavy for her to handle. The CNA indicated usually it took two persons to transfers and walk Resident A. During another interview on 11/10/15 at 12:45 p.m., a Licensed Nurse, (LN 1) stated "The resident was assisted back to bed from the toilet by only one person instead of two as assessed." The facility identified Resident A as requiring two persons physical assistance with ambulation and transfer. However, the facility utilized one person to assist the resident in ambulation. As a result of this failure, Resident A fell and sustained fractures of proximal tibia and fibula.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. |
| 060002181 |
LONIKA'S HOME |
060009504 |
B |
19-Sep-12 |
HCUC11 |
11541 |
W&I 4502(d)Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but no limited to, the following: (d) A right to prompt medical care and treatment.The above statute was NOT MET as evidenced by:The facility failed to ensure Client A received prompt medical treatment when he was found unresponsive during the night (NOC) shift. A possible delay in treatment may have impacted the outcome for Client A who was pronounced dead by paramedics at the scene at 0425 hours on 2/7/12. Findings: It was reported to the Department by the facility that on 2/7/12 at 0310 hours, Client A was checked and found not breathing and without a pulse. The report indicated that staff called 911, were instructed to begin CPR (cardiopulmonary resuscitation) and the paramedics arrived 7 to 10 minutes later.An unannounced visit was made to the facility on 2/17/12, to investigate the above incident.The LVN (Licensed Vocational Nurse) and RNC (Registered Nurse Consultant) were interviewed on 2/17/12 at 0900 hours. According to the facility LVN, he was called by DCS 1 (direct care staff) on 2/7/12 at 0425 hours, who requested he come to the facility as Client A had passed away. The LVN stated when he arrived at the facility at 0435 hours, he saw two sheriff deputies providing CPR to the client on the floor of the client's bedroom.The RNC stated according to her investigation, DCS 1 placed the call to 911 at approximately 0420 hours and was instructed by the 911 operator to begin CPR on the client.DCS 1 was interviewed by telephone on 3/12/12 at 1015 hours, as she no longer worked at the facility. DCS 1 stated she had been terminated. She stated although there was live in help at the facility, she worked by herself at night. Her routine was to check the clients every two hours. DCS 1 stated she found Client A unresponsive between 0300 and 0340 hours. She said she had changed the client's diaper at the start of her shift at 2300 hours and checked on him again at 0100 hours. She said she knew the client was alive at that time because she remembered him having movements. She recalled the next time she saw Client A was when she went to change his diaper at approximately 0300 hours. She said she changed the client in the room next to Client A first and then came into his room. She went on to say she was unable to wake up Client A and he did not move. She called 911 but DCS 1 said it took three attempts to get through to the 911 operator. After calling 911, DCS 1 called the LVN. DCS 1 also said after she called 911 she started chest compressions on Client A, and when the police arrived they moved the client from his bed onto the floor. She stated it was approximately seven minutes from the time she called 911 to the time the police arrived.DCS 1 further stated she woke up the live in help after the paramedics arrived.During the interview, DCS 1 was unable to give a clear explanation how she knew it was between 0300 to 0330 hours when she found Client A unresponsive or why there was more than 45 minutes gap from the time she stated she found the client to the time the paramedics were called.Review of the police report showed the following: - Two deputies were dispatched to the facility on 2/7/12 at approximately 0420 hours. - DCS 1 directed the officers to the client's room when they arrived at the facility. - Upon entering the client's bedroom the officers saw Client A was in bed, not breathing and without a pulse. - The officers moved the client from his bed to the floor to perform CPR. - When turning the client to move him, the officers noted the client had dependent lividity over the entire length of his back and back legs (Dependent lividity or livor mortis is one of the signs of death caused by settling of the blood in the lower (dependent) portion of the body, resulting in a purplish red discoloration of the skin. Livor mortis starts twenty minutes to three hours after death and is congealed in the capillaries in four to five hours. Maximum lividity occurs within 6-12 hours. The presence of livor mortis is an indication of when it would be futile to begin CPR or continue if it is in progress.) - The officer documented the client's body was still warm to the touch when he arrived on the scene. - The paramedics then arrived and pronounced the client dead on arrival at 0425 hours. - The reporting officer documented DCS 1 changed her story several times regarding what time she last saw the client alive. He documented the staff finally concluded she last saw the client alive at 0330 hours, when she went to check if he needed his diaper changed. According to the Orange County Fire Authority's paramedic report, the call to 911 was made at 0420 hours. The paramedics arrived to the facility at 0427 hours. The paramedics noted the client had dependent lividity at that time and the client was pronounced dead at the scene.A second visit was made to the facility on 3/16/12. The facility's assistant administrator and live in staff were interviewed.The assistant administrator stated the facility's expectation is that staff should know how to perform CPR and renew their training prior to their card expiration. She stated it is also the expectation of the facility that when a client is found unresponsive with no pulse or not breathing, the staff will call 911 and begin CPR immediately.According to the live in staff (DCS 2), DCS 1 knocked on her bedroom door at 0420 hours on 2/7/12 and told her "___(Client A's name) is gone." DCS 2 got up and went to Client A's room. She described the client as having a yellow color to his skin. She stated there were no other staff in the facility and no emergency personnel had arrived yet. DCS 2 further stated DCS 1 was on the phone talking with someone; however, she did not know to whom the DCS was speaking. DCS 2 went on to say when DCS 1 was finished on the phone she asked DCS 2 for help by getting another client (Client B) ready for a shower.DCS 2 further stated she went in the other client's bedroom and saw the shower chair had already been pushed up alongside the bed. DCS 1 came into the room, helped transfer Client B into the shower chair and then DCS 1 took Client B to the shower. DCS 2 saw two policemen go into Client A's bedroom and transfer him to the floor to begin CPR. DCS 2 then went to relieve DCS 1 from showering Client B so she could answer questions for the police. DCS 2 stated she did not see DCS 1 do CPR on the client. DCS 2 further stated she herself did not do CPR. When asked why, she answered because the client was already yellow in color.In a follow up interview with the RNC and the LVN on 3/16/12 at 1045 hours, the RNC stated DCS 1 first reported finding Client A unresponsive at 0330 hours and then changed the time to 0400 hours. The RNC was asked how DCS 1 knew what time it was. The RNC replied DCS 1 stated she always changed Client B before 0400 hours because he would always have a bowel movement around that time of the morning. According to the RNC, DCS 1 said she went into Client A's room, saw he had expired and while she was still with Client A, Client B started screaming. DCS 1 told her Client B's indicated he already had, or was going to have a bowel movement. DCS 1 told her she called 911 and then changed Client B and put him in the shower. DCS 1's employee file was reviewed on 3/16/12, and contained the following: - A formal counseling citing the employee had not renewed her CPR card or checked Client A's vital signs when she found him unresponsive. It was also documented DCS 1 failed to notify the facility LVN for more than one hour after the client's change in condition was first noted. In the "Incident/Accident Investigation Report," the RNC documented DCS 1 was giving showers to the other clients too early in the morning between 0400 and 0430 hours. The investigation findings included that Client B was being taken into the shower at 0430 hours, as Client C was getting out of the shower. The RNC documented DCS 1 summoned help from the live in staff because Client A had been unresponsive since 0330 hours.Review of Client A's clinical record showed documentation by the LVN dated 2/7/12, indicating he received a call from DCS 1 at 0425 hours, to report Client A was not breathing. The LVN documented he arrived at the facility at 0435 hours and informed the RNC by phone.When asked for records of in-service training provided to staff regarding medical emergencies, it was disclosed that all of the staff were given training on 2/7/12, on providing first aid, reporting significant changes in condition and NOC shift duties. Prior to that date, training was given on 11/4/11, covering first aid and SBAR (situation, background, assessment, and response) but DCS 1 was not in attendance. On 5/27/11, DCS 1 did attend training covering DCS responsibilities. The course outline showed the training included reporting a change in condition to the RNC and QMRP. There was no documented evidence to show DCS 1 had received training on responding to a medical emergency. A follow up telephone interview with DCS 1 was conducted on 3/26/12 at 1223 hours. She stated Client A was unresponsive when she found him. She reiterated this was between 0300 and 0340 hours. She went on to say she called 911 but it took her three attempts before her call went through. She stated when the paramedics and police arrived she went to help another client who was yelling. DCS 1 stated as soon as she found Client A she called 911. However, when asked again what time this happened, DCS 1 insisted it was between 0300 and 0340 hours. When it was pointed out to her again, that was 40 to 50 minutes before the call to 911 was made she replied she had to dial 911 three times and maybe it had taken that long for the call to go through or the 911 system was wrong and had reported the time incorrectly. DCS 1 stated she did not attempt CPR until instructed to do so by the 911 operator.During a follow up telephone interview with the RNC on 4/27/12, she stated she was notified on her cell phone by DCS 1 regarding Client A's death on 3/7/12 at 0435 hours.According to the facility's documentation and interviews with facility staff, there was a possible delay of as much as one hour in activating the emergency response system (calling 911). DCS 1 was insistent in her interviews that she found the client between 0300 and 0340 hours. According to facility documentation, DCS 1 was found to have delayed reporting a change in condition of the client for one hour. Per the paramedic's report, Client A had dependent lividity in his back and was determined an obvious death upon their arrival to the facility at 0427 hours. It is not known if Client A would have responded to resuscitation efforts between 0300 and 0340 hours, when DCS 1 stated she found him unresponsive. The failure of the facility to activate the emergency response system timely either jointly, separately, or in any combination had a direct or immediate relationship to patient health, safety, or security. |
| 630011296 |
LONIKA HOME MINOS |
060009829 |
B |
05-Apr-13 |
J28Z11 |
8846 |
W386 - The facility must, on a sample basis, periodically reconcile receipt and disposition of all controlled drugs in schedules II through IV (drugs subject to the Comprehensive Drug Abuse Prevention and Control Act of 1970, 21 U.S.C. 801 et seq., as implemented by 21 CFR Part 308).The facility must periodically reconcile receipt and disposition of all controlled drugs. The facility was entered on 2/13/13 for an unannounced recertification survey.Based on observation, staff interview and clinical record review, the facility failed to ensure periodic reconciliation, either weekly or monthly, of receipt and disposition of a Schedule III controlled medications prescribed for two of three sampled clients (Clients 3 and 4). According to the DEA's (Drug Enforcement Administration) Office of Diversion Control web site, Schedule III drugs have a potential for abuse and may lead to moderate or low physical dependence or high psychological dependence. Example of Schedule III narcotics includes combination products containing less than 15 mg of hydrocodone per dosage unit.1. Clinical record review for Client 3 was initiated on 2/14/13 at 0830 hours. The current physician's orders for February 2013 included an order for "Norco 5/325 (hydrocodone 5 and acetaminophen 325 mg) - Take 1 to 2 tablets by mouth every 6 hours as needed for pain." Norco contained hydrocodone and is determined to be a Schedule III controlled drug.Review of the LVN (licensed vocational nurse) notes dated 11/20/12 disclosed Client 3 came home from the day program with swelling on the left arm. The client was immediately taken to the hospital and had an x-ray taken. The x-ray results disclosed the client had comminuted distal fracture of the left wrist (the bone near the wrist is broken into more than two pieces). The client had a soft cast applied. The client was discharged from the hospital at 2100 hours with prescribed medications for pain as follows: "Norco 5/325 - one to two tablets as needed every 4 - 6 hours for moderate to severe pain and Ibuprofen 600 mg every 8 hours as needed for pain and to decrease inflammation."Review of the MAR (medication administration record) from 11/20/12 to 11/30/12 showed Client 3 received one dose (one tablet) of Norco on 11/22/12 at 2400 hours.Further review of the MAR showed from 12/1/12 to 12/31/12, Client 3 received one dose of Norco on 12/30/12 at 1000 hours. The client was assessed to have a pain level of 6, based on a pain scale of 1-10, 10 being the highest (severe pain). The MAR did not disclose if the client received one or two tablets of Norco; however, since the pain level of the client was assessed as 6, or moderate, the client was assumed to have been given one tablet of Norco only. It was further documented the client had decreased pain when reassessed at 1130 hours.Further review of the MARs from the period 11/20/12 to 1/12/13 showed Client 3 was medicated with Ibuprofen 600 mg twice a day when he complained of pain with effective results. Review of the MARs from the period 1/1 to 1/31/13 and from the period 2/1 to 2/13/13, showed no documentation the client received further doses of Norco since 12/30/12. Thus, the client received a total of two tablets of Norco from 11/22/12 to 2/14/13. On 2/14/13 at 0930 hours, review of the current physician's orders showed Client 3 continued to have an order for Norco for moderate to severe pain. The surveyor requested the LVN for the Norco bubble pack for Client 3. Observation of the bubble pack label showed a delivery date of 11/21/12 for 20 tablets of Norco. Further observation of the Norco bubble pack showed eleven (11) of the 20 doses had been removed from the bubble pack. Therefore, based on documented evidence of Norco administered to the client of two tablets and the amount left (nine tablets), there were nine tablets of Norco missing or unaccounted for.Due to the noted discrepancy, the surveyor requested for the facility's P&P (policy and procedure) on "Controlled Substance Storage." The RN/C (registered nurse/consultant) gave a copy of the facility's Pharmacy P&P which read in part: "A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV, and V medications (See Form 12: Individual Resident's Controlled Substance Record)... including those in the emergency supply." The P&P also included that at each shift change, or when keys [medication cart] are transferred, a physical inventory of all controlled substances including the emergency supply is conducted by two licensed nurses and is documented on a form-shift verification of controlled substances count.The same P&P also included that the consultant pharmacist or designee routinely monitors controlled substance storage, records (i.e., change of shift sheets, individual controlled substance accountability sheets, MARS, delivery confirmation sheets) and expiration dates during (monthly) medication storage inspection.The facility is a licensed health care facility for developmentally disabled clients with nursing and habilitation needs. The requirement for this type of facility is to have a pharmacy drug regimen review and monitoring on a quarterly basis. During the investigation, it was noted the facility did not have an individual controlled accountability sheet for the use of Norco for Client 3 as per their P&P. In addition, there was no documented evidence that the RN/C or the contracted pharmacist did a periodic monitoring, reconciliation and disposition of the Schedule III controlled substance (Norco) that was prescribed and was available for the client since 11/22/12. Furthermore, review of the Pharmacy records disclosed the pharmacist did the quarterly drug regimen review and inspection of drug storage areas on 1/4/13; however, there was no documentation that monitoring and reconciliation of the Norco tablets for Client 3 was conducted. 2. Clinical record review for Client 4 was initiated on 2/14/13 at 1020 hours. The current physician's orders for February 2013 included an order for hydrocodone/APAP (generic for Vicodin) 5/500 (5 mg hydrocodone and 500 mg acetaminophen), 1 tablet per GT (gastrostomy tube) every 6 hours for moderate to severe pain. Vicodin contained hydrocodone and is determined to be a Schedule III controlled drug.Review of Client 4's clinical record showed a diagnosis of an abscess to the right lower extremity and the physician ordered Vicodin as needed on 6/18/12.Review of the pharmacy packing list showed the facility signed for 60 tablets of Vicodin on 6/18/12 at 1525 hours.Review of the MARs showed the following: - The MAR from 6/1/12 to 6/30/12 showed Client 4 received one tablet of Vicodin on 27 occasions.- The MAR from 7/1/12 to 7/31/12 showed Client 4 received one tablet of Vicodin on 19 occasions.- The MAR from 8/1/12 to 8/31/12 showed Client 4 received one tablet of Vicodin once. The above documentation showed Client 4 received a total of 47 tablets of Vicodin; therefore, there should be 13 tablets remaining from the 60 tablets received by the facility on 6/18/12. On 2/14/13, review of the current physician's orders showed Client 4 continued to have an order for Vicodin for moderate to severe pain. When the surveyor requested to see the Vicodin bubble pack for Client 4, the LVN could not find the bubble pack. The RN/C stated no Vicodin had been delivered. The surveyor pointed out the MARs showed Client 4 received Vicodin 47 times. The RN/C could not account for the remaining 13 tablets. Due to the noted discrepancy, the surveyor requested for the facility's P&P on "Disposal of Medications and Medication-related supplies, IE1: Controlled Substance Disposal." The RN/C gave a copy of the facility's Pharmacy P&P which included the following: "Accountability records for controlled substances that are disposed of or destroyed are maintained with the unused supply until it is destroyed or disposed of and then stored for five years." During the investigation, it was noted the facility did not have an individual controlled accountability sheet for the use of Vicodin for Client 4. In addition, there was no documented evidence the RN/C or the contracted pharmacist did a periodic monitoring, reconciliation and disposition of the Schedule III controlled substance (Vicodin) that was prescribed and was available for the client since 6/18/12. Furthermore, review of the pharmacy records showed the pharmacist did the quarterly drug regimen review and inspection of drug storage areas on 1/4/13; however, there was no documentation to show monitoring and reconciliation of the Vicodin tablets for Client 4 was conducted. The facility's failure to ensure Schedule III drugs prescribed to Clients 3 and 4 were monitored and reconciled had a direct relationship to the health, safety, or security of the clients. |
| 060001096 |
LENMAR HOME |
060011196 |
B |
30-Dec-14 |
QG7F11 |
6625 |
CLASS B CITATION - Right to prompt medical care and treatment Welfare and Institutions Code, Section 4502(d). 4502 - Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following: (d) A right to prompt medical care and treatment. The above STATUTE was not met as evidenced by: On 12/2/14 at 0730 hours, an unannounced visit was made to the facility to investigate an ERI (Entity Reported Incident) regarding Client 1 falling and breaking his left lower leg on 11/21/14, while he was out in the community with his Job Coach. Client 1 was a 56 year old ambulatory man with diagnoses including severe intellectual disability (person with an IQ score of 25-40) and seizure disorder.On 12/2/14 at 0740 hours, Client 1 was observed sitting on the couch with a cast boot on his left lower leg and foot. An interview was conducted with Client 1. Client 1 was able to ambulate independently to his room. Client 1 stated, "It hurts when I walk." When Client 1 was asked what happened to his foot, Client 1 stated he was not paying attention when he was walking in the library and he tripped and fell. Client 1 stated his Job Coach witnessed the fall. The client stated his foot hurt a "little bit" after the fall and he told the staff at the facility that he fell while at the day program that day, and that his back hurt.On 12/2/14 at 0805 hours, an interview was conducted with the FM (Facility Manager). The FM stated he noticed Client 1 was limping on 11/24/14 (Monday), so he asked Client 1's Job Coach if anything had happened when Client 1 was at the day program on 11/21/14 (Friday). The FM stated the Job Coach informed him Client 1 tripped and fell at the library on 11/21/14, the Job Coach checked Client 1 for injuries, and Client 1 was "OK." The FM stated since the Job Coach had already checked Client 1 for injuries, he did not check Client 1 for injuries himself. The FM verified he did not inform the RN (Registered Nurse) or QIDP (Qualified Intellectual Disabilities Professional) of Client 1's fall and subsequent limping when he learned of the fall on 11/24/14. The FM further stated on Wednesday (11/26/14), five days after Client 1's fall, Client 1's ankle was bruised and swollen, and he was still limping so he took Client 1 to the urgent care for an x-ray. The x-ray showed Client 1 had a left fractured distal fibula. The FM verified he did not notify the RN or QIDP of Client 1's fall which occurred on 11/21/14; did not notify the RN or the QIDP when Client 1 was observed limping which started on 11/24/14; and did not notify the RN or the QIDP when Client 1's left ankle was observed to be bruised and swollen until 11/26/14. The FM verified he should have notified the RN and QIDP of Client 1's fall when he learned about it. The FM stated he did not receive an incident report from the day program reporting Client 1's fall on 11/21/14.Review of the physician's progress notes from the urgent care dated 11/26/14, showed Client 1 fell six days ago and the x-ray revealed a fractured distal fibula (lower leg bone). A cast boot was placed and the client was ordered to follow up with the orthopedic physician.Review of Client 1's ISP (Individual Service Plan) dated 6/11/14, showed Client 1 was completely ambulatory, walked, moved, and ran independently. In addition, Client 1 had some issues with walking in the community and had fallen, resulting in injuries. The day program had addressed this problem with close supervision and verbal reminders for Client 1 to stay focused.Review of the RN's notes dated 11/26/14, showed the RN was informed on 11/26/14, of the client's fall which occurred on 11/21/14. On 12/2/14 at 0937 hours, an interview was conducted with the QIDP. The QIDP verified he did not learn of Client 1's fall which occurred on 11/21/14 until 11/26/14. The QIDP stated he spoke with the Program Manager at Client 1's day program and requested an incident report. The QIDP received the incident report from the day program on 12/2/14, and faxed a copy to the CDPH. On 12/2/14 at 1120 hours, an interview was conducted with Client 1's Job Coach who stated Client 1 tripped and fell down at the library. The Job Coach stated he checked Client 1 for injuries and he was "OK." The Job Coach stated he called his office to report the fall per their policy on 11/21/14. The Job Coach also stated he asked the day program if Client 1's seizure medications were the same because Client 1 was walking slow and was unsteady all week. The Job Coach stated he informed the FM of Client 1's fall when he returned the client to the facility on 11/21/14. The Job Coach stated he also asked the FM if Client 1's seizure medications had been changed because Client 1 was walking slow and was unsteady, and the FM stated there had been no change in Client 1's medications. The Job Coach stated he was not sure if Client 1 had a seizure when he fell on 11/21/14. The Job Coach stated on Monday (11/24/14), the FM informed him Client 1's left ankle was a little swollen and should not walk much. The Job Coach also stated the FM asked him to keep Client 1 in the car so that was what he did. On 12/2/14 at 1145 hours, an interview was conducted with the Program Coordinator at Client 1's day program. The Program Coordinator verified the Job Coach of Client 1 informed the day program of the fall on 11/21/14. Review of the facility's undated P&P titled Review for Incidents showed all injuries must be reported to the RN and QIDP immediately; and the DCS must request an incident report from appropriate parties if the incident occurred outside of the home. The facility failed to ensure the RN and QIDP were promptly informed of Client 1 falling while out in the community. In addition, the facility failed to ensure the physician was promptly notified of Client 1's swollen ankle. This caused a delay in treatment for Client 1's fractured left fibula. As a result, Client 1 went six days without being assessed or receiving treatment for his fractured leg.This failure had a direct and immediate relationship to the health, safety, and security of the client. |
| 060000042 |
Laguna Hills Health and Rehabilitation Center |
060011642 |
B |
28-Jul-15 |
PVEF11 |
12710 |
GLOSSARY OF ABBREVIATIONS AND DEFINITIONS: ADL - Activities of Daily Living ADON - Assistant Director of Nursing B&B - Bowel and Bladder Braden Scale - (an assessment tool to assess a person's risk of developing a pressure ulcer) cm - centimeter(s) CNA - Certified Nursing Assistant CVA - Cerebrovascular Accident (a stroke which can cause a loss of brain function due to disturbance of blood supply.) DON - Director of Nursing DTI - Deep Tissue Injury (purple or maroon discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shearing.) H&P - History and Physical IDT - Interdisciplinary Team LAL - Low Air Loss (a mattress which provides alternating pressure to be used in the prevention, treatment, and management of pressure ulcers). LVN - Licensed Vocational Nurse MDS - Minimum Data Set (a standardized assessment tool) P&P - Policy and Procedure RD - Registered Dietitian RN - Registered Nurse SBAR - Situation Background Assessment Request (a form used to communicate changes in a resident's condition) Stage I Pressure Ulcer - (intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from surrounding area) Stage II Pressure Ulcer - (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) Stage III pressure ulcer - (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are exposed. Slough may be present but does not obscure the depth of tissue loss include undermining and tunneling. UTD - unable to determine F314 The facility failed to assess the resident's skin integrity to identify pressure ulcers, in accordance with the facility's P&P and implement measures to prevent the development and/or deterioration of pressure ulcers for Resident 1 and Resident 2.* Resident 1 was assessed with no skin breakdown on 4/4/15. The following day (4/5/15), Resident 1 was identified to have redness to his coccyx (tailbone) area. Twelve days later, on 4/17/15, Resident 1 reddened coccyx area had deteriorated from a Stage I pressure ulcer to a Stage III pressure ulcer.* Resident 2 was assessed to have redness to her coccyx area on 2/12/15 and on 3/16/15, Resident 2 developed a DTI to her coccyx area. There were no preventative measures implemented when the Stage I was identified to prevent further deterioration of the resident's skin. Findings: According to the 2009 National Pressure Ulcer Advisory Panel (NPUAP), pressure ulcers have been defined as localized tissue injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure (due to staying in one position for too long without shifting weight).Review of the facility's P&P titled Pressure Ulcer Risk Assessment revised 2/2014 showed staff will perform routine skin inspections (with daily care) and licensed nurses will conduct skin assessments at least weekly to identify changes. The licensed nurses are to be notified of any skin changes and inspect the skin. Residents at risk for skin breakdown need interventions implemented promptly in an attempt to prevent further skin breakdown; a pressure ulcer can develop within two to six hours.1. Closed clinical record review was initiated for Resident 1 on 4/30/15. Resident 1 was admitted to the facility on 4/4/15, with diagnoses including generalized body weakness. Review of Resident 1's discharge H&P from the acute care hospital dated 4/3/15, showed Resident 1 had a decreased oral intake and was to receive oral supplements three times a day at the skilled nursing facility. However, review of physician's admitting orders to the facility did not include oral supplements.Review of the Nursing Admission and Assessment form dated 4/4/15, and Physician Admitting Order form dated 4/4/15, showed Resident 1 had no skin break down.Review of the Braden Scale form dated 4/4/15, showed Resident 1's score was 19 (a score of 12 or less represents high risk of developing pressure ulcers).Review of the updated Nursing Admission and Assessment form dated 4/5/15, showed Resident 1 had redness to his coccyx area.Review of Resident 1's plan of care identified a short-term care plan problem dated 4/5/15, to address Resident 1's reddened peri-area (area between her legs). The interventions included to cleanse with water and apply zinc oxide cream (skin protectant), monitor for signs of infection, and notify the physician if the treatment was ineffective. However, there were no interventions to address turning, repositioning and/or devices to relieve the pressure to Resident 1's reddened coccyx area.Review of Resident 1's plan of care identified a care plan problem dated 4/5/15, to address her risk for pressure ulcers manifested by impaired mobility had no interventions for a turning or repositioning program or the use of pressure-relieving devices.Review of the Nutritional Screening and Data Collection form dated 4/6/15, showed the dietary technician documented no nourishment or supplements were indicated.Review of the MDS dated 4/11/15, showed Resident 1 required one staff member's assistance for bed mobility and all ADL care. The MDS also identified Resident 1 was at high risk of developing pressure ulcers upon admission.Review of the facility's shower schedule showed Resident 1 was scheduled to be showered every Tuesday and Friday. With each shower, staff were to complete a Shower Skin Check form. There were no shower skin checks documented for Resident 1 on Tuesday (4/7/15), Thursday (4/10/15), or Tuesday (4/14/15). Review of a blank Shower Skin Check form showed a diagram of a body. The instructions on the form showed staff were to document any bruises, rashes, redness, skin tears, and pressure ulcers since the last shower.Review of Resident 1's SBAR form dated 4/16/15, showed a Resident 1 had a new pressure ulcer. Staff documented, "The pressure ulcer was discovered during the assessment of the coccyx area." The pressure ulcer measured 1.5 cm (length) x 1.0 cm (width) x 1.0 (depth), with 80 percent slough. Resident was not aware of this condition, stated that feels pain in the area..." Review of the Wound Evaluation Flow Sheet form initiated on 4/16/15, showed Resident 1 had a Stage III pressure to his coccyx and the physician was notified.Review of the physician's ordered dated 4/16/15 at 0715 hours, showed to cleanse Resident 1's coccyx pressure ulcer with normal saline and apply Santyl (chemical deriding ointment) and cover with a dressing daily.Review of the licensed progress notes dated 4/16/15 at 1320 hours, showed Resident 1 was evaluated by a wound care physician. Staff documented the physician pre-medicated the resident and applied Lidoderm ointment (to numb the area). He then performed sharp curette debridement (removal of dead tissue) to the resident's coccyx pressure ulcer.Review of the Physician's Progress Notes dated 4/17/15, showed Resident 1 had a Stage III pressure ulcer to his lower back (coccyx area).A care plan problem dated 4/16/15, titled Pressure Ulcer Coccyx Stage III was developed. However, there were no interventions identified to address how to treat and promote the healing of the Stage III pressure ulcer on the coccyx area.Review of the IDT Wound Management form initiated on 4/16/15, showed Resident 1 developed a Stage III pressure ulcer after admission to the facility. On 4/24/15, the IDT documented the wound care physician had assessed the resident's wound and performed mechanical debridement (removal of dead tissue) and the resident had a LAL mattress in place.On 4/30/15 at 1415 hours, an interview was conducted with LVN 1. LVN 1 stated staff were to check a resident's skin during their scheduled showers. LVN 1 stated the CNAs were to report any skin changes to the treatment nurses or licensed nurses. LVN 1 stated when there was a change of condition, the licensed nurses would be required to write a report, notify the physician, obtain any new orders, and notify the resident's responsible party. On 4/30/15 at 1430 hours, an interview and concurrent closed clinical record review was conducted with the RD. The RD stated the licensed nurses were to notify her when there were any changes of condition and she then documented any necessary recommendations. The RD verified there was no documented evidenced the licensed nurses had notification her of Resident 1's development of the pressure ulcer.Review of Resident 1's CNA - ADL Tracking form for the month of April 2015 showed between 4/5/15 and 4/20/15, Resident 1 required one staff member's assistance for transfers and two staff members' assistance for bed mobility and personal hygiene care.On 4/30/15 at 1500 hours, an interview and concurrent closed clinical record review was conducted with CNA 2. CNA 2 stated when there were any changes of condition in a resident's skin, the CNAs were to document it on the back of the CNA - ADL Tracking form. CNA 2 verified Resident 1's CNA - ADL Tracking forms had no information pertaining to Resident 1's skin.On 4/30/15 at 1530 hours, an interview and concurrent closed clinical record review was conducted with LVN 2. LVN 2 stated Resident 1 had a Stage I pressure ulcer to his coccyx which had deteriorated to a Stage III pressure ulcer. When asked if Resident 1's Stage III pressure ulcer could have been prevented, LVN 2 stated if appropriate measures and interventions were provided, the pressure ulcer might not have deteriorated to a Stage III pressure ulcer. LVN 2 confirmed there was no documented evidence any preventative measures were in place when Resident 1's Stage I pressure ulcer was identified on 4/5/15.During an interview and concurrent closed clinical record review with the ADON on 4/30/15 at 1640 hours, the ADON confirmed there was no documented evidence staff had documented the shower checks for Resident 1 for 4/7, 4/10, and 4/14/15.2. Closed clinical record review was initiated for Resident 2 on 4/30/15. Resident 2 was readmitted to the facility on 2/12/15, with diagnoses including CVA with right-sided weakness. Review of the Nursing Admission and Assessment form dated 2/12/15, showed Resident 2 had redness to her coccyx area. Review of the physician's admitting orders dated 2/12/15, showed a treatment order to cleanse Resident 2's reddened coccyx area with normal saline, pat dry, and apply zinc oxide cream every eight hours for 14 days.Review of Resident 2's treatment administration record from 2/12/15 to 2/26/15, failed to show the treatments to the reddened coccyx area were performed as ordered to prevent deterioration for 14 days. There was no documentation to show why the treatments were not done or that the physician's order had been discontinued.Continued review of Resident 2's closed clinical record found no documentation to show a care plan problem was developed to address the resident's development of skin redness on the coccyx area, treatment, or interventions to prevent further skin breakdown. Review of Resident 2's MDS dated 2/19/15, showed the resident required total assistance by one staff member for all her ADL care and was incontinent of both B&B.Review of the physician's progress notes dated 2/17/15 and 3/11/15, showed Resident 2 continued to have diarrhea.Review of Resident 2's SBAR dated 3/16/15, showed Resident 2 was identified with a DTI to her sacrococcyx area, measuring 2 cm (length) x 1.5 cm (width) x UTD. Staff identified the resident's surrounding skin as dark plum red discoloration at the wound base.Review of the physician's order dated 3/16/15, showed to apply zinc oxide cream to her sacrococcyx DTI twice a day for 14 days.Further review of Resident 2's treatment record showed only one treatment was performed on 3/17/15, not two as ordered. There was no documentation as to why one more treatment on this day was not performed as ordered.Review of the physician's progress note dated 3/18/15, showed Resident 2 now had a Stage II pressure ulcer.On 5/20/15 at 1705 hours, an interview and concurrent closed clinical record review was conducted with LVN 2. LVN 2 reviewed Resident 2's treatment record and confirmed Resident 2's coccyx treatment was not documented as done as ordered from 2/12/15 to 2/26/15. He stated Resident 2's skin was being monitored and preventative measures should have been implemented. When asked if Resident 2's DTI could have been prevented. LVN 2 stated if appropriate measures and interventions were provided Resident 2's pressure ulcer might not have deteriorated. When asked to locate any documented preventative interventions implemented for Resident 2, LVN 2 was unable to do so. |
| 060000048 |
LEISURE COURT NURSING CENTER |
060011825 |
B |
05-Nov-15 |
M2F811 |
12172 |
F309 G dual enforcement to Class B citation from survey 7-23-15 F309: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 1a. Review of the facility's policy and procedure (P&P) titled Care for Residents With Dementia dated 5/14 indicated under Procedure, "Residents who exhibit...worsening BPSD [Behavioral or Psychological Symptoms of Dementia] are to be evaluated by the interdisciplinary team, including the physician, in order to identify and address treatable medical...factors that may be contributing to behaviors. The resident will be assessed by nursing to ensure the behaviors are not related to pain but are cognitive in nature." During the initial tour round on 7/21/15 at approximately 0940 hours, accompanied by Registered Nurse (RN) 1, Resident 1 was observed in her room, lying in bed on her back. Resident 1's lips, which she repeatedly licked, appeared dry and slightly chapped. Resident 1 yelled out, "Hurry, hurry! Help me!" During a concurrent interview, RN 1 stated Resident 1 needed extensive assistance with her activities of daily living (ADL) care, such as eating, bathing, dressing, toileting, and transferring. RN 1 further indicated Resident 1 exhibited behaviors of constantly yelling and was a fall risk.Clinical record review for Resident 1 was initiated on 7/21/15. Resident 1 was an 82 year-old admitted to the facility from a behavioral health acute hospital on 7/13/15, with diagnoses including dementia (status post psychosis), depression, GERD (Gastroesophageal Reflux Disease) with hiatal hernia, anemia, arthritis, peripheral vascular disease, severe osteoporosis with kyphosis, cachexia, recent dehydration, and urinary tract infection.Review of Resident 1's current plans of care confirmed she needed extensive assistance with ADL care and further indicated she was at risk for dehydration, weight loss, and gastrointestinal (GI) distress. Resident 1's "GI distress" plan of care dated 7/13/15, indicated approaches such as assessment for pain including intensity; monitoring for signs and symptoms of GI distress such as abdominal pain; and assessing for abdominal distension, bowel sounds, and tenderness. Resident 1's clinical record showed an Initial Pain Assessment dated 7/13/15, indicating licensed nursing staff documented zero pain on admission (based on a pain scale of 0 equal to no pain and 10 equal to worst possible pain).Review of Resident 1's July 2015 Medication Administration Record (MAR) indicated nurses were also monitoring for non-verbal pain symptoms every shift (days, evenings, and nights), including moaning, grimacing, vocal complaints of pain, guarding of body areas, and shortness of breath. The MAR indicated zero for all indicators since admission. On 7/21/15 at 1435 hours, Resident 1 was observed in her room lying in bed on her back, with facial grimacing, hands positioned on her stomach, yelling, "Oh my God it hurts!"During an interview on 7/21/15 at 1615 hours, Certified Nursing Assistant (CNA) 2 stated she had frequently provided care to Resident 1 during the past eight days. CNA 2 stated Resident 1, who could be resistive to care, frequently complained of stomach pain and the need to go to the bathroom. Shortly after the interview, Resident 1 called out, "I gotta go potty! Hurry, hurry!" Review of Resident 1's psychotherapeutic medication admission orders included an order dated 7/13/15, for Depakote (a medication used for seizure disorder but also used for bipolar mania) 250 mg twice daily for labile mood and agitation manifested by yelling without provocation. On 7/21/15 at 1400 hours, the licensed nursing staff obtained an order from MD 3 (Psychiatrist) to increase Resident 1's Depakote to 250 mg in the morning and 500 mg at bedtime. Review of Resident 1's Nurses Notes for 7/21/15, did not indicate MD 2 (primary care physician) was contacted regarding Resident 1's escalating behaviors. During an interview on 7/21/15 at 1645 hours, RN 4 stated Resident 1 was afraid of soiling the bed; therefore, the resident called out for assistance with toileting.During the medication administration observation on 7/21/15 at 1735 hours, Licensed Vocational Nurse (LVN) 2, who was present in Resident 1's room, acknowledged Resident 1's complaints of stomach pain. CNA 2, who was also present in the room, indicated Resident 1 had eaten only a small amount of her dinner. Resident 1, who was lying in bed on her back, with facial grimacing, stated, "I ate too much - my stomach hurts! I can't breathe! I can't breathe!" Resident 1's hands were positioned over her stomach area. Review of the physician's admission orders dated 7/13/15, showed orders that included Tums 500 mg three times daily as needed for gastric upset and Pepcid (heartburn relieving medication) 20 mg every 12 hours as needed for gastric discomfort.Further review of the July 2015 MAR indicated no Tums or Pepcid had been administered to Resident 1 since admission until 7/21/15, when LVN 2 documented Pepcid 20 mg at 1800 hours for gastric discomfort and relief was obtained at 1900 hours. Review of the July 2015 MAR showed the licensed nurses documented zero pain indicators such as grimacing, vocal complaints of pain, guarding of body areas, or shortness of breath for all three shifts (days, evening, and nights) on 7/21/15.On 7/22/15 at 0910 hours, Resident 1 was observed in her room lying in bed on her back, yelling, "I'm thirsty!" At 0920 hours, Resident 1 was observed yelling, "Hurry - I gotta go potty!" During an interview on 7/22/15 at 1510 hours, the Director of Nursing (DON) confirmed Resident 1's clinical record findings and acknowledged the licensed nursing staff should have performed and documented the assessments based on the resident's verbalized discomfort prior to requesting a dosage increase in Resident 1's Depakote on 7/21/15.During an interview on 7/22/15 at 1545 hours, RN 3 indicated she had admitted Resident 1 the afternoon of 7/13/15, and had conveyed Resident 1's admission orders to MD 2 over the phone at 2000 hours.During a follow-up interview on 7/22/15 at 1645 hours, the DON confirmed the licensed nursing staff had not documented Resident 1's non-verbal pain indicators such as moaning, grimacing, guarding of body areas, or shortness of breath, and vocal complaints of pain on the MAR since admission. During a telephone interview on 7/23/15 at 0915 hours, Resident 1's grandson indicated he frequently visited Resident 1 in the evening at the facility and Resident 1 seemed to be complaining of stomach pain more frequently. b. Further review of Resident 1's clinical record indicated a history and physical examination dated 6/26/15, from the acute behavioral health hospital indicating Resident 1 had severe back and hip pain and difficulty walking. Resident 1 had a physician's order dated 7/14/15, for physical therapy daily five times per week. Resident 1's current physician's orders included an order dated 7/15/15, for Tylenol 1 gram every 8 hours for pain.Resident 1's "Alteration in Comfort - Pain" plan of care dated 7/15/15, indicated potential for arthritis and generalized body pain, and the approaches included to assess the resident's intensity of pain, using a pain scale of 1 to 10. Review of the July 2015 MAR pain assessment documentation indicated the licensed nursing staff documented pain levels of 6 out of 10 (indicating moderate pain) twice on the day shift (7/15/15 and 7/22/15) since admission. During an interview on 7/22/15, LVN 3 stated she had obtained the routine Tylenol order from MD 2 on 7/15/15 for Resident 1's complaints of stomach and body pain. During a telephone interview on 7/23/15 at 0915 hours, Resident 1's grandson indicated the resident had been hospitalized in June 2015 after complaints of severe left hip pain. Resident 1's grandson confirmed an acute care hospitalization confirmed Resident 1 had a hairline left hip fracture.On 7/23/15 at 1320 hours, a voicemail telephone message was left (requesting an interview) for MD 2 who did not return the telephone call. During an interview on 7/23/15 at 1505 hours, the DON indicated if a resident was exhibiting acting out behaviors, the licensed nurses should contact the resident's primary care physician first to rule out medical factors, then coordinate with the resident's psychiatrist if the issue was solely related to behaviors. During an interview on 7/23/15 at 1535 hours, MD 3 confirmed she had overseen Resident 1's psychiatric care at the acute behavioral health facility and was continuing oversight of Resident 1's psychiatric care at the current facility. MD 3 stated she increased Resident 1's Depakote on 7/21/15, based on the licensed nursing staff's reports of Resident 1's continued yelling and restlessness. MD 3 acknowledged the licensed nursing staff did not indicate Resident 1 was complaining of pain. Additional information related to Resident 1's acute behavioral health hospitalization (obtained from the DON on 7/23/15 at 1130 hours) indicated a physician's progress note of a "reported hairline fracture on left pelvic area, per report of grandson." Review of Resident 1's Physical Therapist (PT) progress notes dated 7/20/15, and electronically signed by PT 1, for "dynamic standing balance" in order to reduce risk for falls indicated poor progress. During an interview on 7/23/15 at 1025 hours, PT 1 indicated he was not aware of Resident 1's report of a hairline left hip fracture from prior to admission. PT 1 indicated Resident 1 may need stronger pain medication than Tylenol for comfort prior to PT sessions. 2. Review of the facility's P&P titled Intake and Output (I&O) Measurement dated 10/11 indicated: "The following residents require measurement and documentation of intake and output every 8 hours including 24-hour totals and weekly evaluations x 30 days...4. Residents...with a need to increase fluid intake secondary to potential for dehydration." Review of Resident 1's "Nutrition and Hydration Risk Assessment" dated 7/13/15, showed a score of 18, indicating she was at high risk for malnutrition and dehydration. The licensed nursing staff had indicated Resident 1's estimated need for fluid intake (for residents on I&O) was 1000 to 2000 cubic centimeter (cc) of fluid daily. Review of Resident 1's July 2015 MAR for the time period of 7/13 to 7/22/15, indicated she was consuming 0 to 60% of her breakfast, 0 to 60% of her lunch, and 20 to 80% of her dinner meals. With regard to her 8 ounces of liquid protein supplement, Resident 1 was consuming 0 to 100% in the morning and 40 to 100% in the late afternoon. The MAR did not identify the total amount of fluids that Resident 1 was receiving daily. Review of the consultant dietician's initial assessment dated 7/14/15, indicated Resident 1's estimated fluid consumption needs were 1320-1540 cc daily. During an interview on 7/23/15 at 1515 hours, when asked how staff could ensure the residents were receiving adequate fluids, the DON confirmed the licensed staff documented the meal percentages on the MAR but had not documented the estimated fluid intake in the clinical record, and the documentation for residents at high risk of dehydration was the same as for other residents. The DON was unable to estimate Resident 1's fluid intake since admission to the facility. During an interview on 7/23/15 at 1530 hours, the DON stated there was no I&O fluid assessments completed for Resident 1 prior to the surveyors identifying the potential hydration concerns on 7/22/15. The facility failed to ensure licensed staff evaluated Resident 1's pain indicators, and documentation of Resident 1's hydration status was not implemented in accordance with the facility's P&P. Resident 1, who was receiving psychotherapeutic medications, was not thoroughly assessed for medical causes of behavior manifestations.The failure of the facility to assess Resident 1's pain and hydration status had a direct relationship to the health, safety, or security of the resident. |
| 070001333 |
LENA'S HOUSE |
070009578 |
B |
14-Nov-12 |
XFVT11 |
1513 |
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. The facility failed to notify the California Department of Public Health immediately or within 24 hours of alleged abuse of a client. Client 1's picture was taken and publicly posted on a social network by a Day Care Program staff without the client's permission. Client 1 was described as alert and able to make his own decisions. He required some assistance with activities of daily living. During the investigation on 10/26/12, Client 1 was alert and oriented.During an interview at 7:30 a.m., Client 1 stated about two weeks prior his picture was taken by a staff at the Day Care Program during an outing. He stated the staff did not ask his permission prior to taking his picture and posting it on a social network. On the same date at 8:00 a.m. during an interview, the administrator/qualified mental retardation professional (adm/QMRP) stated the Day Care Program director informed him regarding Client 1's incident on 10/16/12. The adm/QMRP stated he did not report the incident to the Department since the Day Care Program had already investigated the incident. The facility failed to notify the Department immediately or within 24 hours after being notified the Day Care Program staff had taken a photo of the client and posted it on a social network site without the client's permission. |
| 070000953 |
LAWRENCE HOUSE |
070011784 |
B |
28-Oct-15 |
24DI11 |
8530 |
Welfare and Institutions Code 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following:(h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to ensure the rights of six of six clients (1, 2, 3, 4, 5, and 6), who were unable to care for themselves and totally dependent on staff, were protected when on 10/5/15 they were left unattended and unsupervised from 5:15 a.m. through 5:45 a.m.Review of Client 1's clinical record indicated he had diagnoses including mild intellectual developmental disability (a disability characterized by significant limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills) sleep apnea (potentially serious sleep disorder in which breathing stops and starts), cerebral palsy (an abnormality of motor function and the ability to move and control movements) and severe scoliosis (a sideways curvature of the spine). During an observation on 10/8/15 at 8:30 a.m. in the facility, six clients (1, 2, 3, 4, 5, and 6) were eating breakfast with staff assistance. After breakfast all six clients left for the day program (DP). During an interview on 10/8/15 at 8:45 a.m., Client 1 stated on the night of 10/5/15 between 11 p.m. and 12 a.m., he heard direct care staff A (DCS A) make a telephone call to the qualified intellectual disabilities professional (QIDP). Client 1 stated, "I guess she told [naming the QIDP] she wanted to leave because she was not feeling good." Client 1 further stated, "I did not get all of the information". He stated the following morning he found out DCS A abandoned the facility while the clients were asleep. Client 1 stated nobody knew she left, and that was "very scary". He stated he had sleep apnea and if no staff were available at night nobody would check on him and he would not be able to get help. Client 1 also stated he heard the oven was left on when the day shift staff arrived in the morning.During an interview on 10/8/15 at 9:30 a.m., the QIDP stated on 10/5/15 at around 6 a.m., he received a call from the facility scheduler (FS) and was told there was no staff in the house and the clients were by themselves when the day shift staff arrived. The QIDP stated he called the facility and spoke with one of the day shift staff and he was informed the clients were found wet with urine and feces.The QIDP stated DCS A called him on 10/4/15 at around 11:30 p.m. and stated she felt ill, overwhelmed with work and was having a panic attack because she had a very busy night with the sick clients. He stated DCS A also told him she could not handle the job anymore. The QIDP stated he had a long telephone conversation with DCS A trying to calm her down. He stated he told DCS A she would be fine. The QIDP stated DCS A stayed until 5:15 a.m. on 10/5/15. The QIDP stated after a long conversation with DCS A over the telephone, he presumed DCS A was alright because she did not call him back. The QIDP stated at 6 a.m. he received a call from the incoming day shift staff and was told the clients were left unattended, wet with urine and feces, and the oven was left on. He stated he did not realize the severity of the situation. When asked, the QIDP agreed he could have come in and helped with the situation.During an interview on 10/8/15 at 12:07 p.m., DCS A stated on 10/5/15 at 11:30 p.m., she called the QIDP and told him she needed a replacement because she was having a panic attack, was overwhelmed with two sick clients (who had vomiting and diarrhea) and she was stressed. She stated she told the QIDP she passed out while she was working with the clients and recovered within approximately five minutes. DCS A stated she got up from the floor and continued to work because she knew she had to go back to her client who was having episodes of vomiting. She stated she stayed and worked until after 5 a.m. because she was told by the QIDP to "stick to it, you could do it, and get through it". DCS A stated the QIDP further told her it was too late to find a replacement. She stated hat at around 5 a.m., she was in pain, shaking and crying and felt she could not handle it anymore so she left the facility and drove home.DCS A stated she was hired approximately one week earlier and it was very difficult to work on the floor without a mentor on her first day. She stated she did not get any support from the QIDP when she called him to find a replacement. DCS A stated she was getting nervous about her condition and was having a problem breathing. She stated she was having a panic attack and did not know what to do, so she left the facility.During a telephone interview on 10/9/15 at 3:30 p.m., DCS B stated when she arrived at the facility at 5:45 a.m. on the morning of 10/5/15, there was no staff available at the house. She stated she called the FS and told the FS the kitchen stove was left on set at 400 degrees with no food being cooked in the oven. In addition, several clients' diapers were soaked with urine and feces. DCS B also stated two of the clients with catheters had their catheters left over the bedrails and one client's catheter was pulled out. She stated the QIDP was aware of DCS A's situation when DCS A had a panic attack and was in distress during her shift. DCS B stated she felt no action was taken and she felt very uncomfortable working in a facility with unsafe practices. She further stated there had been bad practices happening lately with the staff shortage and she could no longer tolerate the unsafe practices, so she had submitted a two week notice of resignation. During a telephone interview on 10/10/15 at 2 p.m., DCS A stated on 10/5/15 she was cooking the clients' meals for the day (breakfast, lunch, and dinner). She stated at around 3 a.m. to 4 a.m., she remembered she was going to start to bake a pizza in the oven but was not able to do so. She stated she was so ill, she could not remember if the oven was left on at the time she left the facility at 5:15 a.m.During the investigation on 10/8/15, the facility incident report, dated 10/7/15, documented the facility night staff telephoned the administrator/QIDP at approximately midnight on 10/5/15 and complained about being fatigued and sleepy and experiencing some pain. The QIDP indicated he asked the staff member if she could work the rest of the shift and she eventually said she could, so he wished her goodnight and hung up the telephone. The QIDP indicated there was no further indication the staff member was having further difficulties. The report also indicated the clients were assessed and no changes were noted when the licensed nurse arrived at the facility in the morning on 10/6/15. However, there was no documentation indicating the clients were assessed by the licensed nurse. The notes also indicated the QIDP called law enforcement (police) to report the incident. During a concurrent interview on 10/8/15 at 10 a.m., the licensed nurse stated she checked the clients but did not conduct comprehensive body check assessments for the clients when she observed they looked fine. During an interview on 10/8/15 at 11:30 a.m., the QIDP acknowledged all six clients were left unsupervised and unattended when DCS A abandoned the facility on 10/6/15. The QIDP stated DCS A was counseled and was informed about the seriousness of her action. A review of the facility's undated policy, "Employment Policies and Practices", indicated employees were expected to work as scheduled, to be on time and prepared to start to work and were expected to remain at work for their entire work schedule. The facility failed to ensure the clients' rights were protected when the facility staff did not stay to work for her entire schedule, left the clients unattended and unsupervised and the facility oven was left turned on. This violation had a direct or immediate relationship to the health, safety or security of clients. |
| 070000012 |
LINCOLN GLEN SKILLED NURSING |
070012174 |
B |
14-Apr-16 |
Y7ND11 |
3614 |
F226, 483.13(c) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to implement their policy and procedure for Resident 6 when an allegation of abuse was not investigated and reported to the California Department of Public Health (CDPH), the ombudsman, and law enforcement within 24 hours as required by law. Resident 6's clinical record was reviewed. Her Minimum Data Set (MDS, an assessment tool), dated 2/29/16, indicated she had impaired cognition.A late entry, dated 3/4/16, in the nurses notes indicated Resident 6 had on her right inner thigh a purplish skin discoloration measuring 2 centimeters (cm, unit of measurement) in length and 4 cm in width. The Wound Assessment Report, dated 3/5/16, indicated the wound type was a bruise, located on the right inner thigh, was not present upon admission, and was of unknown origin. Her care plan, dated 3/4/16, indicated she had a skin discoloration on her right inner thigh. During a telephone interview with licensed vocational nurse A (LVN A) on 3/30/16, at 10:05 a.m., she stated on 3/4/16 the certified nurse assistant (CNA) reported the bruise on Resident 6's right inner thigh and she was unable to state how the resident got the bruise. She also stated she completed a facility incident report on 3/4/16. During an interview with the director of nurses (DON) on 3/30/16, at 10:10 a.m., she stated she was aware of the skin discoloration on Resident 6's right inner thigh and she was trying to determine the origin of the bruise. She also stated she could not remember if the incident was investigated. During an observation and interview with LVN B on 3/30/16, at 11:10 a.m., two skin discolorations were observed on Resident 6's right inner thigh. LVN B stated the skin discoloration on the right inner thigh was 2 cm in length and 2 cm in width. The resident also had another light purple skin discoloration measuring 1 cm in length and 1 cm in width. During a telephone interview with CNA C on 3/30/16, at 11:30 a.m., she stated she noticed the bruise and informed the nurse. She also stated Resident 6 did not move a lot and slept all of the time. CNA C stated she was not sure how the resident got the bruise.During an interview with the DON on 3/30/16, at 12:10 p.m., she stated she could not find an investigation of Resident 6's bruise and she telephoned the assistant administrator who was in charge of screening the facility's incident reports. The assistant administrator told the DON she could not remember if there was an incident report. Review of facility's undated policy, "When Do We Investigate to Rule Out Abuse", indicated bruises and skin tears of unknown etiology should be investigated. Review of the facility's undated policy, "Possible Indicators of Abuse", indicated bruises, welts, and discoloration were possible indicators of abuse. Review of the facility's undated policy, "Lincoln Glen Nursing Facility Abuse Prevention Program", indicated an initial written report should be completed (form SOC 341) and the Department of Health Services should be notified within 24 hours. The ombudsman and law enforcement should be notified in compliance with State and Federal law. The facility failed to investigate and report the possible allegation of abuse to the CDPH, the ombudsman, and law enforcement within 24 hours as required. These violations had a direct or immediate relationship to the health, safety, or security of the resident. |
| 070000067 |
Los Gatos SNF, LLC |
070012420 |
B |
25-Jul-16 |
223Z11 |
4290 |
F201-483.12(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. The facility failed to ensure a safe discharge for Resident 1. Resident 1 was discharged under the care of her family member who was her responsible party (RP, liable for making decisions) and also an alleged abuser. This failure had the potential to endanger the safety of the resident and did not meet her needs. Review of Resident 1's clinical record indicated diagnoses including muscle weakness and cellulitis (inflammation of subcutaneous tissue) of left lower limb. Her Minimum Data Set (MDS, an assessment tool) dated, 3/10/16, indicated Resident 1 had problems in decision making and had highly impaired vision. Resident 1's care area assessment (CAA) for return to community referral, dated 3/10/16, indicated she had a problem with cognition and functional mobility. Review of Resident 1's 30 day transfer/discharge notice dated 5/20/16, indicated the reasons for discharge or transfer included health improvement and failure to pay her share of cost to stay in the facility after a reasonable time, and that appropriate notices were provided to her. Review of Resident 1's social worker (SW) notes, dated 6/17/16, indicated Resident 1 stated she was unable to pay her share of cost at the facility because she did not have money in the bank. Her RP took her checkbook and withdrew money from her bank account without her permission. On 6/18/16, Resident 1 was discharged her RP with no known address. The RP verbalized he would notify the facility of Resident 1's address as soon as it was available. During an interview on 6/23/16 at 4:30 p.m., registered nurse A (RN A) stated Resident 1 was discharged on 6/18/16 and was picked up by her RP but RN A was unable to provide an address where Resident 1 would reside. RN A gave the discharge instructions and medications on the day of discharge. During an interview on 6/23/16 at 3:55 p.m., the SW stated Resident 1 was discharged to her RP who was an alleged abuser and took Resident 1's money from her bank account without her permission. She also stated she reported the incident to the ombudsman and local law enforcement but it was not reported to the California Department of Public Health (CDPH). The SW stated she should have reported the incident to the CDPH. During an interview on 6/23/16 at 5:10 p.m., the director of nurses (DON) stated she issued the 30 day discharge/transfer notice to Resident 1 on 5/20/16 but was unable to find any place to transfer Resident 1. She stated when they give a 30 day notice residents should leave the facility within 30 days from the day of notice. She also stated the RP never called to inform the facility of Resident 1's whereabouts. The facility's 4/2005 policy, "Transfer and Discharge", indicated the process must provide sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from the facility. Provide preparation and orientation to the resident to ensure safe and orderly transfer/discharge from the facility. Preparation and orientation includes informing the resident where he or she is going, involving the resident and family in selecting the new residence, and making appropriate referrals. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the resident. |
| 070000067 |
Los Gatos SNF, LLC |
070012421 |
B |
25-Jul-16 |
223Z11 |
2132 |
F226, 483.13(c) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to implement their policy and procedure for Resident 1 when an allegation of abuse was not reported to the California Department of Public Health (CDPH) within 24 hours as required by law. Failure to report the abuse in a timely manner potentially allowed the abuse to continue, allowed the alleged abuser to have access to the resident, and failed to protect the resident from harm. Review of Resident 1's clinical record and the Minimum Data Set (MDS, an assessment tool) dated, 3/10/16, indicated Resident 1 had a problem in decision making and had highly impaired vision. Review of Resident 1's progress notes, dated 6/17/16, indicated Resident 1 stated she was unable to pay her share of cost because she do not have money in the bank and her responsible party (RP, liable for decision making), took her checkbook and had withdrawn money from Resident 1's bank account without her permission. During an interview with the social worker (SW) on 6/23/16 at 3:55 p.m., she stated Resident 1 did not have money because the son of Resident 1 took her checkbook and withdrew money from her bank account without her permission. She also stated she reported the incident to the ombudsman and local law enforcement but it was not reported to California Department of Public Health (CDPH). The SW stated she should have reported the incident to the CDPH. During an interview with the director of nursing (DON) on 6/23/16 at 5:30 p.m., she stated Resident 1's allegation of abuse should have been reported to the CDPH. The facility's 7/2015, "Abuse Policy", indicated to provide a written report to the local ombudsman, the CDPH and the local law enforcement agency within 24 hours utilizing the California Report of Suspected Dependent Adult/Elder Abuse Form (SOC 341). The above violation has a direct or immediate relationship to the health, safety, or security of the resident. |
| 070001333 |
LENA'S HOUSE |
070012563 |
B |
12-Sep-16 |
F6JG11 |
3317 |
Health and Safety Code 1418.91(a). (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse to a resident of the facility to the department immediately, or within 24 hours. The facility failed to immediately report physical abuse against Client 1 and Client 2 by a client at the day program (DP, a community based facility or program that provides social interaction, engagement, learning objectives, and medical supervision for persons 18 years or older for less than a 24 hour basis). The DP staff reported the incident to the facility's licensed vocational nurse (lead staff) (LVN) the day of the incident. The LVN admitted to not reporting the incident to the Department. 1. On 8/26/16 Client 1's medical record was reviewed, and indicated she had diagnoses that included mild mental retardation (a disability characterized by limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills), cerebral palsy (a group of permanent movement disorders) and severe spastic quadriplegia (a severe permanent movement disorder that affects all four limbs; both arms and legs). She was described as verbal, able to express her needs and required assistance with activities of daily living (ADL). The record indicated on 8/12/16, at 2:30 p.m., a peer at the day program (DP) slapped Client 1. Client 1 was assessed and monitored. During an interview on 8/26/16 at 8:00 a.m., Client 1 stated while at the day program, a peer hit her on her back. She was not able to recall the date she was hit but she reported the event to the facility staff, the day it happened. During an interview on 8/26/16 at 8:20 a.m., the licensed vocational nurse (LVN) stated the DP staff reported the above incident to her on 8/12/16 but she did not report the incident to the Department. 2. Client 2's medical record was reviewed on 8/26/16 and indicated she had diagnoses including mild mental retardation and hypertension (abnormally high blood pressure). Her comprehensive functional assessment (CFA, an assessment tool) indicated she was verbal and was able to express her needs. She was ambulatory and fairly independent with her activities of daily living. The record indicated on 8/12/16, the day program staff telephoned the facility, and reported that the same peer hit Client 2 on her upper shoulder after hitting Client 1. Client 2 was assessed and monitored. The client did not complain of pain or discomfort. The incident was not reported to the Department. During an interview on 8/26/16, the LVN stated the day program reported to her that Client 2 was hit by the same peer who hit Client 1 at the day program. She stated she did not report the incident to the Department because the incident was already reported by the day program staff. The facility policy and procedure for "Reporting of Unusual Occurrences and Special Incident Reports" indicated a notification within twenty-four (24) hours shall be made by telephone to the Department and confirmed in writing within 24 hours of any unusual occurrences including abuse and occurrences, which threaten the welfare, safety, or health of the clients, staff, or visitors. This failure had a direct or immediate relationship to the health, safety, or security of clients. |
| 070000006 |
LOS GATOS MEADOWS GERIATRIC HOSPITAL |
070012573 |
B |
20-Sep-16 |
GTJ011 |
3656 |
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 two residents (3 and 6). Residents 6 alleged abuse by Resident 3, and Resident 6's allegation was not investigated and reported to the Ombudsman or Law Enforcement agency within 24 hours after the incident had occurred. This failure had the potential for continued abuse and harm to residents by a suspected abuser. 1. Resident 6's clinical record was reviewed and indicated she had a diagnosis of dementia (memory disorder). Resident 6's Minimum Data Set (MDS, an assessment tool), dated 8/15/16 indicated the resident had impaired cognition. Review of Resident 6's nurses notes, dated 8/12/16 at 6 p.m., indicated while Resident 6 was resting on her bed, Resident 3 walked towards Resident 6 and multiple times yelled at Resident 6 to move out. During an interview with licensed vocational nurse B (LVN B) on 9/8/16 at 12:10 p.m., she stated Resident 3 walked towards her roommate who was Resident 6, and yelled at Resident 6 to move out. During an interview with the director of nursing (DON) on 9/8/16 at 11:30 a.m. she stated she was aware Resident 3 yelled at Resident 6 while she was resting on her bed. She confirmed there was no investigation and no interdisciplinary team (IDT, staff members from different departments who coordinate a resident's care) notes. She also stated the incident was not reported to the Ombudsman or to the law enforcement agency. 2. Resident 3's clinical record was reviewed on 9/7/16. She had a diagnosis of dementia. Her MDS, dated 12/3/15 indicated she had severe cognitive impairment and behavioral symptoms including physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others such as disrobing (removing all her clothes) in public. Her MDS dated 6/4/16 indicated she was unable to complete the brief screener that aids in detecting cognitive impairment and had behavioral symptoms not directed toward others. Review of Nurses' Notes dated 8/12/16 at 6:15 p.m. authored by licensed vocational nurse I (LVN I), indicated Resident 3 came out of her room very upset, speaking a non-English language. LVN I was able to understand the resident when Resident 3 voiced "out" and pointed to her roommate, Resident 6. She stated Resident 3 was very difficult to redirect. LVN I stated Resident 3 walked toward her roommate's bed "yelling at her." LVN I followed Resident 3 and avoided a resident-to-resident contact. The resident's durable power of attorney (DPOA) was called and a message was left. The roommate was moved to another room. Continued review of Nurses' Notes on the above date at 7:15 p.m. authored by LVN I, indicated Resident 3's family member (FM) came to the facility and took the resident to another floor until Resident 3 was less agitated. Review of the facility's 2/2004 policy, "Elder Abuse Prevention", revised on 9/1/2016 indicated for suspected abuse not resulting in serious bodily injury by a resident with a diagnosis of dementia, the community staff must report the incident to the local Ombudsman or the local law enforcement agency by telephone as soon as possible and a written report must follow within 24 hours to either the local Ombudsman or the local law enforcement agency. The above violation has a direct or immediate relationship to the health, safety, or security of residents. |
| 070000012 |
LINCOLN GLEN SKILLED NURSING |
070012724 |
B |
10-Nov-16 |
MA0411 |
11807 |
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 provide adequate supervision, assistance, and implement interventions to prevent falls for Resident 1 and Resident 2. Staff was unaware Resident 1 required supervision and physical assistance when walking and transferring. The interdisciplinary care team (IDT, facility staff members from different departments who coordinate care provided to residents) recommendations were not followed-up after the 7/10/16 fall for preventing future falls including psychological evaluation and antipsychotic medication (a medication used to treat mental disorder) review and the fall assessment in September 2016 was not performed. On 10/2/16, two visitors found Resident 1 lying on the floor in her room. The resident fell unattended and sustained a hip fracture (broken hip). After Resident 2's 4/5/16 fall, IDT recommendations were not followed-up and the resident had a recurrent fall on 8/1/16. These failures resulted in Resident 1's fall, hip fracture, hospitalization, and surgery, and Resident 2's recurrent fall. 1. Resident 1's clinical record was reviewed. It indicated the resident had diagnoses including dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning), psychosis (a mental disorder causing abnormal thinking and loss of reality), hemiplegia (paralysis on one side of the body), fracture of the neck of the left femur (broken hip), wandering, and a history of falling. It indicated Resident 1 had behaviors of extreme agitation (feeling of aggravation or restlessness), anger, attempting to leave the facility, hitting, scratching staff, hallucinations (an experience involving the apparent perception of something not present), and delusions (irrational belief in something untrue). Review of Resident 1's Rehabilitation Screening Form, dated 12/11/15, indicated staff observed the resident leaning to the left when she ambulated. A rehabilitation therapist assessed Resident 1's strength and mobility and suggested Resident 1 use a foot bike for five minutes, twice a day, and attend the facility's exercise classes to strengthen the extremities (a limb of the body, e.g., legs) and improve her balance. There was no documented evidence the therapist's suggestions were followed-up to have Resident 1 exercise. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/30/16, indicated Resident 1's balance was not steady when moving from a seated to standing position, walking, turning around, and moving surface-to-surface transfer. It indicated Resident 1 required supervision when she walked and one person physical assistance for transferring. Review of Resident 1's Fall Risk Evaluation, dated 6/6/16, indicated the resident had an unsteady gait. There was no Fall Risk Evaluation done when it was due in September 2016. Review of Resident 1's physician orders dated 6/28/16, indicated Seroquel (an antipsychotic medication used for psychosis) 12.5 milligrams (mg, unit of measurement) was initiated by mouth every bedtime. Review of Resident 1's nurse notes, dated 7/10/16, indicated Resident 1 had an unwitnessed fall when she tried to transfer herself from her wheelchair to a sofa chair. Review of Resident 1's Fall Scene Investigation Report (FSIR), dated 7/10/16, indicated Resident 1 was alone in her room, unattended, lost strength, and lost her balance. The FSIR indicated the interventions to prevent future falls included to educate Resident 1 to use her call light when she needed to transfer and have a psychological evaluation. It indicated the resident's mood changes could cause falls. There was no documented evidence Resident 1's psychological evaluation was done. Review of Resident 1's medication regimen review (MRR), dated 7/13/16, indicated a pharmacist recommended to review the resident's antipsychotic therapy (the use of Seroquel), consider to start an anxiolytic agent (medication to treat anxiety), and consider starting Aricept (medication to treat dementia), Namenda (medication to treat dementia), and mood stabilizers when the resident's impulsivity was a concern. There was no physician's response and no documented evidence the pharmacist's recommendations were followed-up to have a physician's response or review. Review of Resident 1's Care Plan Addendum dated 7/27/16, indicated the adverse effects (undesired harmful effect) of the resident's Seroquel included orthostatic hypotension (condition in which blood pressure falls significantly when standing up quickly) and dizziness. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/29/16, indicated Resident 1's balance was not steady when moving from a seated to standing position, walking, turning around, and surface-to-surface transfer. It indicated Resident 1 required supervision when she walked and one person physical assistance when she transferred. Review of Resident 1's care plan for the risk of fall, initiated 5/28/14 and revised 9/6/16, indicated the resident was at risk for fall and injury related to an unsteady gait, one sided weakness, and impaired vision. It indicated to anticipate the resident's needs and check the resident frequently. Review of Resident 1's nurse notes, dated 10/2/16, indicated at 7:35 p.m., two visitors saw the resident laying on the floor when they passed by the resident's room and called staff for help. It indicated the resident tried to close the window blinds and lost her balance. Review of the FSIR, dated 10/2/16, indicated Resident 1 was alone in her room, unattended, lost strength, and lost her balance. The FSIR indicated one of the contributing factors to cause of the fall was the amount of assistance in effect. Review of Resident 1's nurse notes, dated 10/3/16, indicated an X-ray result revealed the resident's left hip fracture and the resident was transferred to an acute care hospital. Review of Resident 1's Operative Report from the acute care hospital, dated 10/3/16, indicated the resident had a diagnosis of left hip fracture and underwent a hip hemiarthroplasty (a surgery that replaces half of the hip joint with a metal implant). During an interview on 10/10/16 at 7:35 a.m., registered nurse C (RN C) stated Resident 1 ambulated with a walker and transferred by herself in her room. She stated Resident 1 was usually stable when she walked but at times when she was tired there was a risk of fall. She stated Resident 1 knew how to use a call light but sometimes she did not use it when she needed help. During an interview on 10/10/16 at 1:45 p.m., the social worker (SW) stated after Resident 1's 7/10/16 fall, she gave Resident 1's responsible party (RP, a person empowered to make decisions for the resident) a list of doctors who could conduct the resident's psychological evaluation. She stated she did not follow-up with the RP to have Resident 1 undergo a psychological evaluation as recommended by the IDT. During an interview on 10/10/16 at 2:15 p.m., certified nursing assistant B (CNA B) stated Resident 1 walked in the room by herself without supervision. During an interview on 10/19/16 at 10:05 a.m., CNA D stated staff set the walker and shoes by the bed when Resident 1 was in bed or by the chair when she was sitting, so she was able to do things on her own. CNA D stated Resident 1 transferred by herself. During an interview on 10/19/16 at 10:20 a.m., CNA E stated Resident 1 leaned to one side when she walked. CNA E stated she did not supervise Resident 1 when she walked in her room but checked on her every two hours. CNA E stated Resident 1 did not need physical assistance when she transferred. During an interview on 10/19/16 at 10:35 a.m., CNA F stated Resident 1 walked slowly and was not balanced when she walked. CNA F stated Resident 1 walked in her room by herself without supervision. During a telephone interview on 10/19/16 at 11:15 a.m., the Minimum Data Set (MDS, an assessment tool) coordinator (MDSC) confirmed she did not complete Resident 1's Fall Risk Evaluation in September 2016 when it was due. During an interview on 10/19/16 at 2:15 p.m., the director of nursing (DON) stated supervision meant staff should be physically with the resident and observe. The DON stated the psychological evaluation after the 7/10/16 fall should have been followed-up. She stated there should have been documentation indicating why the psychological evaluation was not done. The DON confirmed there was no new intervention after the 7/10/16 fall to prevent future falls. The DON stated the pharmacist's recommendation from MRR should have been followed-up to have the physician's response. During a telephone interview on 10/21/16 at 10:30 a.m., the DON stated the physical therapist (PT, a type of rehabilitation therapy) did not communicate to nursing staff his 12/11/15 recommendation for Resident 1 to use a foot bike. 2. Resident 2's clinical record was reviewed. It indicated he had diagnoses including Parkinson's disease (disorder that affects movement) and a history of falls. Review of Resident 2's MDS dated 6/22/16, indicated Resident 2's balance was not steady when moving from a seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfer. It indicated Resident 2 required supervision for transfers and toilet use. Review of Resident 2's nurse notes, dated 4/5/16, indicated the resident had an unwitnessed fall when he tried to ambulate to the bathroom without his walker. Review of Resident 2's FSIR, dated 4/5/16, indicated the interventions to prevent falls included to discuss with the RP to unclutter the room, discuss with RP and Resident 2 the risks and benefits of self-transfer, offer a bedside commode, and PT screening. There was no documented evidence the medication review request was faxed to the pharmacy as the facility's protocol, the PT screening was done, or staff discussed with the RP to unclutter the room, and the risks and benefits of self-transfer. Review of Resident 2's nurses notes, dated 8/1/16, indicated Resident 2 had an unwitnessed fall in his room when he tried to use his urinal (a small container for urination). It indicated Resident 2 forgot to lock the wheels of his wheelchair and sustained a skin tear on his right elbow. During an interview on 10/20/16 at 3 p.m., the DON stated after the 4/5/16 fall, there was no documented evidence the medication review request and PT screening were done. Also, whether staff discussed uncluttering Resident 2's room or the risks and benefits of self-transfer with the RP. Review of the facility's 6/19/15 revised policy, "Falls" indicated after each fall, the care plan will identify approaches to prevent future falls and the interdisciplinary team can make additional recommendations, approaches, or updates as needed. It indicated residents' fall risks should be re-evaluated on a quarterly basis. Review of the facility's 5/2016 policy, "Medication Regimen Review and Reporting," indicated the facility can request medication regimen reviews when medications may have contributed to an adverse consequence. It indicated the pharmacist should work with the facility staff to gather information needed, the findings should be communicated to the director of nursing or designee, and acted upon by the facility and/or physician. Therefore, the facility failed to provide adequate supervision, assistance, and implement interventions to prevent recurrent falls. The above violations had a direct or immediate relationship to the health, safety, or security of residents. |
| 220001000 |
LOS ALTOS SUB-ACUTE AND REHABILITATION CENTER |
070013055 |
B |
21-Mar-17 |
N3JW11 |
4675 |
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 prevent the mistreatment of Resident 1 when during transfer, a certified nurse assistant (CNA) roughly handled Resident 1 causing pain to his legs, and pressured him to eat.
During Resident 1's record review on 3/7/17, it indicated the following diagnoses of difficulty walking, cerebral infarction and weakness. An MDS (minimum data sheet, an assessment tool) dated 3/1/17 indicated Resident 1 needed supervision during eating and he was cognitively intact.
During an interview with the administrator (ADM) and director of nursing (DON) on 3/7/17 at 2:15 p.m., it was stated Resident 1 had informed CNA A he was having some leg pain, and CNA A handled him roughly during transfer. It was reported by another resident that CNA A was pressuring Resident 1 to eat, even after he said he had enough. CNA A had been terminated.
During an interview on 3/7/17 at 2:37 p.m., the director of resident services (DRS) stated, a resident heard Resident 1 yelling from pain and telling CNA A he was in pain, but CNA A would not stop transferring Resident 1. DRS stated, when she talked with Resident 1 he was crying, shaking, and seemed scared. Resident 1 had told her he felt overwhelmed and he wanted some pain medication for his legs. DRS stated she spoke with the director of staff development (DSD), and both of them went to speak with Resident 1 who was teary eyed and crying. DRS stated Resident 1 again asked for pain medication for his legs. DRS stated CNA A should have seen that Resident 1 was in distress.
During an interview on 3/7/17 at 3 p.m., DON stated CNA A's performance had decreased lately.
During an interview on 3/7/17 at 3:30 p.m., Resident 1 stated CNA A attempted to feed him, but he was not supposed to. Resident 1 stated he told CNA A he did not want any food, and to "back-off". Resident 1 stated CNA A had a fork of food in front of Resident 1's face and tried to get him to eat it. CNA A told Resident 1 to eat the food. Resident 1 stated he told CNA A he can feed himself and he did not need any help. Resident 1 stated, while CNA A was transferring him from his wheelchair to his bed, he was not very careful. Resident 1 stated he told CNA A he could help him to stand, but he did not need to "man-handle" him. Resident 1 said he thought CNA A was trying to hurt him and CNA A seemed angry. Resident 1 stated, he did not want CNA A to touch him again, and he would have been apprehensive to have CNA A to help him again. Resident 1 said he was not afraid of CNA A causing any physical harm, but he could not be sure. Resident 1 again stated he did not want CNA A to help him.
A social service note dated 2/27/17, in Resident 1's clinical record, indicated Resident 1 had stated he was not comfortable with the care he had received that day by CNA A. The SBAR (communication notes following an incident) dated 2/27/17 indicated after the incident with CNA A, Resident 1 had pain which he rated as 7, on a scale of 0-10, and Tylenol (a pain medication) had been administered. A care plan for "risk for decline in psychosocial well-being related to: allegation of rough care provided by CNA during meals, forcing resident to eat after patient refused", was initiated on 2/27/17.
The facility's "Abuse Prevention, Intervention, Investigation, & Crime Reporting Policy" revised November 2016 indicated the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility is responsible for assuring resident safety by prohibiting verbal, mental, sexual, or physical abuse.
The facility failed to prevent the mistreatment of one resident when the CNA handled him roughly and pressured him to eat. |
| 220001000 |
LOS ALTOS SUB-ACUTE AND REHABILITATION CENTER |
070013069 |
B |
3-Apr-17 |
FBQS11 |
8227 |
F312 -- 483.24(a)(2) ADL CARE PROVIDED FOR DEPENDENT RESIDENTS
(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
The facility failed to provide the necessary care and services for Resident 1 who was unable to carry out activities of daily living (ADL) in regards to foot care (1). Resident 1 had a problem behavior of refusing care. The licensed nurses and certified nurse assistants (CNAs) did not follow up on Resident 1's refusal of care, specifically removal of her socks. Resident 1 developed macerations (skin condition that occurs when fluid or moisture is in contact with the skin for extended periods of time, particularly when the skin is covered) and fungal infection to her feet. This failure compromised the resident's health and had the potential to cause pain and suffering.
During an observation on 3/20/17 at 9:50 a.m., Resident 1 was seated on her bed and her feet were exposed to air on a mattress. Both of her feet and toes had macerated areas.
Review of Resident 1's undated Admission Record form indicated she was admitted to the facility on XXXXXXX13 and had diagnoses including cerebral palsy (permanent movement disorders that resulted from injury to the brain after birth or during early childhood), quadriplegia (paralysis of all four limbs), rheumatoid arthritis (form of arthritis that causes pain, swelling, stiffness and loss of function in a person's joints), and chronic pain. Resident 1 was self- responsible for making her own health care decisions.
The Minimum Data Set (an assessment tool), dated 7/5/16, indicated Resident 1 did not have problems with daily decision-making skills, was dependent on staff for all ADLs such as eating, had functional limitation in range of motion (movement) to her upper and lower extremities, and was at risk for developing pressure ulcer (wound that occurs as a result of prolonged pressure on a specific area of the body, commonly known as bed sores).
During an interview on 3/20/17 at 10:15 a.m., certified nurse assistant (CNA) A stated she had been taking care of Resident 1 the last couple of months and she had been refusing care. The resident wore the same pair of socks for many days, would not let anyone remove her socks or clean her feet, and would "get mad."
During an interview on 3/20/17 at 12 noon, CNA B stated Resident 1 was given a bed bath on 3/1/17 because she refused to be showered. Resident 1 would "cry a little," when she refused care, such as having her socks removed. When the resident was bathed she had her socks on and CNA B stated she did not see her feet. Resident 1's refusal of taking off her socks and not cleaning her feet was not reported to the charge nurse.
In a follow-up interview on 3/20/17 at 12:10 p.m., CNA A stated she did not remember when she last saw Resident 1's feet and did not report the refusal because "everyone" knew about Resident 1's refusal for foot care.
Review of Resident 1's Skin/Wound Note dated 5/25/16 at 2:10 p.m., indicated a wound specialist physician noted Resident 1's toe nails were long on both feet. The resident refused podiatry (specialized medical care and treatment of the human foot) services and was informed her nails could dig into the skin.
During an interview on 3/20/17 at 1:45 p.m., with the director of nurses (DON) who reviewed the record, she stated there was no further documentation after 5/25/16 indicating Resident 1 was offered further podiatry services.
Review Resident 1's "Altered behavior" care plan started on 10/21/14 identified problems behaviors such as refusing help from staff but did not specify Resident 1's refusal for removing her socks and receiving foot care.
During an interview on 3/20/17 at 2 p.m., with the DON, she stated the refusal of foot care should have been included in the care plan.
Review of Resident 1's Nursing Weekly Summary Review (NWSR) form dated 3/1/17, indicated Resident 1 had rashes on her groin, abdominal folds and arms. Under the Body Check/Skin Inspection of the form there was a checkmark indicating "Current skin concerns" but there was no narration indicating what the concern was.
During an interview on 3/20/17 at 3:10 p.m., the licensed vocational nurse (LVN) C who completed the 3/1/17 NWSR stated she did not document the condition of Resident 1's feet because the resident refused to have her socks removed. LVN C stated she should have documented the refusal.
During an interview on 3/20/17 at 2 p.m., the DON stated when Resident 1 was transferred to an acute care hospital on XXXXXXX17 staff knew about her skin rash over her body but did not know about the condition of her feet. The DON recalled she was contacted by a hospital case manager around 3/9/17 and was informed about the feet maceration.
Review of the acute care hospital "PODIATRY CONSULT NOTE," dated 3/7/17 at 8:44 p.m., indicated Resident 1 had "Severely unmanaged feet bilateral (both). Multiple grossly elongated (unusually long) and thickened nails bilateral. Left hallux (great toe) partially avulsed (injury in which a body structure is forcibly detached from its normal point of insertion) with minimal proximal medial (situated nearer to the point of attachment) border attached which was removed. No purulence (pus) underneath. There are maceration and thick amounts of fungal (yeast) debris throughout her interspaces as well as peeling epithelial tissue (sheet of cells that covers a body surface or lines a body cavity) throughout. There is more raw epithelial layer overlaying the dorsal (back) left foot."
Review of Resident 1's Skin Inspection Assessment (SIA) form under the Body Check/Skin Inspection section provided guidance to document the type, length, width, depth and stage of the skin. The SIA form dated 3/11/17, after Resident 1 was readmitted to the facility, indicated she had scattered redness to both her feet and legs, scaly/dry skin to both legs, and scattered scabs to her left arm. There was no notation about the toe nails and no further description of the feet such as indicating location and size of maceration.
During an interview on 3/20/17 at 3:10 p.m., registered nurse (RN) D who reviewed his 3/11/17 SIA note stated Resident 1's feet were red and dry and he did not remember how the toes looked. RN D stated his documentation of the resident's wounds to her feet should have been specific.
Review of Resident 1's NWSR form dated 3/13/17, under the Body Check/Skin Inspection Section G number 5: All skin sheets updated under order only identified "bilateral feet."
During an interview on 3/20/17 at 3:20 p.m., RN E, who reviewed his NWSR note dated 3/13/17 described Resident 1's usual behavior of not letting staff touch her feet, taking off her pink socks, and screaming at staff when she refused care. RN E acknowledged the 3/13/17 documentation lacked a description of Resident 1's skin condition.
The "Skin Integrity" policy, dated December 2016, indicated all new admissions were to have a skin risk assessment and an initial head to toe skin assessment by a licensed nurse. Weekly "head to toe" assessments were to be completed for all residents by a licensed nurse.
The "JOB DESCRIPTION / PERFORMANCE EVALUATION" of CNAs included a task to notify the charge nurse/supervisor of concerns promptly including safety concerns and resident health/status change.
During an interview on 3/20/17 at 2 p.m., the DON stated when she found out about Resident 1's foot, she interviewed CNAs from the weekend of March 18th and 19th and learned about the resident's refusal of removing her socks and the CNAs not reporting to licensed nurses. The DON further stated when residents refused care, staff were supposed to continue to offer services, work with residents and document. They did not do this for Resident 1.
The facility failed to provide the necessary care and services for Resident 1 who was unable to carry out activities of daily living in regards to foot care.
The above violations of the regulation had direct or immediate relationship to the health, safety, or security of residents. |
| 070000012 |
LINCOLN GLEN SKILLED NURSING |
070013089 |
B |
29-Mar-17 |
9L0E11 |
5463 |
F281 -- 483.21(b)(3)(i) SERVICES PROVIDED MEET PROFESSIONAL STANDARDS
(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
The facility failed to provide services according to professional standards of clinical practice for one resident (5). A nurse inserted a rectal tube (a long slender tube inserted into the rectum to relieve gas) for resident 5 without removing the cap. This practice resulted in Resident 5 needing to be hospitalized and undergo a procedure to remove the retained rectal tube cap from his rectum.
Resident 5's clinical record indicated he was admitted on XXXXXXX14 with diagnoses of transverse myelitis (inflammation of the spinal cord), paraplegia (paralysis of the legs and lower body), Ogilvie syndrome (distension of the colon in the absence of obstruction), and neurogenic bladder (bladder dysfunction due to disease of the central nervous system).
Resident 5's risk for constipation care plan, dated 12/9/16, indicated, "Administer rectal tubes as ordered by MD."
A physician's order, dated 2/27/17 at 1:30 p.m., indicated Resident 5 was to have a rectal tube inserted for abdominal girth (measurement of distance around the abdomen) greater than 120 centimeters (cm, a unit of measurement).
A physician's order, dated 2/27/17 at 4:00 p.m., indicated Resident 5 was to be sent to the hospital for evaluation and treatment.
A nurse's note, dated 2/27/17 at 6:44 p.m., signed by licensed vocational nurse D (LVN D), indicated Resident 5 was sent to the hospital because the cap of the rectal tube was dislodged in his rectum.
During an interview with LVN D on 3/14/17 at 3:35 p.m., she confirmed she inserted the rectal tube for Resident 5. She stated there was a "blue part" on the tip of the rectal tube that she did not realize was a cap. LVN D stated she inserted the rectal tube, including the cap, and when she pulled the tube out, the cap remained in the resident's rectum.
During the same interview, LVN D stated she had never inserted a rectal tube before attempting it on Resident 5. She also stated she did not have any formal training on how to do it. LVN D explained that on the day of the incident, she asked nurses on the other units if they knew how to insert a rectal tube, but they told her they did not. LVN D stated that after the incident, the assistant director of nursing (ADON) instructed her not to perform any procedures she did not feel comfortable with.
During an interview with registered nurse H (RN H) on 3/16/17 at 10:55 a.m., she stated she was working on the day of the incident involving Resident 5's rectal tube. She stated LVN D asked her if she had ever inserted a rectal tube for Resident 5, to which RN H replied, "No."
During a telephone interview with RN G on 3/16/17 at 12:55 p.m., she stated she was also working on the date of the incident involving Resident 5's rectal tube. She stated LVN D asked her if she knew how to insert a rectal tube, and RN G replied, "No." RN G stated she had not received any in-service (training) about rectal tubes prior to the incident involving Resident 5.
During an interview with the ADON on 3/15/17 at 1:20 p.m., she stated she was in the facility when LVN D inserted Resident 5's rectal tube. She explained that LVN D did not tell her about the rectal tube until after the incident occurred. The ADON stated LVN D should have informed her before attempting to insert the rectal tube, because LVN D had never done it before. The ADON stated, "I could have helped her." According to the ADON, she has instructed staff to ask for assistance with procedures they are unfamiliar with.
During an interview with LVN F on 3/15/17 at 3:50 p.m., she stated the same incident occurred with Resident 5 once in the past. She stated that "a couple of years ago," another nurse inserted a rectal tube without removing the cap and the cap remained in the resident's rectum.
During an interview with the ADON on 3/16/17 at 8:25 a.m., she confirmed the same incident happened to Resident 5 once in the past. She stated she gave an in-service on rectal tubes "a couple of years ago," but did not give any rectal tube in-services during the time between the first incident and the most recent incident involving Resident 5.
A history and physical (H&P) from the hospital, dated 2/27/17, indicated Resident 5 had a "dislodged plastic rectal tube left in his colon/rectum." The H&P indicated manual retrieval (removal using the hands) of the dislodged rectal tube could not be done.
A consultation report from the hospital, dated 2/28/17, indicated Resident 5 had a computerized tomography scan (CT scan, a computerized x-ray image) done, which showed a 12 cm "foreign body" about 8 cm from the anus. The consultation report also indicated the resident would have a sigmoidoscopy (insertion of a flexible tube through the anus into part of the large intestine) to remove the "foreign body."
A physician progress note from the hospital, dated 2/28/17, indicated Resident 5 had "discrete superficial ulcerations" of the rectum, and that the retained "foreign body" was removed with a roth net (a foreign body retrieval device).
Therefore, the facility failed to provide services according to clinical standards of practice.
The above violation had a direct or immediate relationship to the health, safety, or security of the resident. |
| 070000067 |
Los Gatos SNF, LLC |
070013344 |
B |
17-Jul-17 |
AAGU11 |
2534 |
F517--483.75(m)(1) WRITTEN PLANS TO MEET EMERGENCIES/DISASTERS
The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents.
1. During an observation and record review with the Registered Dietician (RD) on 7/7/17 at 10:45 a.m., the emergency food supplies were not separated from the kitchen food supplies. The emergency and disaster menu indicated the milk powder, canned beef stew, canned three bean salad, canned meat raviolis, canned chili with beans, canned peas or beets, low sodium tuna, low sodium vegetable, canned pork and beans were not available for the three day emergency and disaster menu.
During a concurrent interview with the RD, she stated the kitchen food supplies should have been separated from the emergency food supplies. She also stated the above emergency food supplies should have been available for the three days menu for residents, visitors, and staff members during a disaster.
2. During an observation and interview with the maintenance supervisor (MS) on 7/7/17 at 7:20 a.m., the emergency disaster kit was inspected. Two First Aid Kits had expired antibiotic ointments. The first kit had an expiration date of 1/2003 and the second kit had an expiration date of 2008 (month was not visible). The MS stated that he was in the process of replacing the kits and the antibiotic ointments should not be used.
Review of the facility's undated policy, "Emergency And Disaster Procedures," indicated the facilities will have a written plan of action which includes emergency menus to be used in the event of an emergency or disaster. The facilities will maintain an emergency supply on the premises. The menu was designed for disasters which stop gas, electricity, telephones, and water. The emergency and disaster menu must be written to provide adequate nourishment for all residents.
Review of the facility's undated policy, "Emergency Diet Information for End Stage Renal Disease on Hemodialysis" indicated emergency supplies on hand at all times. It should be canned or dried so that they will not spoil. Use foods free from salt that will not create thirst in the resident.
Review of the facility's undated "Disaster Kit Fire & Disaster Manual" indicated the contents of the disaster kit should be inspected and inventoried after each use/or disaster rehearsal.
The above violation has a direct or immediate relationship to the health, safety, or security of the resident. |
| 080000059 |
LAKESIDE SPECIAL CARE CENTER |
080011307 |
B |
06-Mar-15 |
D3GJ11 |
2800 |
The inspection was limited to the specific facility event investigated and does not represent the findings of a full inspection of the facility. 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 in the facility to the department immediately, or within 24 hours. b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report resident to resident abuse in accordance with the facility's abuse policy and within 24 hours, to the Department of Public Health, as required per regulation. On 12/29/14 at 1 P.M., an initial on-site visit to the facility was made to investigate a self- reported elopement incident (Resident 1). During Resident 1's clinical record review, a nurse's note on 11/11/14 at 10:45 A.M., described a resident to resident assault (Resident 1 and Resident 2). Further investigation revealed the facility did not report the abuse to the Department of Public Health. On 12/29/14 at 2:30 P.M., Resident 2's clinical record was reviewed. There was a nursing note, dated 11/11/14, at 10:45 A.M., which described the same assault between Resident 1 and Resident 2. According to the note, Resident 2 reported to LN 1 that Resident 1 punched her on the left side her face and left a red mark. On 12/29/14 at 3:30 P.M., the DON (Director of Nursing), Corporate Administrator, and Administrator stated they were aware of the incident on 11/11/14, but did not report all abuse allegations. Per the DON, Corporate Administrator, and Administrator, the facility did not report abuse to the Department if there were no marks (on a resident). The DON was asked what the facility's policy on reporting abuse was, and the DON replied, "It depends on the injury" and, "I don't know what's written in our policy". The DON stated the facility followed the policies and procedures for reporting the incident to the proper authorities. According to the facility's policy on abuse reporting titled "Rights - Protection From Abuse Adult/Elder Abuse Reporting" (undated) 3.0 (3.1) "Any elder care custodian, medical practitioner... The report shall be telephoned to the local Ombudsman, Department of Licensing and Certification...immediately or as soon as practical." On 8/3/11, the facility was cited with a CLASS B CITATION -ABUSE/FACILITY NOT SELF REPORTED for a similar incident involving an unreported resident to resident abuse allegation. The facility's POC (Plan of Correction), completed on 8/15/11, included: "- Incidents of Physical Resident to Resident altercation will be reported to D.P.H./Ombudsman" and, "- Episodes of suspected/alleged/witnessed physical altercations will be reported toDPH/Ombudsman per facility abuse policy" |
| 080000307 |
LAS VILLAS DEL NORTE HEALTH CENTER |
080011883 |
B |
11-Dec-15 |
60IU11 |
6837 |
F 226- 483.12 (c)(1)(i)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: 1. Verify the professional licenses of 8 of 18 Licensed Nurses ( LNs 1, 2, 4, 5, 6, 7, 8, and DON 1) and maintain copies of current licenses on file at the facility. 2. Verify the certifications for 12 of 22 Certified Nursing Assistants (CNAs 1, 2, 3, 4 ,5 ,6, 7, 8, 9, 10, 11, and 12) and maintain copies of current certification on file at the facility. 3. Follow their policy on annual abuse prohibition training for 8 of 40 direct care staff (LN 1, LN 5, LN 8, LN 10, LN 11, LN 12, LN 13, and CNA 13). As a result, CNA 4 provided care to residents for 23 days while her certification was expired. There was the potential for additional LNs and CNAs to have been working while their licenses were expired. In addition, 8 staff did not receive annual abuse training in order to protect all resident from potential abuse. On 8/4/15 at 5 P.M., the Department made an unannounced visit to the facility for a complaint investigation regarding staff training and qualifications. During an interview on 8/4/15 at 6:45 P.M., the Director of Staff Development (DSD) stated the staff were responsible to know when their license and Cardiopulmonary Resuscitation (CPR) would expire, and to provide the facility with an updated copy of each. The DSD stated the Business Office Manager was responsible for the license verification of staff upon hire. The DSD further stated, she kept a book with copies of the LNs and CNA's licenses in her office. The DSD stated, "I noticed that one CNA [CNA 4] had an expired certification."On 8/4/15 at 6:50 P.M., the Regional Director and DON provided employee records for all LNs and CNAs employed by the facility. The employee records were reviewed: 1. CNA 4's professional certification expired on 6/18/15. There was no verification of the CNA's license documented in the employee file. CNA 4 was under suspension pending an allegation of abuse against a resident during the survey. 2. The Director of Nursing's (DON 1) professional license expired on 4/30/15. DON 1 provided her license from her purse and confirmed the facility did not have a current copy of her license on file. DON 1 acknowledged her license had not been verified by the facility. 3. CNA 1's (who was working at the time of the survey) certification expired on 5/17/15. There was no verification of certification in the CNA's file. During a joint interview with CNA 1 and DON 1 on 8/4/15 at 8:45 P.M., CNA 1 stated he provided the DSD a copy of his updated certification "last week." The CNA went home to retrieve his professional certification. DON 1 confirmed the facility had not verified CNA 1's certification. 4. LN 2's (who was working at the time of the survey) license expired 6/30/15. During an interview on 8/4/15 at 9:20 P.M., the DSD confirmed the facility did not have a current valid license on file nor did the facility perform license verification for LN 2. According to the facility's records, 8 current employees, who provided direct care to residents, did not have a valid license/certification on file at the facility. According to the facility's records, 20 current employees who provided direct care to residents, did not have verification of their license/certification on file at the facility. During a follow up visit to the facility on 8/5/15 at 9:20 A.M., the DSD provided CNA 4's time sheets from 6/21/15- 7/25/15. The DSD confirmed, CNA 4 provided direct care to residents for 23 days after her certification had expired. The DSD stated, she should have obtained a current valid certification from CNA 4 and verified it prior to the CNA providing care to the residents. During a subsequent follow up visit to the facility on 8/20/15 at 1:35 P.M., DON 1 was asked to provide documentation of annual abuse prohibition education for all direct care providers. DON 1 stated, "It's all over the place right now, I'll see if I can find it." During an interview on 8/20/15 at 2:35 P.M., the Administrator (NHA) stated she was aware the facility should have copies of all professional licenses and employee abuse education in the employee file and readily available. The NHA stated the staff should be responsible to renew their licenses, but the DSD should verify the CNA certifications and the DON should verify the LN licenses. During an interview on 8/20/15 at 4:40 P.M., the NHA stated, the DSD was responsible for training all staff who worked in the facility for abuse prohibition. The NHA further stated, "The [DSD] has stuff everywhere in stacks and we are trying to sort through and find the sign in sheets." The facility was unable to provide documentation of abuse prohibition training for all staff by the end of the onsite visit on 8/20/15. On 9/4/15 a subsequent visit was made to the facility. During a joint interview with the DON and DSD at 3:40 P.M., DON 1 stated, the facility did not have a policy and procedure for verification of licenses/certifications. DON 1 further stated the DSD should verify all licenses and certifications when staff renewed them. The DSD stated, when she started in her position on April 26, 2015, "verifications and staff education were backed up and they continued to get backed up." The DSD stated, the facility did not have a system in place to keep track of license/certification renewals, verifications, or abuse prohibition training. Both the DSD and DON confirmed, the facility had not verified professional licenses, kept records of all current licenses, or current abuse prohibition training. The DSD was unaware if all direct staff had been trained in abuse prohibition over the past year. As of 9/4/15, the facility was unable to provide documentation 8 of 40 direct care staff completed annual abuse prohibition training. According to the facility's policy and procedure entitled, Resident Abuse, dated 7/11/11. "... at least annually Associates review the topics of Resident Rights and definitions of abuse and requirements for reporting ... " According to the policy entitled, State Nurse Assistant Registry Reference Check, dated 5/98, "... The DSD or designee will recheck certifications annually and document the information obtained ... Documentation of certification checks will be maintained in the employee's file ..." The Facility was unable to provide a policy on verification of Licensed Nurse license verification. The facility failed to verify the licenses of 8 LNs and the certifications of 12 CNAs. The facility also failed to provide abuse prohibition training for 8 staff members who provided direct care to residents. These violations had a direct relationship to the health, safety, or security of the residents. |
| 080000307 |
LAS VILLAS DEL NORTE HEALTH CENTER |
080011884 |
B |
11-Dec-15 |
XOG211 |
11925 |
483.25 - The facility must ensure that 1. Resident environment remains free of accident and hazards as is possible and 2. Each resident receives adequate supervision and assistive devices to prevent accidents. The facility failed to: 1. Provide training and conduct competency assessments for Certified Nursing Assistants (CNA) who used the facility's EZ Lift mechanical lift to transfer dependent residents from their beds to wheelchairs. (The EZ lift uses a sling, designed for use with that specific lift, which is placed under the resident and is attached to the lift with loops to support the resident safely during the transfer.) 2. Ensure CNAs used a sling designed for the EZ Lift mechanical lift, according to the manufacturer's guidelines.3. Perform maintenance on the EZ Lift mechanical lift (1 of 1 mechanical lifts utilized by the facility), according to the manufacturer's guidelines. 4. Remove a lift sling which was worn and frayed from resident use for 1 sampled resident (Resident 1). As a result, CNAs used the incorrect sling, which was worn and frayed, on the facility's EZ Lift mechanical lift to transfer Resident 1. During the transfer, 2 of the 4 straps on the sling broke; Resident 1 fell to the floor, and sustained a fractured vertebrae (broken back). Resident 1 experienced severe pain for four days, had to wear a back brace for over 4 weeks, and was unable to eat independently as a result of the fall.Resident 1 was admitted to the facility on 12/26/08 with diagnoses which included Multiple Sclerosis (a chronic, progressive disease involving damage of nerve cells in the brain and spinal cord). Symptoms may include numbness, impairment of speech, muscular coordination and paraplegia (paralysis of the legs and lower body). Resident 1 was her own responsible party, according to the Face Sheet. According to the MDS (Minimum Data Set- a tool used to assess the resident), dated 7/22/15, the facility assessed the resident as unable to transfer herself, requiring the assistance of 2 staff with a mechanical lift. During an interview on 10/13/15 at 2 P.M., Resident 1 stated, CNA 1 and CNA 2 were transferring her from a bed to a wheelchair using a sling and the facility's mechanical lift. Resident 1 stated, during the transfer, 2 of the straps on the sling used to transfer her broke and she fell to the floor and sustained a fractured vertebrae. Resident 1 stated, she was sent to the hospital for treatment. Resident 1 explained she had to wear a brace on her back as a result. Resident 1 stated the CNAs used a gray and black sling which was kept in her closet for the transfer. Resident 1 stated, "They call it mine [the sling], I think because I'm the only one who uses it, but it's not really mine." Resident 1 stated there were 2 gray and black slings in her closet but she told the staff not to use one of them because it was broken. During an interview on 10/13/15 at 2:15 P.M., CNA 1 stated she and CNA 2 used a gray and black sling to transfer Resident 1 with the EZ Lift mechanical lift on 6/6/15. CNA 1 stated, they lifted the resident from the bed and moved the lift away from the bed toward the chair when the straps on the sling broke and Resident 1 fell to the floor. CNA 1 stated she learned how to use the mechanical lift from another CNA who no longer worked at the facility. CNA 1 stated the facility did not provide any formal training on the EZ Lift mechanical lift and did not review her competency on using the lift. During a joint observation and interview with CNA 3 on 10/13/15 at 2:40 P.M., three blue mesh slings were observed in the facility's linen closet. CNA 3 confirmed the writing on the tags of all three slings was worn and he was unable to read the brand or size. CNA 3 stated the slings found in the closet were not the same as the slings used for Resident 1. CNA 3 stated, "They [Resident 1's slings] were much older and frayed." CNA 3 stated the slings used on Resident 1 were gray with black trim. CNA 3 stated he learned how to use the facility's mechanical lift by watching CNA 1 and CNA 4. CNA 3 stated all slings were interchangeable and any sling could be used with the EZ Lift. On 10/13/15 at 2:50 P.M., the DON provided 2 gray and black slings which she stated were removed from Resident 1's room, one of the two was the sling which broke during the mechanical lift transfer. Both slings were made of solid gray material in the shape of a rectangle with black nylon binding around the exterior and black nylon loops at each corner. The DON stated, Resident 1 asked staff not to use one of the slings due to a broken plastic strip in the binding of the sling. The sling which was used to transfer Resident 1 was observed with the DON. On the right side of the sling both the top and bottom black nylon loops, which were placed on the hook of the mechanical lift, were broken in half in the middle. Both slings were observed to be frayed on the stitching of the black nylon. The writing on the manufacturer's label could not be read due to wear. During a joint interview and review of the EZ Lift Manufacturer's Guidelines on 10/13/15 at 3:10 P.M., the Maintenance Supervisor (MS 1) stated he was responsible to perform scheduled maintenance on the EZ Lift. MS 1 stated the facility did not have a policy on how often the mechanical lift should be inspected. MS 1 stated, "It's inspected annually." According to the EZ Lift manufacturer's guidelines, the lift should be inspected at intervals not greater than one month. MS 1 confirmed, he was not inspecting the EZ Lift according to the manufacturer's guidelines. MS 1 confirmed, the facility did not follow manufacturer's guidelines for replacing slings after 6 months to 1 year. MS 1 stated, "They get replaced when nursing orders them." MS 1 was unaware if the gray and black sling used to transfer Resident 1 when she fell from the mechanical lift was an EZ Lift brand sling. MS 1 stated, "The sling she [Resident 1] has now is not an EZ Lift sling; it's an Invacare sling." MS 1 further stated, "The manufacturer would say not to use it, but I don't see a problem with it." On 10/15/15 at 7:45 A.M., Resident 1's record was reviewed. According to the Nursing Notes on 10/5/15 at 10 A.M., Resident 1 sustained a fall from the facility's EZ Lift mechanical lift and was transported to the hospital for evaluation at 10:40 A.M. According to the CT scan report, (several X-ray images of structures inside the body converted into pictures on a monitor), dated 10/5/15, at 1:55 P.M., "...There is an acute appearing T 12 compression fracture (broken back) resulting in 25% height loss..." According to the September 2015 Medication Administration Record (MAR), the LNs documented "0" pain prior to 10/6/15 when the resident fell from the mechanical lift. According to the Acute Pain Assessment dated 10/6/15-10/10/15, the LNs documented Resident 1 complained of moderate to severe pain daily and required Percocet (narcotic pain medication) administration 1 to 3 times daily. According to the Occupational Therapy Plan of Care, dated 10/7/15, The Occupational Therapist (OT 1) documented "... Pt (Resident 1) also has new complaint of right arm pain and increased weakness limiting ability to self feed s/p (following) fall... without skilled OT intervention, patient is at risk for increased burden of care..." Under Prior Residence and Living Arrangement, OT 1 documented, "... is able to feed self with built up grip utensils..." During an interview on 10/15/15 at 8:55 A.M., CNA 5 stated she sometimes trained the new CNAs on use of the EZ Lift mechanical lift and instructed them that all slings were interchangeable with the lift. CNA 5 stated, slings that were broken or worn should have been removed from service and a new sling should have been ordered for the resident. During an interview on 10/15/15 at 10 A.M., CNA 4 stated the facility had 4 different brands of slings and all 4 could be used with the EZ Lift mechanical lift. CNA 4 stated, she learned how to use the lift from "the other CNAs", but could not remember who. CNA 4 stated the facility did not assess her competency with the use of the EZ Lift. CNA 4 stated, she did not use one of Resident 1's slings because "it had a piece sticking out" but confirmed the broken sling remained in the resident's closet. During an interview on 10/15/15 at 9:30 A.M., the Social Service Designee (SSD 1) stated, on 10/2/15, Resident 1 reported her slings were "old and wearing down" and requested new slings. The SSD stated, she did not notify the staff of Resident 1's complaint that her slings were worn. The SSD was unaware who was responsible for ordering new slings for the resident. The SSD stated, "By the time I found out the slings were provided by the facility, she had already fallen." During an interview on 10/15/15 at 10 A.M., Occupational Therapist (OT 1) stated, since Resident 1's fall from the mechanical lift, she had not been able to feed herself without assistance. OT 1 stated, "[Resident 1] needs assistance especially with breakfast and lunch and she was independent before. She likes being very independent." During a joint interview with the DON and Central Supply Director (CSD 1) on 10/15/15 at 10:25 A.M, CSD 1 stated she was responsible for ordering the slings for the facility's EZ Lift mechanical lift. CSD 1 stated she ordered a blue mesh Invacare brand sling for Resident 1 in March 2015. The CSD further stated, all slings were interchangeable and any sling could be used with the EZ Lift mechanical lift. CSD 1 provided her product catalog she used to order the slings and opened it to the page which contained the information on the Hoyer brand gray and black sling which was used to transfer Resident 1 when she fell from the mechanical lift. CDS stated, "This is the sling the resident had." The DON confirmed the sling was a Hoyer brand sling. At the bottom of the page for the ordering information on the gray and black sling was an "Important Safety Note" which warned "Hoyer slings must be used with Hoyer lifts." The DON confirmed the sling was not used per the manufacturer's guidelines. During a follow up interview on 10/15/15 at 11 A.M., Resident 1 stated her physician told her she would need to continue to wear the torso brace for an additional 4 weeks. Resident 1 stated, "The pain was bad" for approximately 4 days after her fall. Resident 1 further stated, she fell on her right arm and it had been weak since the fall. Resident 1 stated, "I use my right arm to eat so I've needed more help with that which I don't like." Resident 1 also stated she notified SSD she needed new slings approximately one week before she fell from the facility's mechanical lift. The DON was unable to provide records of staff training on the facility's EZ Lift mechanical lift during the investigation. The facility did not have a policy for scheduled maintenance for the mechanical lift or lift slings. According to the EZ Lift Manufacturer's Brochure, revised 1/9/06, "... For safe operation... watch the video training tape, read through the operator's manual, and practice on fellow staff members before using on patients...insure that the sling is not ripped or frayed..." According to the FDA Patient Lifts Safety Guide located on the EZ Lift website (http://www.ezlifts.com/downloads/), "... Only use a sling specifically designed for your lift. Using the wrong sling may cause serious injury..."The facility failed to assess the competency of staff utilizing the EZ Lift mechanical lift and failed to perform routine maintenance on the mechanical lift and lift slings, according to manufacturer's guidelines. In addition, the facility failed to ensure staff used a sling designed specifically for the EZ Lift mechanical lift and failed to remove a sling which was worn and frayed from use. These violations had a direct relationship to the health, safety, or security of the residents. |
| 080000089 |
LA PALOMA HEALTHCARE CENTER |
080012010 |
B |
04-Feb-16 |
GPWG11 |
3091 |
F225 483.13(c)(2) The facility failed to report an allegation of resident abuse by a CNA to the Department for 6 days after the alleged abuse occurred. As a result, the Department was not aware of the allegation within twenty-four hours as required per regulation and facility policy. On 9/14/15, an unannounced visit was made to the facility to investigate an incident of alleged abuse regarding Resident 1, reported by the facility to the Department on 9/12/15 at 12:12 P.M. Resident 1's clinical record was reviewed on 9/14/15. The resident was admitted to the facility on 8/25/15, per the Resident Admission Record. According to the Brief Interview for Mental Status Assessment, conducted on 9/1/15, Resident 1 scored 15 out of 15 points, indicating no cognitive losses. The Director of Nursing (DON) was interviewed on 9/14/15 at 3:30 P.M. According to the DON, the facility was made aware, on 9/7/15, of an allegation that a Certified Nursing Assistant (CNA) put her finger into Resident 1's vagina during care on 9/5/15. The DON stated the Administrator decided the allegation was not abuse and failed to report the allegation to the Department until after the police came to the facility to interview the resident after the family reported it on 9/11/15. LN 1 was interviewed on 9/14/15 at 4 P.M. Licensed Nurse 1 (LN) said, Family Member 1 (FM) telephoned the facility on Monday 9/7/15 at 6 P.M. and told her Resident 1 said a Certified Nursing Assistant (CNA), who was cleaning the resident after a bowel movement on 9/5/15, placed a finger in her vagina. LN 1 said she interviewed Resident 1 at the resident's bedside with the help of CNA 1 and FM 2 as interpreters. LN 1 said because the resident said she was afraid in the facility, she considered the allegation to be an abuse allegation, so she notified the Administrator and DON by text message. FM 2 was interviewed by telephone on 9/22/15 at 12:15 P.M. FM 2 stated Resident 1 told her the CNA put her finger in her vagina purposefully and she relayed that information to LN 1 when she spoke with LN 1. According to the Administrator's investigative report, dated 9/8/15, he spoke with FM 2 and Resident 1 about the allegation. The Administrator failed to report it to the Department at that time. The DON was interviewed on 10/7/15 at 4:40 P.M. The DON said the facility failed to follow their abuse policy and procedure, regarding reporting all allegations of abuse to the Department. Per the facility's policy and procedure, entitled Reporting Abuse to State Agencies and Other Entities/Individuals, revised November 2010, "Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident) be reported, the facility Administrator, or his/her designee will promptly notify the following persons or agencies (verbally and written) of such incident. The State licensing/certification agency responsible for surveying/licensing the facility........ Verbal and written notices will be made within twenty-four hours of the occurrence...." |
| 080000307 |
LAS VILLAS DEL NORTE HEALTH CENTER |
080012219 |
B |
05-May-16 |
2HY711 |
5384 |
F 206 A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services. The facility refused to re-admit 1 of 3 sampled residents (1) after Resident 1 was admitted to the hospital for treatment for 8 days. In addition, the facility failed to establish a policy which allowed for readmission to the facility upon the first available bed, when the seven day bed-hold period (time in which the facility is required to hold a bed for a resident while they are in the hospital and plan to return to the facility) had lapsed. As a result, Resident 1, who had lived at the facility for over 4 years, was denied readmission after her hospitalization and was discharged to another facility, which her family said caused her to be, "heartbroken". Resident 1 was admitted to the facility on 1/12/11 with diagnoses which included anxiety and custodial care [long term care] and had fluctuating capacity to make her own decisions, according to the admission History and Physical. Resident 1 had a Responsible Party (RP 1) to assist in her decision making, according to the most recent History and Physical, dated 6/19/15. On 2/19/16 Resident 1's clinical record was reviewed. On 10/8/15, the facility obtained a physician's order to transfer Resident 1 to the hospital, due to the resident's complaints of abdominal pain. On 10/15/15, the facility's social worker (SW 1) documented, she notified the hospital "... [Resident 1] would need to go to another facility that would be able to meet her needs for custodial care [long term care]..." According to the facility's daily census, on 10/15/15 the census was 20 and Resident 1's bed remained empty. The facility was licensed for 37 beds. On 10/16/15 the census was 20 and Resident 1's bed remained empty. There was no documentation in Resident 1's clinical record which indicated the facility notified the resident of the facility's bed hold or readmission policy when the resident was transferred to the hospital. During an interview on 2/26/16 at 12 P.M., the hospital's social worker (SW 2) stated she called the facility to arrange Resident 1's return to the facility on 10/15/15, seven days after the resident was admitted to the hospital. SW 2 stated the facility informed her they would not accept the resident because they did not have a bed available. SW 2 stated Resident 1 was discharged to another skilled nursing facility on 10/16/15. During an interview on 3/14/16 at 3:50 P.M., the facility's Admissions Director (AD 1) stated the facility held Resident 1's bed at the facility for 7 days. AD 1 further stated, she discussed the plan for Resident 1 to return to the facility with the Administrator. AD 1 stated the Administrator decided Resident 1 would not be allowed to return to the facility if she remained in the hospital longer than 7 days because the resident's payor source was Medical. AD 1 confirmed the facility would have been able to provide the necessary care for the resident after her hospital stay. AD 1 also confirmed Resident 1's bed was available on 10/16/15, when the hospital discharged the resident. AD 1 stated, she told the hospital social worker the facility was unable to provide custodial care for the resident and therefore, the facility would not readmit Resident 1. During an interview on 3/10/16 at 4:30 P.M., the Interim Director of Nursing (DON 1) stated there was no documentation in Resident 1's clinical record which indicated the facility notified the resident's RP of the facility's bed hold policy when the resident was transferred to the hospital on 10/8/15. DON 1 also stated the facility did not have a policy for readmission to the facility upon the first available bed after the bed-hold period had lapsed. Admin 1 and SW 1 no longer worked at the facility and were unavailable for interview during the investigation. During an interview on 3/15/16 at 11 A.M., RP 1 stated she was not informed of the facility's bed hold policy when the resident was transferred to the hospital. RP 1 stated, AD 1 told her the facility did not have an open bed for Resident 1 when the hospital was planning to discharge the resident. RP 1 further stated she returned to the facility approximately 1 week after the resident was discharged from the hospital to a different long term care facility, to collect Resident 1's belongings. RP 1 stated, Resident 1's bed remained empty and her belongings were still in her room. RP 1 stated she asked why Resident 1 was not allowed to return to the facility when her bed remained open. RP 1 stated, "They told me the rules were if a resident was in the hospital for over 7 days, they were not allowed to return." RP 1 stated Resident 1 was heartbroken she could not return to the facility. RP 1 stated, "She kept asking why she couldn't go home." RP 1 stated the facility should have allowed Resident 1 to return to her home after she was discharged from the hospital. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 010000428 |
Lakeview House |
110010096 |
A |
10-Mar-14 |
1WCB11 |
5806 |
A008 W&I 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to ensure the right to be free from physical, mental and verbal abuse for Client 2 when House Manager B screamed, yelled at Client 2, shoved her from behind and grabbed her left arm resulting in a spiral fracture of her left forearm. The facility is a 6 bed Intermediate Care Facility for the Intellectually Disabled licensed to provide care and services to people with varying degrees of developmental and intellectual disability.Client 2 was severely developmentally delayed and was unable to accurately communicate details about the incident.During an interview on 6/28/13 at 3:30 p.m., SLP Supervisor A stated that she came to the facility to pick up supplies on 6/27/13. She stated that she could hear House Manager B yelling from outside the building. When she walked through the door, she saw House Manager B yelling at Client 2. When she walked into the house, House Manager B was in the dining room with Client 2. She stated that she was yelling at her: "Quit obsessing over your sunglasses! Quit obsessing! If you're going to obsess over them, we'll take them away from you!" SLP Supervisor A stated that she then saw House Manager B rip the sunglasses off of Client 2's head, shoved her towards her room and then grabbed her by her arm in a rough manner and forcefully escorted her towards her room.SLP Supervisor A stated that this incident was witnessed by five clients (Clients 1, 3, 4, 5 and 6) and two staff members (Direct Care Staff C and D). During an interview on 6/28/13 at 4:40 p.m., Direct Care Staff C related his recollection of the events of 6/27/13 at 8:30 a.m. as follows:House Manager B was yelling at Client 2 to stop obsessing about her sunglasses. He stated that he heard House Manager B yelling at Client 2, and saw House Manager B rip the sunglasses off Client 2's head, and shoved Client 2 from behind to get her to go towards her room. He stated that Client 2 was shoved so hard that she lost her balance. She didn't actually fall, but Client 2 wobbled as she tried to regain her balance. When questioned as to if he had ever witnessed House Manager B being "rough" with clients in the past, Direct Care Staff C stated that House Manager B has grabbed Clients 1 and 2 at times from behind and walked them to their rooms "rather forcefully". During a Document Review on 6/28/13 at 5:15 p.m., written statements were reviewed from: Supervisor A, Nurse E, Direct Care Staff C, and Direct Care Staff D. The written statements supported the observations and sequence of events that Supervisor A had shared.During an observation on 6/28/13 at 5:10 p.m., when Nurse E examined Client 2 was not able to use her left arm and was guarding it. Client 2 held her left arm crooked inward, close to her chest as much as possible, as if to protect her left arm. Nurse E stated that she took Client 2 to the Emergency Room that same evening for evaluation and treatment. During record review, the Emergency Room (ER) report for Client 2 indicated the following:Client 2 was evaluated and treated at the ER on 6/28/13. An X-ray report of the left forearm and left humerus (the bone that extends from the shoulder to the elbow), dated 6/28/13, confirmed a non-displaced fracture of the mid-ulna. This is two oblique fractures (a slanted fracture of the shaft along the bone's long axis) which meet in the center. Left forearm show a Spiral-Oblique Fracture of the distal left ulnar diaphysis (growth plate) with a butterfly fragment (a wedge-shaped fragment of bone split from the main fragments). Client 2 was placed in a short-arm fiberglass cast.During a document review, the facility's Abuse Policy indicated the following: Policy (no date) - (Name of Organization) ...forbids at any time abuse, neglect, exploitation or corporal punishment...failure of any staff member to immediately report suspected abuse will result in disciplinary action....It is the responsibility of all employees to intervene and to report suspected abuse....Ethical and moral principles require that agencies employ positive behavior interventions ...while prohibiting and preventing the use of procedures that may cause physical or psychological harm or are dehumanizing. Review of information relating to spiral fractures (a fracture in which the bone has been twisted apart and the line of break is helical) revealed that these types of fractures occur when a twisting motion is applied to a limb. The resultant fracture has a diagonal angle to it. Spiral fractures are highly indicative of child abuse, as opposed to accidental. Source:The facility's violation of Client 2's right to be free from physical, mental and verbal abuse when House Manager B screamed and yelled at Client 2, shoved her from behind and grabbed her left arm resulted in a spiral fracture of her left forearm, caused her physical pain and made her feel fearful and unsafe in her home.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. |
| 110000031 |
La Mariposa Care & Rehabilitation Center |
110010873 |
B |
14-Aug-14 |
PIH511 |
3397 |
?1418.91(a) - Health and Safety Code (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. The facility failed to report an allegation of physical abuse to the Department of Public Health, State Licensing and Certification Agency. This failure resulted in the Departments inability to independently investigate the abuse allegations in a timely manner and had the potential for this and other residents to be exposed to abuse.Resident 1 was admitted to the facility on 5/17/13 with diagnosis that included a stroke, diabetes and chronic kidney disease. Resident 1's physician had noted that Resident 1 was blind. During a record review, on 6/25/14 at 10:30 a.m., nursing notes dated 5/12/14 at 5 p.m. noted that Resident 1's daughter notified Licensed Nurse (LN) A that Resident 1 complained that he was hurt when a CNA hit him in the face with a rag the prior week. LN A noted that Resident 1 did not have any bruising to the face and that the attending physician was notified of the concern/allegation. A Care Plan dated 5/12/14 indicated "Potential for Emotional Distress due to allegations of being hurt by a CNA."During an interview, on 6/25/14 at 11:50 a.m., when asked if this allegation of abuse had been investigated by the facility, Management Staff B stated that the allegation had not been reported to management staff at the facility and therefore had not been investigated and not reported to the Department. During an interview, on 6/25/14 at 10:50 a.m., the Director of Nurses stated that this allegation had not been reported to her, and that she was on vacation during that week. During an interview on 6/25/14 at 2 p.m., LN A stated that a grievance/complaint form had been completed. LN A stated that Resident 1 had been asked 3 or 4 times that evening about the allegation and that Resident 1 could not identify the CNA and just stated that it had occurred the previous week when a CNA was washing his face. LN A stated that Resident 1 had probably confused washing of the face with a washcloth with being hit with a rag. LN A stated that she was aware of the policy and procedure for potential abuse. LN A had not notified administration of this allegation and thought that the grievance / complaint form was adequate as the specific individual could not be identified. The facility policy and procedure titled: Abuse Investigation and Reporting, dated 8/31/05 indicated "...all suspected or alleged occurrences of abuse will be investigated and reported according to the required regulation...1. Upon any suspected/alleged violation of abuse the licensed charge nurse will immediately notify the Administrator and Director of Nurses... This is to provide directions on which interventions should take place for the protection of our residents. It is also so that we will be in compliance with the 24 hour reporting requirements under the State regulations." The facility document "Abuse Program," not dated, includes: "...If abuse is suspected or confirmed, a report will be made within 24 hours to both the ombudsman's office and to the Department of Health Services using the SOC 341 Report of Suspected Dependent Adult/Elder Abuse form." The violation of this regulation had a direct relationship to the health, safety or security of residents. |
| 110000863 |
Laurel Creek Health Center |
110013307 |
B |
20-Jul-17 |
5D9F11 |
3892 |
B 985 T22 DIV5 CH3 ART3-72315(b) Nursing Service - Patient Care
(b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind.
Based on observations, interviews, and record reviews, the facility failed to treat 2 of 2 sampled residents with dignity and respect and not subjected to verbal or physical abuse of any kind when:
1. Resident 2 was handled roughly and sustained bluish discoloration on right wrist and purplish discoloration to left inner wrist and left outer forearm. CNA C (Certified Nursing Assistant) took a towel soaked with water and squeezed over Resident 2's chest and saturated Resident's 2's pad on the bed. 2. CNA C called Resident 1 an old hag.
Findings:
On 4/11/17 the Department received a report from the facility regarding an allegation of abuse by a CNA, the letter indicated that on 4/10/17 at approximately 4:30 p.m., CNA C verbally abused Resident 1 by calling her an old hag and then physically and verbally abusing Resident 2 when CNA C took a towel soaked with water and squeezed over Resident 2's chest and saturated Resident's 2's pad on the bed.
1. Resident 2 was a XXXXXXX year old female, admitted to the facility on XXXXXXX08 with the diagnoses of dementia including blindness of both eyes. Resident 2's MDS (Minimum Data Set, an assessment tool) dated 1/12/17 indicated Resident 2's cognitive skills for daily decision making was moderately impaired and supervision was required. The MDS also indicated Resident 2's vision was severely impaired.
During an interview on 4/12/17 at 2:35 p.m., CNA B stated the following: CNA B and CNA C went to Resident 2's room to give a bed bath to Resident 2. CNA C pulled up Resident 2's shirt. CNA C smelled Resident 2's armpits and said "Is that you, I am going to start calling you Queen Must." CNA C started squirting water with no soap on Resident 2's chest. Resident 2 asked CNA C "What are you doing." CNA B told CNA C that what CNA C was doing is wrong. CNA C continued what she was doing. Resident 2 was so soaked and everything [meaning linens] required changing. CNA C turned Resident 2 roughly towards CNA B. CNA B told CNA C you are going to get into trouble. Resident 2 stated "I feel like I am throwing up." CNA B stepped back so Resident 2 would not throw up on her. CNA C started to laugh. CNA C then took off Resident 2's socks and said "Look at those mother f...kers."
The Interdisciplinary progress notes dated 4/10/17 at 5:20 p.m., after the above incident on 4/9/17, indicated Resident 2 had skin changes noted: bluish discoloration to right wrist, purplish red discoloration to left inner wrist and left outer forearm.
2. Resident 1 was a XXXXXXX year old female admitted to the facility on XXXXXXX15 with the diagnosis of multiple sclerosis (neurological disorder).The MDS (Minimum Data Set, an assessment tool) dated 2/23/17, indicated that Resident 1's cognitive skills for daily decision making was moderately impaired and supervision was needed. The MDS also indicated Resident 1 had a minimal difficulty in hearing and impaired ability to see in adequate light.
During an interview on 4/12/17 at 2:35 p.m., CNA B stated while they were putting Resident 1 to bed on 4/9/17 at 9:30 p.m., CNA C was behind Resident 1 and CNA B overheard CNA C said [Resident 1 named], "you old hag."
The facility's definition of abuse is the "Willful infliction of injury, unreasonable confinement, intimidation, exploitation, or punishment with resulting physical harm, pain or mental anguish. In general, elder abuse is a term referring to any knowing, intentional, or negligent act by a caregiver or any other person or self that causes harm or a serious risk of harm to a vulnerable adult."
These failures had a direct relationship to the health, safety, and security of the residents. |
| 120000901 |
LOYD'S LIBERTY HOMES, INC. - COLONY OAK |
120010532 |
A |
24-Mar-14 |
KSZE11 |
6616 |
W319 (a)(1): The facility must ensure the availability of physician services 24 hours a day. W331: The facility must provide clients with nursing services in accordance with their needs. Based on interview and record review, the facility failed to ensure: 1. Client 1 was assessed by the Registered Nurse (RN) and 2. The emergency medical system (911) was activated when Client 1 became gravely ill. These failures resulted in a delay in Client 1 receiving emergency lifesaving care during a life threatening illness. On 5/3/11 at 9:17 AM, an unannounced visit was made to the facility to investigate one complaint and one entity reported incident of the death of a client (Client 1). Client 1 had diagnoses of severe developmental disabilities, blindness, and moderate cerebral palsy (is a term that describes a group of disorders that affect movement control) with spastic quadriplegia (a subset of spastic cerebral palsy that affects both arms and legs).During an interview with Family A on 5/2/11, at 3:45 PM, she state when Client 1 was gravely ill, the facility staff should have sought emergency help for Client 1 sooner than they did. Also, she was upset because the facility should have call an ambulance to transport Client 1 to a hospital instead of driving him to the hospital in the facility van.During an interview with Staff A on 5/3/11, at 9:45 AM, she stated Client 1 was usually very talkative and would eat anything given to him. She stated he had been sick with influenza the weekend of 4/16/11 and 4/17/11. The morning of 4/18/11, he was sick in bed and staff brought him out and placed him in a reclining chair. She stated he was very lethargic and did not help with his transfer from the wheel chair to the recliner as he normally would do. She left the facility for a while and when she returned, he was still in the reclining chair. When she was helping the staff to prepare him to be transported to a hospital, he was very pale and lethargic. He moaned during this process. During an interview with the Qualified Developmental Disability Professional (QDDP) on 7/27/11, at 8:45 AM, she stated she was off work the weekend Client 1 became sick. She stated the staff was trained in an emergency situation to call 911, the RN, and the QDDP in that order. During an interview with Staff B on 7/27/11, at 1:15 PM, he stated when he arrived at the facility at 2 PM on 4/18/11; Client 1 was sitting in a reclining chair and was very weak. Staff B stated the Licensed Vocation Nurse (LVN) was in the facility talking with the QDDP or RN on the telephone. She was instructed to send Client 1 to Hospital A via the facility's van. Staff B stated, "I put (Client 1) in the van and he was not talking. Usually (Client 1) was very talkative and would sing while in the van but he would not say anything when I was talking to him." Staff B stated in an emergency situation, he had been trained to call the RN or QDDP before calling 911. The clinical record for Client 1 was reviewed. The "Psycho-Social Assessment," dated 10/2010, indicated Client 1 was able to verbally communicate consistently with staff, as well as, by using his hands and facial expressions. He was able to do numerous things with his upper torso but could not bear weight on his lower legs. The nursing progress notes written by the RN, dated 4/18/11, indicated she informed, via a phone call, the LVN to transport Client 1 to the hospital for evaluation. This progress note also read, "Client (Client 1) in hospital with congestion and dehydration. Arrived at house (RN arrived at the facility approximately 1 1/2 hours after Client 1 went to the hospital) at 7:30 PM...admitted to ICU (intensive care unit) at (Hospital A)." During an interview with the LVN on 9/1/11, at 2 PM, she stated the day Client 1 was sent to the hospital, he was sitting in the reclining chair. When she called his name, he would lift his head up a little but he seemed very lethargic. She stated she call the RN twice before she was told to send Client 1 to Hospital A in the facility's van. She stated by the time Client 1 was placed in the van, he was not responding but he was breathing. She state when she tested his oxygen level it was 89% (normal oxygen level is 96% or higher). She stated she had charted his oxygen level at 98% but that was a mistake. She meant to chart 89%. She stated she became concerned when Client 1's blood pressure and heart rate were high and then went lower. When asked about calling 911 for emergency medical transport, she stated she was told to transport Client 1 by the facility's van. During an interview with the RN on 9/1/11, at 2:30 PM, she stated she was called on 4/16/11 because Client 1 was sick and had diarrhea. She stated she came to see Client 1 on 4/17/11. At that time, he was in bed sleeping and when she called his name, he answered her. She stated she looked at his face but did not do an assessment because he was so sleepy and she wanted him to rest. So she went to review the charting written by the staff to see what had been happening with Client 1 prior to her visit. She stated she found out later the staff had not charted every time when Client 1 had vomited or had diarrhea. She stated when the LVN called her; she was not told Client 1 was very lethargic or not responding. She stated, "The LVN should have called 911, that's protocol." The clinical record for Client 1 from Hospital A was reviewed. The discharge summary dated 4/18/11, indicated Client 1 presented to the emergency department (ED) at Hospital A with respiratory failure (not breathing) and sepsis (an infection that has spread throughout the body), he was placed on life support to breathe for him and he was receiving medication to increase his low blood pressure. The ED report, dated 4/18/11, indicated Client 1's oxygen level was 70% when the ED physician examined him. Client 1's diagnoses by the ED physician at that time were aspiration pneumonia (pneumonia caused by inhaling fluid), respiratory failure requiring support by a ventilator (a machine that breaths for the patient), acute renal failure (kidneys not functioning), sepsis, and hypotension (low blood pressure) requiring medication support. Client 1 died on 4/18/11, at 9:58 PM; approximately 4 hours after arriving at the ED. Therefore, the facility failed to ensure Client 1 was assessed by the RN timely and failed to activate the EMS (Emergency Medical Services) when he became gravely ill, which resulted in a delay in life saving medical care. This violation presented a substantial probability that death or serious physical harm would result. |
| 120000826 |
LOYD'S LIBERTY HOMES, INC. - IRONWOOD HOME |
120011271 |
A |
18-Feb-15 |
W2LY11 |
5357 |
W149 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. On 2/2/15, an unannounced visit was made to the facility to investigate an entity reported incident regarding a client's fall incident while riding in the facility van for an outing event.Based on interview and record review, the facility failed to ensure safety of a client (Client A) when two of the facility direct care staff (DCS 1 & 2) did not follow the facility's policy to have one staff to sit at the back of the van for client observation. Such failure caused Client A to unfasten her seat belt and walk to the back of the van unnoticed. Client A fell onto a metal frame of the third seat and sustained a laceration on her head.During a review of Client A's health records, it revealed that she is a 43-year-old female with a diagnosis of severe mental retardation (Intelligent Quotient scores of 20-40, may master very basic self-care skills and some communication skills). She can ambulate but with unsteady gait. Client A has been residing at the facility for more than 20 years and requires staff supervision in her daily activities.During an interview with the facility's Qualified Intellectual Disabilities Professional (QIDP) on 2/2/15, at 5:20 PM, she stated, on 1/18/15, two Direct Care Staff (DCS 1 and 2) took a few clients in the facility van for an outing. One of the staff involved in the incident is on duty right now. During an interview with DCS 1 on 2/2/15 at 5:25 PM, DCS 1 stated it was about 10:30 AM on 1/18/15, she and DCS 2 took two or three clients for a ride to a park in the facility van. DCS 1 was unable to remember the exact number of clients in the van that day but recalled Client A was sitting on the second row behind the driver by the aisle. All of the clients were buckled in. As the van turned a street corner, they heard a loud noise and saw one of the clients (Client A) on the floor. Client A had unfastened her seat belt and walked towards the back of the van. Client A hit her head on a metal frame and sustained a laceration to her head. They returned to the facility and took Client A to an emergency room at an acute hospital. During an interview with the QIDP on 2/2/15, at 5:30 PM, QIDP was questioned if Client A had a history of unbuckling her seat belt while riding in the van. The QIDP stated she was not sure but would check with the Program Coordinator (PC). The PC, who was present at the facility during the visit, stated the school bus driver had reported to the facility on several occasions that Client A, while in the bus, would unbuckle herself. The bus driver would then have to stop the bus and buckle the client back in the seat.At this time, the QIDP was asked in regards to the facility's policy in transporting clients, she replied, "The policy is to have one staff to sit in the back of the van except when there is only the driver (in the van)."During an interview with DCS 1 on 2/2/15 at 6:15 PM, DCS 1 was asked if she was aware when two staff accompany the clients in transportation, one of them needed to sit behind the clients, DCS 1 stated, "Yes." During an interview with DCS 2 on 2/6/15, at 8:22 AM, she stated, on the day of the incident, she and DCS 1 took three clients in the facility van to a park. DCS 2 was the driver and DCS 1 sat in the front passenger seat. The facility van has three rows of seat behind the driver. Each seat holds two people. DCS 2 stated Client A was sitting on the second row by the aisle. When DCS 2 turned a corner on the way to the park; she heard a bump and saw Client A on the floor. She stopped the van and went to check the client with DCS 1. As Client A was trying to get up from the floor, she fell again and hit her head on the metal frame of the last seat. "We went home immediately, reported the incident to the nurse." The nurse assessed her and instructed the staff to take Client A to a hospital. DCS 2 was asked if DCS 1 should have sat in the back of clients, DCS 2 replied, "Yes, but we were just going for a ride." DCS 2 was then asked if she had training in transporting clients prior to operating the facility van, she stated she had training about a year ago when she was hired and was aware of the facility policy that when two staff transport clients, one should sit behind the clients for supervision. During an interview with the Regional Director (RD) on 2/3/15, at 2:50 PM, RD was asked about the facility policy in transporting clients, she stated, "If two staff were in the van, one should sit behind clients." On 2/5/15, at 2 PM, the RD was asked if both DCS 1 and 2 had training in transporting clients prior to operating the facility van, she stated, "Yes, they did." The facility's policy on "TRANSPORTING CLIENTS", undated, read: "If two staff are traveling in a company van with consumers, the staff not driving must be seated in the back of the van for consumer observation and interaction. If a consumer needs additional supervision or increased monitoring during transport, they must be seated where a staff has visual contact al all times and ability to intervene if necessary." The violation of this regulation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000903 |
LOYD'S LIBERTY HOMES, INC. - JOELYLE |
120012514 |
B |
23-Aug-16 |
8CC211 |
3089 |
Health & Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. On 6/16/16, an unannounced visit was made to the facility to investigate an entity reported incident regarding Client 1's incident of an alleged sexual abuse by another client. Based on interview and record review, the facility failed to report an allegation of sexual abuse to the Department within the required time frame for one sampled client (1) per the facility's policy and procedure. This failure had the potential to place all clients at risk of unreported abuse to the required agencies in a timely manner. Client 1 was a 64 year old female who was admitted to the facility on 7/27/11, with diagnoses of mild intellectual disability, hypertension (elevated blood pressure), COPD (chronic obstructive pulmonary disease-lung disease that makes it hard to breathe), seizure disorder (brain disorder causing convulsions, muscle spasms, and loss of consciousness), depression, and anxiety. She was able to make her needs known. During a review of the clinical record for Client 1, the document titled "NURSING PROGRESS NOTES" dated 6/1/16 indicated in part, "Assessing consumer at this time after receiving report that another consumer in the home had tried to touch (Client 1) in pelvic area. Incident per staff occurred 2 months ago but was not reported to me until this time..." The document titled "Narrative Notes" dated 4/10/16 indicated in part "...(Client 2) displayed inappropriate behavior (with) another client (Client 1) (and) was told to never do that again..." During an interview with Direct Support Professional (DSP) 1, on 6/16/16, at 8:40 AM, she stated in part "... (Client 2) had her hand on her (Client 1's) private area..." DSP 1 stated, "It [the alleged sexual abuse] happened on 4/10/16 during the day...We are supposed to call the (Qualified Individual Intellectual Disability Professional - QIIDP)...and the licensing...I didn't remember to call the licensing. I should have done it..." During an interview with the QIIDP, on 8/15/16, at 11:15 AM, she stated she spoke to DSP 1. QIIDP added, "I told her (DSP 1) why did you have to wait two months to report to us..." The facility incident report regarding the alleged sexual abuse incident (4/10/16) was received by the Department on 6/3/16 at 3:34 PM. The facility policy and procedure titled "PREVENTION OF ABUSE, NEGLECT and MISTREATMENT" dated 7/10 indicated in part "...The following procedures should be followed in the event of an allegation of abuse, neglect or mistreatment: All allegations of mistreatment, neglect, or abuse...will be reported immediately to the (QIIDP)/Administrator...The (QIIDP)/Administrator will report the incident to required agencies within 24 hours..." Therefore, the facility failed to notify the Department of an allegation of sexual abuse within 24 hours in accordance with Health and Safety Code Section 1418.91 (a), this violation is a class "B" violation. |
| 120001477 |
LINWOOD MEADOWS CARE CENTER |
120013095 |
B |
11-Apr-17 |
3NR911 |
2661 |
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 to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of the section shall be a class "B" violation.
Based on interview and record review, the facility failed to report to the California Department of Public Health (CDPH) an allegation of financial abuse for one of three sampled residents (Resident 1). This had the potential for abuse incidents to go unreported to the Department.
An unannounced visit was made to the facility on 2/23/17 at 3:29 PM, to investigate an allegation of resident financial abuse.
The clinical record for Resident 1 was reviewed. The progress notes for Resident 1 dated 6/30/16, at 10:52 AM, indicated "SSD (Social Service Director) spoke with (District Attorney-DA) at Tulare County DA office today. (DA) states she received allegations of financial abuse from (Resident 1's son) and has forward the report to APS (Adult Protection Services)."
The progress notes for Resident 1 dated 7/6/16, at 4:17 AM, indicated the DA was in the facility to speak to Resident 1 regarding the allegation of abuse from an old caregiver.
There was no indication the allegation was report to the Department, found in Resident 1's clinical record.
During an interview with SSD, on 2/23/17, at 5:37 PM, SSD stated the facility did not report the abuse allegation to the required agencies.
During an interview with the Director of Nurses (DON), on 2/23/17, at 5:43 PM, the DON stated, "We didn't report it."
The facility policy and procedure titled "Reporting Abuse to Facility Management" revised date 10/09, indicated "It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors etc, to promptly report any incident or suspected incident of neglect or resident abuse, including injures of unknown source, and theft or misappropriation of resident property to facility management. When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, or his/her designee, will immediately within two hours for major injury and within twenty-four hours in case of minor injury of the alleged incident or abuse shall notify the following persons or agencies of such incident: The State licensing/certification agency (CDPH) responsible for surveying/licensing the facility (and) The local/State Ombudsman."
Therefore, the facility failed to report an allegation of abuse to the Department within 24 hours. |
| 170001773 |
LANTERMAN DEVELOPMENTAL CENTER D/P ICFDD |
170010187 |
B |
26-Mar-14 |
FC5F11 |
4418 |
76525 - Clients' Rights (a)Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The following citation was written as a result of an investigation of ERI #CA338925 and #CA00338571.The Department determined the facility failed to follow procedures listed in Client 1's Individual Program Plan (IPP) that indicated Client1 required an enhanced level of supervision on and off residence, defined as being in the presence of a staff member during waking hours.During record review conducted on 9/18/13 for Client1, it was revealed Client1 was a 51 year old male with diagnoses that included severe intellectual disability, epilepsy, and high cholesterol. He expired on 1/5/13 after being found unresponsive in bed at approximately 4:30 PM.Review of the Crime/Incident Report - Investigative Report completed 7/18/13, indicated on 1/5/13 Client 1 returned home and had a snack in the dining room. He finished his snack, and his group leader, Psychiatric Technician X (PTX), accompanied Client 1 to take a shower. At approximately 1630 the shift lead, Psychiatric Technician Y (PTY),entered the group room and saw PTX, but did not see Client 1. Client 1 was on enhanced supervision (defined as to be in presence of a staff member during all waking hours due to self-injurious behavior and elopement). PTX stated Client 1 was lying down in his room. PTY went immediately to Client 1's room and found him lying on his side, his face blue, and with blood and saliva on the pillowcase. Client 1 had no pulse and was moved to the floor where PTX began CPR. PTY called for help, Code Blue and 911 were called. Client 1 was pronounced dead at 5:06 PM.An interview was conducted with the Residence Manager (RM) on 1/24/13 at 10:10 AM. She stated that on 1/5/13, she was notified of the death of Client 1 and came to the residence. She was informed by PTY, who was the relief charge that day, that when Client 1 returned from a walk, he wanted to lie down. When PTX returned to the to the dayroom after assisting Client 1 to lie down, PTY informed him that Client 1 was on "enhancement" and was to be monitored at all times. Staff went to the room to check on the client and found him not breathing.Review of statements made to the law enforcement agents who conducted the investigation, indicated PTY was interviewed on 3/5/13. She indicated she was the team leader for the unit on 1/5/13, and she assigned PTX to care for Client 1. PTY indicated she was aware that Client 1 was on enhanced supervision, and she explained to PTX that Client 1 was not to be out of PTX's sight.The Office of Protective Services (OPS) Investigative Report dated 8/5/13, included documentation of an autopsy completed by the [County Coroner's office] on 1/16/13. The autopsy reported the immediate cause of death was listed as Idiopathic Cardiomyopathy and the manner of death was natural.The OPS investigative Report also documented and concluded: the client's IPP required enhanced supervision on and off the residence (in the presence of staff during waking hours; PTX did not confirm Client 1 was asleep prior to leaving Client 1 unsupervised. PTX admitted that leaving a client alone who was on one to one supervision was neglect. Client 1 was left unsupervised for at least 10 minutes. During this period he became non-responsive and was subsequently pronounced dead. Client 1 would have been undiscovered in this condition if another PT [PTY] had not intervened.Review of Approaches and Strategies dated 6/14/12 for Client 1 was conducted on 9/18/13. The plan indicated the following: under "Alert/Risks/Safety Issues -Supervision Level: enhanced supervision on and off residence, defined as: to be in the presence of a staff member during all waking hours due to SIB ( Self-Injurious Behavior) and elopement." The facility failed to ensure the supervision level for Client 1 was at an enhanced level during waking hours, resulting in Client 1 not receiving immediate needed medical attention.This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 170001773 |
LANTERMAN DEVELOPMENTAL CENTER D/P ICFDD |
170010360 |
B |
04-Apr-14 |
FC5F11 |
8429 |
76525 - Clients' Rights(a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect.The facility failed to ensure that Client 1 was free from harm by failing to protect Client 1 from sexual abuse when after examination by the SART Nurse it was determined that Client 1's vaginal laceration was due to sexual assault. The clinical record of Client 1 was reviewed on 11/20/12 at 10:50 a.m. The annual Individual Program Plan (IPP) Narrative dated 9/18/12, indicated that Client 1 was a 75 year old female who had lived in the facility since childhood. She was admitted with diagnoses that included severe mental retardation, dysphagia (difficulty swallowing), hypothyroidism (low thyroid hormone), paraplegia (paralysis of lower extremities), and cataracts.Client 1 was verbal with limited vocabulary, but able to understand simple directions and could follow directions. She was able to alert staff of pain or illness with sounds such as moaning, whining, and grunting. She also enjoyed frequent social interactions with others and was able to recognize familiar staff members. She initiated social interaction with staff but disliked being approached by unknown peers. There was no information found in the IPP Narrative that indicated Client 1 would engage in self-injurious behaviors.On 11/7/12 at 2:20 p.m., an unannounced visit was made to investigate an entity reported incident of Client 1, who was noted to have a genital injury of an unknown origin on 11/6/12. During an interview with the Director of Quality Assurance (DQA) on 11/7/12 at 2:20 p.m., she stated that the client resided in Residence 21. According to the DQA, the client had severe intellectual disability, non-ambulatory, and used a diaper due to incontinence.During an observation on 11/7/12 at 3:20 p.m. in Residence 21, Client 1 was observed in her bed, located in room 50. Room 50 was shared by Client 1 and two other clients divided by a partial wall. Client 1's bed was located near the door entrance of the room, while the two other beds for clients were located behind a partial wall separating the space. During a concurrent interview with Client 1, she was unable to respond verbally when asked how she was feeling.During an interview with the Residence Manager (RM) of Residence 21on 11/7/12 at 3:40 p.m., he stated that Psychiatric Technician 3 (PT 3) discovered the laceration in the vaginal area of Client 1 while conducting perineal care on the morning of 11/6/12. PT 3 immediately reported to the Health Service Specialist. Client 1 was examined by the residence physician and determined a possible sexual assault.Client 1 was transferred to the community hospital on 11/6/12, for a sexual assault examination. The RM stated four other female clients in the residence were examined by the residence physician for possible sexual assault and the 13 male clients would be examined.The General Event Report dated 11/6/12 was reviewed on 11/20/12. The Level I review indicated, "On 11/6/12 [Client 1's name] sustained a laceration to her vaginal left labia area. The laceration is 1 cm (centimeter) in width and 2 mm (millimeter) deep... Upon changing [Client 1's name], observed dried blood surrounding [Client 1's name] rectal area with a small amount of BM (bowel movement) in her attends (diaper)...staff thought the dried blood was possibly contributed to her hemorrhoids condition...[Client 1's name] was assessed by the HSS and it was still determined that the blood was a result of her hemorrhoids... "Staff commenced to clean the client's perineal area and at that time it was discovered that the blood was not coming from her hemorrhoids or rectal area, but a cut located at the base of her vaginal left labia area.The residence physician was notified of the injury and through examination and nature of the injury he determined that a possible sexual assault might have occurred. ...[Client 1's name] was escorted to [Community Hospital's name] sexual assault response unit for further examination..." During an interview with the CHP Investigator on 12/20/12 at 10:02 a.m., he stated that the investigator at the facility was told by the SART Nurse that it was a sexual assault and they were notified by the facility investigator a day later after the incident.The Sexual Examination Report dated 11/6/12, conducted by the SART Nurse was received and reviewed on 2/7/13. The review indicated that Client 1 had a red hymenal bruise located at a 9 o'clock (clock reference) position, one large laceration with bridging at 6 o'clock in the posterior fourchette (fork-shaped fold of skin at the bottom of the entrance to the vagina), and one purplish bruise to the posterior fourchette at 7 o'clock position. During an interview with the Standard Compliance Coordinator (SCC) on 8/6/13 at 10:15 a.m., she stated that PT 1 passed away in June 2013, due to his medical condition.During an interview with the CHP Investigator on 8/6/13 at 11:05 a.m., he stated that they finally concluded their investigation. The DNA test results came back negative and could not be linked to any staff investigated. He also stated that even though the DNA test came back negative, it did not mean that Client 1 was not sexually assaulted.During an interview with the SART Nurse on 9/9/13 at 2 p.m., she confirmed the findings on the Sexual Examination Report dated 11/6/12. She stated that the injury of Client 1 was consistent with sexual assault. She also stated that the injury was not consistent with "cleaning her area" because there was a certain degree of force applied to the area. She further stated, "It was some type of blunt force trauma, but I cannot tell what." The Daily Time Record for the morning shift and night shift dated 11/5/12 was reviewed on 9/9/13. The reviewed confirmed the assignments of staff on 11/5/12 during NOC shift. The review also indicated that PT 1 reported to work in Residence 21 at 2:30 p.m. on 11/5/12 and continued to work until 7 a.m. on 11/6/12 for overtime.During another interview with the RM of Residence 21 on 9/9/13 at 12:30 p.m., he stated that Client 1 was on general supervision on 11/5/12 during NOC shift. PT 1 was assigned to Client 1 on the night of 11/5/12 and had full access to the client. The CHP "ARREST - INVESTIGATION REPORT" dated 8/8/13, reviewed on 9/13/13 at 11:40 a.m., "Analysis and Opinion:...Therefore, it is my opinion that the evidence and timeline of events proved that [PT 1] sexually assaulted [Client 1]. This opinion is based upon the fresh injuries sustained to [Client 1], the daily report listing that there were no injuries prior to [PT 1] taking care of her, the interview conducted, reviewing the Sexual Assault Report, and reviewing the Forensic Reports. Recommendations: I recommend this report be forwarded to the Pomona District Attorney's Office for review. Due to the demise of [PT 1], I do not recommend any charges against [PT 1]." PT 1 expired on 6/25/13 due to septic shock as an immediate cause of death, according to the Certificate of Death. The facility policy and procedure titled "Client Services - 227: Alleged Abuse, Neglect or Exploitation" dated 10/26/11, reviewed on 9/25/13 at 4:20 p.m. indicated, "1. POLICY - ...Any neglect, abuse, or exploitation by any person, whether staff, visitor, volunteer, student, family, or other clients, is prohibited....Training: ...All staff shall receive training to assist in the prevention of abuse, neglect, mistreatment and misappropriation of property as well as client abuse reporting procedures..." The review also indicated, "2. DEFINITIONS - 2.3 Sexual Abuse - Sexual contact that results from threats, or fear, and involving range of activities, including, but not limited to, assault, rape, molestation sexual harassment."The facility failed to ensure that Client 1 was free from harm by failing to protect her from sexual abuse when after examination by the SART Nurse it was determined that Client 1's vaginal laceration was due to sexual assault. These violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 170001774 |
LANTERMAN DEVELOPMENTAL CENTER D/P SNF |
170010361 |
A |
11-Aug-14 |
CBZG11 |
5526 |
F309 - Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychological well-being, in accordance with the comprehensive assessment and plan of care.On 3/14/13 at 9:42 a.m., an unannounced complaint investigation visit was conducted at the facility. The Department determined that the facility failed to provide the necessary care and services required to Resident A when Psychiatric Technician (PT1) failed to provide required line of sight supervision on the morning of 9/25/11, leaving Resident A unattended. The resident was found unresponsive on 9/25/11 at approximately 9:25 a.m. with bluish/grey skin color and his tracheostomy tube dislodged. He was pronounced dead by the Medical Officer of the Day (MOD) on 9/25/11 at 9:51 a.m.The clinical record for Resident A was reviewed on 3/14/13 at 10:55 a.m. The Individual Program Plan (IPP), dated 8/16/11, indicated that Resident A was a 59 year old male admitted to the facility on 8/17/62 with diagnoses that included profound mental retardation (intellectual disability), epilepsy (seizure), and unspecified chronic obstructive pulmonary disease (lung disease). The resident had a tracheostomy (a surgical opening to the front of the neck to help the person breath), performed on 1/12/10 due to his acute respiratory distress and recurrent pneumonia (lung infection). He had no self-help skills, was very dependent and required staff assistance in all activities of daily living. The Summary of Psychological Evaluation conducted by the psychologist dated 7/11/11, indicated that Resident A had a history of pulling his tracheostomy tube out.The evaluation indicated that Resident A would have line of sight observation (constant visual contact with Resident A) during the AM/PM (morning and afternoon) shift and 1:1 observation from HS (hour of sleep) to 0700 (morning).The Individual Program Plan ( IPP - treatment and plan of care of the resident) dated 8/6/11, under "Team Decision", indicated that the team discussed that the residence Physician discontinued the 1:1 supervision during the HS ( hour of sleep) on 8/11/11 and agreed to continue line of sight supervision during waking hours. The team agreed with the Psychologist's recommendation.Review on 3/14/14 of the "Death Review Summary", documented by the Resident Manager (RM) and dated 9/26/11, indicated that on 9/25/11 at approximately 9:25 a.m., PT 1 observed the resident in his room with bluish/gray skin color and his tracheostomy tube dislodged. The Medical Officer of the Day (MOD) pronounced Resident A dead on 9/25/11 at 9:51 a.m. due to cardiorespiratory failure. The Department of Coroner's Supplemental Report dated 1/4/13 was reviewed on 3/14/13 at 4 p.m. The report indicated the cause of death as asphyxia (suffocation caused by insufficient intake of oxygen) due to dislodgment of indwelling tracheostomy tube. The manner of death was accidental. During an interview with the MOD on 10/12/13 at 2:10 p.m., he stated the line of sight failed during the time of the incident, because the staff left the resident without supervision. He stated, "The outcome could have changed if there's someone there who could help at once."During interview on 10/17/13 at 10 a.m., the Health Services Specialist (HSS) 1 stated, "I saw [Resident A] inside the room, hole in the neck, pale, unresponsive, and no pulse at 9:30 a.m., basically already dead. She stated, "[Resident A] should had not been left by the group leader (referring to PT 1), because he was on line of sight supervision."The monthly Risk Assessment /Care Planning Meeting for Residence 54 was reviewed on 10/21/13 at 10:30 a.m. The monthly Risk Assessment /Care Planning Meeting dated 8/26/11 documented the following plans for Resident A: "...2. Line of sight observation during the AM and PM shift..." During an interview on 10/24/13 at 2:27 p.m., PT 2 stated, "[Resident A's] level of supervision was line of sight, meaning constant visual contact and unobstructed view of the patient." She stated PT 1 was assigned to conduct the line of sight supervision to Resident A on 9/25/11. She stated PT 1 was in the break room when the tracheostomy tube came out of Resident A.PT 2 stated, "To my knowledge, PT 1 did not let anyone know that she was going to the restroom." PT 2 acknowledged that by not notifying anyone before leaving Resident 1 unattended, PT 1violated the line of sight supervision. The facility's Policy and Procedure (P&P) titled "Client Services - 226: Client Supervision and Personal Care" dated 6/6/08 indicated, "4. RESPONSIBILITY...4.5 Staff Assigned Responsibility For Any Client...4.5.6 Ensure that adequate supervision is provided whenever leaving clients, keeping in mind the health, physical, and behavioral issues for each client... The facility failed to provide the necessary care and services required when Resident 1, who had a tracheostomy tube, necessary for breathing, and with a known history of pulling out his tracheostomy tube, was left unattended by facility staff on the morning of 9/25/11. Resident 1 was found unresponsive on 9/25/11 at approximately 9:25 a.m. with bluish/grey skin color and his tracheostomy tube dislodged. He was pronounced dead by the Medical Officer of the Day (MOD) on 9/25/11 at 9:51 a.m. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 220000512 |
LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF |
220009366 |
B |
20-Jun-12 |
195H11 |
5905 |
T22 DIV5 CH3 ART6-72637(a)(c) General Maintenance (a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff and visitors. (c) All buildings, fixtures, equipment and spaces shall be maintained in operable condition. These regulations were not met as evidenced by: The facility failed to: 1. ensure that the facility was maintained in good repair at all times to ensure the safety of patients. 2. ensure that all buildings and fixtures were maintained in operable condition. On 8/7/11 at about 10 PM, Resident A's 200 lb. sliding door at the entrance to his room came off its roller track at the top and fell on his overbed table, pushing him to the floor and fracturing three of his ribs. The sliding door had been a reported problem in May 2011. The facility failed to have a routine maintenance program to ensure that the doors were safe for residents.The above violation has a direct relationship to the health, safety or security of patients. Resident A was admitted to the facility on 11/3/06 with diagnoses including dementia and diabetes. His 2/16/10 Annual Patient Medical Review showed he was alert, hard of hearing, required staff help with dressing and personal hygiene, and was able to ambulate with a walker.Review of Resident A's 8/7/11 Integrated Progress Notes indicated, "Found on the floor between the sliding door and table at end of bedside table." Review of Resident A's Physician's Progress Notes, dated 8/7/11 at 10:30 PM indicated, "Reported patient was found lying on the floor on his left lateral side and beneath the left side of body rib-cage area was metal bar from the table and noted patient's room entrance sliding door was over the lower half of the body. Seems the sliding door fell on the patient and patient forced to fall down to the floor. Exam noted patient is awake, alert, not remember the event...Slight redness over left shoulder, left lateral side of the rib cage area and slight abrasion (superficial) over the left rib cage area without bleeding." Review of the Integrated Progress Notes, dated 8/8/11 at 11 AM indicated, "Chest x-ray done.....there's a fracture on left 3rd, 5th & 6th ribs." At 2:30 PM the Integrated Progress Notes stated, "Resident is lying in bed. Denies any pain. But he appears hard to get up from bed, and hard to turn side to side. Resident is able to dressing (sic) up by himself and able to move his upper and lower extremities. Able to ambulate without discomfort. (L) rib under armpit still redness. No bruise and swollen noted." Review of the Integrated Progress Notes, dated 8/10/11 at 3 PM indicated, "Clarification of documentation dated 8/7/2011......8/7 incident when staff at about (10 PM) heard a loud noise and resident calling for help. When staff responded to the resident's room, Resident A was seen on the floor under the bedside table, his left upper side leaning against the foot of the table. The one side of the sliding door was against the wall and the other end held up by the foot of the bed. The door was not touching the resident."In an observation on 8/12/11 at 2:30 PM, Resident A sat quietly in a chair in front his overbed table in his room and appeared comfortable. His room's sliding door had been removed and was replaced by a curtain. All the other doors on this unit were sliding doors similar to Resident A's. Each door was hung from a track at the top, but there was nothing to guide or to keep the roller on track on the bottom. The other intact sliding doors were secured but did take some effort to slide them mainly from the top. In an interview on 8/12/11 at the same time, Resident A said he did not know exactly what happened when the door landed on him.During an interview on 8/12/11 at 2:45 PM, the Risk Manager said it (the sliding door) was a reported problem in May 2011. There was a complaint of difficulty in moving it, but it was fixed and it was working again until now.During a phone interview on 8/12/11, the spokesperson for the company that installed the sliding door said the facility wanted to have a sliding door that could be opened by less than 5 lbs. of force, but the sliding door weighed about 200 lbs. on average. He said it was not easy to take the door off, that it took two big technicians 15 minutes to remove the door from the roller track. He said the sliding door was put up two years before the new building was put to use, and Resident A was the first resident to occupy that unit.Review of a document entitled, "Agenda: Sliding Door Maintenance and Adjustment Training, dated 8/11/11," indicated, "As the supplier and installer of the sliding doors on this project (the door maintenance company) is conducting this hands on training session for the facilities staff that will be responsible for working on and maintaining these doors. By providing a comprehensive look at the hardware and its function, as well as the tools and techniques required for adjusting, these doors will be kept in safe and smooth operating condition." This training included "Visual inspection (door hanging): for... "ease of operation," and "signs that adjustments are needed" including, "door is dragging on the floor, handle or door is hitting the wall," and "excessive movement of door (front to back)." The Visual Inspection should also include, "double nuts on roller cars are securely fastened." The training's "Conclusion" stated, "A regular maintenance and inspection program should be developed to ensure maximum longevity to the doors and hardware as well as providing safe and smooth operations for the residents and staff."The facility was unable to submit any documentation showing that they had a regular maintenance and inspection program for the doors. The above violation has a direct relationship to the health, safety or security of patients. |
| 220001000 |
LOS ALTOS SUB-ACUTE AND REHABILITATION CENTER |
220010218 |
A |
18-Oct-13 |
Z0JD11 |
12122 |
F 323 483-25(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 received adequate supervision and assistance devices to prevent accidents.This regulation was not met as evidenced by: Based on interview, observation, record, and document review, the facility failed to ensure an environment that was free of accident hazards for one sampled resident (Resident 1), when a heating pad was placed on Resident 1 on 11/29/12, resulting in a 2nd degree burn of the left upper back, pain, and complex wound treatments. According to the Medline Plus Medical Encyclopedia of the US National Library of Medicine, National Institutes of Health website at http://www.nlm.nih.gov/medlineplus/ency/article/000030.htm), a 2nd degree burn covers an area larger than 2 to 3 inches in diameter (width), includes the outer layer of skin called the epidermis and the underlying layer of skin called the dermis, and is an injury from exposure to a source of heat, resulting in an intensely reddened and splotchy appearance, blisters, severe pain, and swelling. Findings: Resident 1 was admitted on 03/23/05 and readmitted on 11/24/12. Resident 1's diagnoses were osteoporosis (loss of density of bone tissues), depression, muscle spasm, mononeuritis (inflammation of a nerve), and non-Alzheimer's dementia (loss of brain function that can include memory loss, impaired judgment, behavior changes, learning difficulties, and communication problems). Resident 1's Brief Interview for Mental Status (BIMS) from the MDS (Minimum Data Set, a federally-mandated data collection tool for long term care facilities) dated 4/28/12, in item C0500, indicated a Summary Score of 15, meaning that Resident 1 was cognitively intact. Resident 1's Functional Status from the 4/28/12 MDS in item G0110, Activities of Daily Living Assistance, was indicated as extensive assistance for bed mobility in self-performance/support; total dependence/extensive assistance for transfers in self-performance/support; and extensive assistance/limited assistance for dressing in self performance/support. During an interview with Resident 1 in her room on 12/13/12 at 12:34 pm, she stated that she had used a heating pad for several years and that the facility staff knew she was using it. Resident 1 reported that she normally placed it on the front surface of her upper body and was not clear how the injury happened to the left side of her back, as she was unable to place the heating pad at that location. Resident 1 stated that while in bed during the night of 11/29/12, she had been repositioned by staff and fell asleep after being repositioned. She stated that the heating pad was kept in a pillowcase and had been relocated under her body. The Resident complained of pain at the site of injury. The Resident stated that CNA (Certified Nursing Assistant) 1 noticed a, "skin discoloration" on her left back while providing morning care on 11/29/12 and CNA 1 reported to licensed nursing staff. During an observation on 12/13/12 at 12:34 pm, TN (Treatment Nurse) 1 changed Resident 1's left back dressing, medicated the wounds, and acquired pain medication for the Resident. TN 1 confirmed multiple areas on Resident 1's left back that were irregularly shaped, reddish, and several with yellowish slough (dead tissue) near the center of each area. TN 1 also confirmed other areas of skin that were observed on the left side of the resident's back that were reddish colored. Review of the December 2012 Treatment Administration Record (TAR) and Medication Administration Record (MAR) indicated that Resident 1 received: 1) silver sulfadiazine 1% (an antibacterial treatment for burn wounds) topical cream daily and as needed, 2) Santyl (a medication that removes dead tissue through a process called debriding) 250 units/gram ointment daily, 3) fentanyl (a potent narcotic pain medication) 50 micrograms/hour transdermal (route of delivery is through or across the skin's layers into the body) patch, 4) wound care daily and as needed with the topical medications in 1) and 2) above administered, followed by the application of a Telfa pad, which is a non-adherent (non-sticky) dressing, and 5) oxycodone-acetaminophen 10 milligrams-326 milligrams tablet, 1 tablet orally every 4 hours as needed for pain. Review of the December 2012 MAR indicated that Resident 1's pain level was documented on a 0-10 scale (with 0 denoting the absence of pain and 10 denoting "horrible/excruciating" pain), as moderate to severe pain: 1) 12/12/12, 8-10 pm: 9/10, severe pain in left shoulder 2) 12/14/12, 8-10 pm, 8/10, severe pain in back Review of "Wound Care | First and Second Degree Burns | Burn Treatment | WoundSource" at http://www.woundsource.com/blog/wound-care-first-and-second-degree-burns, indicated that wound care treatment for a 2nd degree burn included these care and treatment considerations, "Dressing second-degree burns should take into account keeping the wound bed moist and protected, as well as clean. In addition, patient comfort must be considered... Silver sulfadiazine may be used for deep partial thickness burns. It is a broad spectrum antimicrobial... Dressings may require changing twice a day, but should be changed once per day at a minimum." During an interview on 12/13/12 at 3 pm, the Administrator reported that the facility did not have a policy and procedure for the use of heating pads. During an interview at 4:05 pm on 12/13/12, the Administrator acknowledged that facility staff knew the heating pad was used by Resident 1. The Administrator also acknowledged that Resident 1's skin was assessed as a "rash" instead of a 2nd degree burn by the licensed nursing staff. The Administrator reported that the heating pad did not have an auto shut-off feature, had been discarded after being removed from Resident 1's room, and acknowledged that there was no MD order for the use of a heating pad. The Administrator further acknowledged that she did not know the brand of the heating pad. Record review with concurrent interview with the Administrator and ADON (Assistant Director of Nursing) on 12/13/12 at 4:15 pm of Resident 1's Physicians Orders for November 2012 reflected that there was no physician order for the use of a heating pad. Review of Care Plans on 12/13/12 reflected that the Restorative Care-Plan [sic] dated 5/10/2011 included, "Moist heat pack (cervical) with 2 towels on right shoulder", and that no other Care Plans included the use of a heating pad, which was confirmed by the Administrator and ADON. During an observation on 12/14/12 at 4 pm, the surveyor observed multiple areas on Resident 1's left back that were irregularly shaped, reddish, and several with yellowish slough (dead tissue) near the center of each area and also observed other areas of skin on the left side of the resident's back that were reddish colored. During this observation, TN 2 measured Resident 1's left back area of injury and reported a length of 24 centimeters (cm is abbreviation for centimeters, 24 cm equals 9.45 inches) and a width of 13.5 cm (5.31 inches). There was no depth measured, but TN 2 estimated the depth at approximately 0.2 cm (0.08 inches). TN 2 stated the entire area of 24 cm by 13.5 cm was red before treatments began and that wound measurements had been taken of the entire reddened area, not of the several, separated reddened areas with yellowish slough at the time of the 12/14/12 observation. During an interview with Resident 1 on 12/14/12 at 4 pm, she stated that her use of the heating pad began in 2005. The Resident reported that a second heating pad had been mailed to her by her daughter "about 3-4 weeks ago" when the first one stopped working. Review of "General Heating Pad Safety" by the FDA (Food and Drug Administration) was found online on 3/20/13 at http://www.fda.gov/medicaldevices/safety/alertsandnotices/patientalerts/ucm069997.htm and noted in the "General Heating Pad Safety" section, "Always:... -Place heating pad on top of, and not underneath of, the body part in need of heat. (The temperature of a heating pad increases if heat is trapped.) -Unplug heating pad when not in use. -Read and follow all manufacturers' instructions on heating pad or on outside package prior to use.... and Never:... Use on a sleeping or unconscious person." Review of "Heating Pad Safety Awareness" by Kentucky Pain Management Services was found online at http://www.kypainmed.com/articles_heatingpadsafety.shtml on 9/30/13, and noted, "Never use on a sleeping or unconscious person ... ". Review of a Physician's Note signed by PA 1 and dated 12/02/12 at 8:21 pm reflected,"... Patient has a new onset of skin burn on her back as a result of a hitting [heating] pad use at night. Skin lesion involves about 30% of her L [left] upper and middle back, wound care with triple antibiotic ointment was initiated this morning... second degree skin burn, L upper/middle back... ". Review of Physician Notes signed by PA 1 and dated 12/02/12 at 8:21 pm reflected, "... Patient has a new onset of skin burn on her back as a result of a hitting [sic] pad use at night. Skin lesion involves about 30% of her L [left] upper and middle back... ". Review of the 12/02/12 with no time noted Doctor's Order Sheet orders signed by PA 1 reflected, "1) Lidoderm [anesthetic medication] patch ... R [right] shoulder q [every] 24 h [hours], 2) D/C the hittin [sic] pad, use warm compress on R shoulder prn [as needed] by nurse, 3) Augmentin 500/125 mg [milligrams] PO [by mouth] BID [twice a day] for 10 days (for skin burn), and 4) App. [apply] Silvadene 1% cream BID to the back. Monitor skin for increased edema [swelling] and infection. Consider wound nurse eval [evaluation] and treatment". Review of Resident 1's Non-Pressure Skin Condition Report signed by RN 4 and dated 12/02/12 with no time documented reflected the skin condition as a 2nd degree burn with wound measurements as length of 28 cm, width of 14 cm, and depth of 0.1 cm. Review of a Report of Incident SBAR - Physical Injury dated 12/02/12 at 10 am by RN 4 documented the situation was reported as, "burn injury and multiple blister [sic] popped up back of the trunk" with new orders to "cleanse with NS [normal saline solution] & pat dry & apply silvadene [sic] 1% cream and cover with dry dsg. [dressing] BID until resolved". This resulted in the use of hydrocortisone anti-inflammatory medication for the treatment of a 2nd degree burn injury from 11/29/12 until 12/02/12. Review of the Resident Treatment Administration Record for December 2012 reflected that hydrocortisone 1% was administered topically to the "upper back redness/rash) BID (twice daily) starting on 11/29/12 and ending on 12/02/12, when Silvadene medication (generic form is silver sulfadiazine) was started. Review of the Medline Plus Medical Encyclopedia of the US National Library of Medicine, National Institutes of Health, website at http://www.nlm.nih.gov/medlineplus/ency/article/000030.htm noted, "if a second-degree burn covers an area more than 2 to 3 inches in diameter.....treat the burn as a major burn. " ; "Second-degree (partial thickness) burns affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering."; and "Do NOT [sic] apply ointment, butter, ice, medications, cream... to a severe burn." Review of Physician Notes signed by PA 1 and dated 12/02/12 at 8:21 pm reflected, "... Patient has a new onset of skin burn on her back as a result of a hitting [sic] pad use at night. Skin lesion involves about 30% of her L [left] upper and middle back... ". Therefore, the facility failed to ensure an environment that was free of accident hazards for one sampled resident (Resident 1), when a heating pad was placed on Resident 1 on 11/29/12, resulting in a 2nd degree burn of the left upper back, pain, and complex wound treatments. The violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 220000512 |
LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF |
220012588 |
AA |
23-Dec-16 |
M7GR11 |
11280 |
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 interview and record review, the facility failed to ensure an environment free of accident hazard and failed to provide adequate supervision for one of one sampled patient (Patient 1) when: A facility staff Certified Nurse Assistant (CNA 1) failed to implement a care plan requiring Patient 1 to be kept in line of sight while in his wheelchair and failed to lock both wheels of Patient 1's wheelchair during an off facility activity on 11/26/14. Before assisting Patient 1, into the facility vehicle, CNA 1 left Patient 1 on the curbside on an incline unsupervised, while CNA 1 returned to the front of the van to turn on the engine and the heater. This deficient practice resulted in Patient 1's fall when his wheelchair rolled down the incline towards the edge of the curb causing Patient 1 to fall face first onto the street directly behind the facility vehicle. Patient 1 sustained multiple injuries including a face laceration (a deep cut or tear in skin or flesh), hip fractures (a medical condition in which there is a break in the bone), and internal head bleeding. Patient 1 expired on XXXXXXX14 due to a traumatic brain injury from the fall. Findings: Patient 1 was admitted on XXXXXXX with diagnoses that included dementia (a general term for a decline in mental ability severe enough to interfere with daily life), neurogenic bladder (inability to drain urine due to nervous system) requiring indwelling bladder catheter (a tube to help drain urine), and diabetes (metabolic disease in which there are high blood sugar levels). Record review of the most recent comprehensive Minimum Data Set (an assessment tool) dated 02/14/14 indicated Patient 1 needed extensive assistance for activities of daily living like transfer and locomotion in unit. Patient 1 was not steady on his feet and only able to stabilize with staff assistance. Patient 1 used a wheelchair every day and ambulation was minimal. Record review of a Patient 1's facility form titled "Admission Nursing Assessment" dated 02/27/14, indicated he has history of falls, wandering/confusion/cognitive deficit has mobility or gait problems due to lower extremities weakness. Record review of Patient 1's "Activity Therapy Quarterly Note" dated 11/10/14 4:00 PM stated: "...The resident is very polite during daily activities...has maintained current level of participation. Resident needs daily reminders and assistance to and from daily on and off ward activities...attending community outings, restaurant, scenic outings and movies... " Record review of Patient 1's Interdisciplinary Team Meeting Note dated 11/19/14 stated under Discharge Plan "...24 hr. care and supervision secondary to functional limitations and cognitive impairments...". Record review of Patient 1's care plan dated 02/27/14, identified the problem of risk for falls related to mobility or gait problems, cognitive deficits, confusion, and or wandering, and medications. Another active care plan open on 6/20/14 and with a review date of 9/2014, for " At risk for easily bruising secondary to fragile skin, on aspirin therapy, tendency to slide down to the floor when in wheelchair ... " , indicated under "Date- Intervention: ...6/20/14 Line of sight to be provided when in wheelchair ... " . On 01/28/15 at 10:30 am during an interview with the Nurse Manager (NM) and the Nursing Director (ND), ND stated that Patient 1 had been part of a group outing on 11/26/14, a trip to a local theater to watch a movie. The group was composed of eight residents and three staff members including the driver. Upon exiting the theater, Patient 1 fell forward out of his wheelchair and sustained injuries that required transfer to an emergency room at a local General Acute Care Hospital (GACH 1). During the same interview, ND showed a copy of a diagram of the location where the incident occurred. It indicated there was a downhill slope from the theater door to the street loading zone. The diagram also indicated the two patients (Patients 1 and 2) were positioned on the side entrance of the bus but Patient 1 fell off the curb and was found at the back of the bus. During an interview with CNA 1 on 02/04/15 at 12:20 PM and with ND present, CNA 1 acknowledged driving the facility van to an outing with eight residents and three staff members including self. CNA 1 stated as the movie was ending, taking two wheelchair bound patients (Patient 1 and Patient 2) by himself to an elevator and out of the theater towards the curbside at the spot where the facility van was parked to assist the residents back into the facility vehicle. CNA 1 stated he stopped at the curbside at the front of the van passenger entrance door. CNA 1 demonstrated having been "in between the two wheelchairs and I locked the brakes like this..." (CNA 1 demonstrated locking one brake for each wheelchair, the left brake of Patient 2's wheelchair and the right lock of Patient 1's wheelchair). Asked if he locked only one wheel of each wheelchair, CNA 1 acknowledged this in the affirmative and added "...I don't know why...I know I should lock both wheels... " CNA 1 stated Patient 1 was closer to the back end of van. CNA 1 stated that he instructed Patient 1 and Patient 2 "stay here...", while CNA 1 was not looking at Resident 1, he turned and went into the vehicle to turn the engine on and the heater on. CNA 1 stated when he returned, only Patient 2 was at the curbside while Patient 1 was lying on the ground behind the van, bleeding from his face. CNA 1 stated he ran towards Patient 1 and lifted him off the ground stating "...I am sorry, I am sorry... " CNA 1 was asked for the location of Patient 1 wheelchair and how the transfer from the ground had taken place, CNA 1 stated " I don't remember...I have a mental block...", "I lifted him back to his wheelchair..." During an interview with CNA 1 on 02/04/15 at 12:30 PM and with ND present, Surveyor asked CNA 1 what he could have done to prevent this accident. In response, CNA 1 stated: "I would wait for my coworkers and stay with the patients, check for the (wheelchair) locks, not stop looking at the residents, not turn on the engine and heater if I am by myself with residents...not trust residents will follow my direction to ?stay here?..." Record review of an EMS Resident 1's report titled "Pre-Hospital Care Report" dated 11/26/14, stated: "Arrived at the scene to find patient (Patient 1) sitting in wheelchair with bleeding noted to the right side of head. Patient was waiting in wheelchair when the attendant looked away. Patient' 1s wheelchair then rolled toward curb falling off curb face forward unto the ground..." Record review of a 11/26/14 8:39 PM Patient 1's physician progress note stated under History of Present Illness (HPI): "Patient was reported out and about today when his wheelchair fell from the vehicle that he was riding in to the ground and he tipped over sustaining a head injury..."; and under Assessment and Plan: "Altered Mental Status - uncertain why he remains altered....head CT negative...However this does not exclude the possibility of slow subdural bleed after the fall...Will sent to [GACH 2] for further evaluation..." Record review of Patient 1?s facility integrated progress note on 11/26/14 indicated at 9:00 PM: "Resident still not fully awake. No verbal responding, only responds to painful stimulation with moving upper extremity, open eyes, mouth, but not talking. Resident's baseline mental status is verbally responding well". A 9:30 PM progress note stated: "Resident will be transferred to [GACH 2] to have further evaluation..." A 10:40 PM progress noted stated: " Resident was transferred to [GACH 2] for further evaluation due to altered mental status..." Record review of Patient 1's facility form titled Inter Facility Transfer Record Nursing Information stated: " Resident (Patient 1) had a fall from wheelchair at 2 PM 11/26/14. Hit his head on the ground. Resident was sent out to hospital via 911....Hospital sent him back to facility, upon arrival resident mental status: stuporous (level of consciousness wherein a person is almost entirely unresponsive and only responds to base stimulation such as pain)...only respond to painful stimulation...had laceration of right forehead 4 sutures (stitches to hold body tissue together)..., had abrasion of right elbow from fall...". Patient 1 was transferred to another hospital. Record review of a 12/03/14 GACH 2 Discharge Summary indicated from an abdomen and pelvis, and head Computerized Tomography (CT), (a computer processed X rays), that Patient 1 had sustained "Nondisplaced fractures of the right superior and inferior pubic ramus..." (A bone that forms part of the hip) and had "intraparenchymal hemorrhage..." and "Subarachnoid hemorrhage..." (Internal bleeding of the head). Record review of a death summary by physician MD 1, signed on 12/12/14 indicated that Resident 1 returned to the facility on XXXXXXX and stated under "Discharge Diagnosis: Traumatic brain injury from fall...". Patient 1 expired on XXXXXXX14 at 10:49 PM. Record review of a one page Autopsy Report dated 7/16/15 from the San Francisco Medical Examiner ' s Office, Case 2014-1157, stated: "Cause of death: Blunt force injuries of head." During a 9/8/15 4:30 PM telephone interview, the Director of Staff Development DSD, was asked regarding content of Certified Nurse Assistants in-services on wheelchair safety, and specifically the locking one or two resident's wheelchair brakes. DSD stated: "Of course we teach CNAs to lock both brakes." During a 1/22/16 8:50 AM follow-up telephone interview DSD stated: "We orient CNAs for two weeks, we give out documents with pictures, and ask for a return demonstration to make sure they lock both wheelchair brakes. The Physical Therapy Department was consulted in the development of this educational material. We revised it last in 2007... " Review of photographs taken by the surveyor dated 7/21/16 at 2:24pm of the sidewalk outside the movie theater where the incident occurred, indicated, there was a downhill incline from the theater to the street. Therefore, the facility failed to ensure an environment free of accident hazard and failed to provide adequate supervision for one of one sampled patient (Patient 1) when: A facility staff Certified Nurse Assistant (CNA 1) failed to lock both wheels of Patient 1's wheelchair when he parked the wheelchair on an incline curbside during an off- facility activity on 11/26/14. The facility failed to implement the care to provide supervision to keep Patient 1 in line of sight while in his wheelchair during an offsite facility activity on 11/26/14. CNA 1 left Patient 1 on the curbside while he returned to the van to turn on the engine and the heater. The deficient practice presented either 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. |
| 230000039 |
Lassen Nursing & Rehabilitation Center |
230009299 |
B |
13-Feb-14 |
P6GM11 |
5262 |
F 323 483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide adequate supervision to prevent an avoidable fall when Patient 5 was left unattended in her room, sitting in her wheelchair next to her bed with the privacy curtain closed around her, preventing visual supervision by staff. Patient 5 fell forward out of her wheelchair sustaining facial and head injuries with a displaced nose, bleeding, and pain. This failure caused Patient 5 unnecessary injuries and the inability to maintain her highest practicable level of well-being.Patient 5 was admitted to the facility on 2/21/12 with diagnoses that included diarrhea, diabetes, generalized weakness and loss of strength, a pressure ulcer on her buttock, and kidney failure. The Minimum Data Set (MDS - a patient assessment tool), dated 3/8/12, reflected that Patient 5 had impaired cognition and memory, and had difficulty making her needs known. Patient 5 was assessed and considered a fall risk due to impaired balance, an inability to walk, need for maximum physical assistance with transfers and toileting, medications, chairbound mobility, poor memory, mental health, diarrhea, and poor intake. Patient 5 lived in a four bed room, and three of the four beds were occupied by patients.During an interview at 11:30 am on 5/8/12, Certified Nurses Assistant (CNA) B stated that on the morning of 3/10/12, she had been informed that Patient 5 was very weak, would be up only for meals, and then returned to bed to rest. CNA B stated that on 3/10/12 at 1:30 pm, after assisting Patient 5 with her lunch meal, she left Patient 5 in the dining room with other Patients and staff. CNA B stated that the next time she saw Patient 5 was a half an hour later, at 2 pm, when she went into Patient 5's room to get another patient ready for a shower. CNA B stated that while in the room, a visitor who was visiting another Patient in the room, told her that he "heard something" from Patient 5's area of the room. CNA B stated that she looked behind the curtain, that was drawn closed around Patient 5's bed, and saw Patient 5 "on the floor." CNA B stated that Patient 5 was "lying face down on the floor in front of her wheelchair, next to her bed in a pool of blood." CNA B stated she immediately called for help.During an interview conducted on 5/10/12 at 12:30 pm, Licensed Nurse (LN) C stated that on 3/10/12, CNA B called for help at 2 pm, when Patient 5 was found on the floor face down in a large pool of blood. LN C stated that she saw a lot of blood from Patient 5's nose. LN C stated that emergency first-aid care was given to Patient 5 at the facility, then Patient 5 was taken by ambulance to the hospital.LN C stated that Patient 5 was weak, and after lunch, Patient 5 should have been taken to the bathroom and then put in bed. LN C stated that Patient 5 should not have been left in her room unattended. LN C stated, "for patients who are identified as a fall risk, the staff attempt to know the patients whereabouts and visualize the patients when they're up." LN C stated that she immediately started the investigation into Patient 5's fall and learned that Patient 5 was in the dining room from 12:15 pm to 1:15 pm. After 1:15 pm, it was unknown how Patient 5 left the dining room, or for how long she was in her room, before she was found on the floor.On 5/8/12 at 10:30 am, LN D stated that she had also helped with Patient 5's care after Patient 5 had been found on the floor. LN D stated that Patient 5 had a disfigured nose and lacerations on her forehead and under her left eye. LN D stated, "Patients who are at risk to fall are not to be left alone in their rooms, unless they are safe in their beds. Patients are kept by the nurses station, or out in the hallway by their room, where they can be seen."On 4/9/12 at 9 am, the Director of Nurses (DON) stated that Patient 5 was considered a fall risk, and that the facility's practice was not to leave fall risk patients alone, unattended in their wheelchairs. He stated, "All staff are educated in this practice." DON stated that it was "unknown how or by whom Patient 5 was put in her room, how long Patient 5 was left unattended, and unknown how long Patient 5 had been lying on the floor in her room." On 4/9/12, Patient 5's hospital record was reviewed. The admission record, dated 3/10/12, showed that following the fall, Patient 5 was admitted to the hospital with fractured nasal bones.Therefore, the facility failed to provide adequate supervision to prevent an avoidable fall when Patient 5 was left unattended in her room, sitting in her wheelchair next to her bed with the privacy curtain closed around her, preventing visual supervision by staff. Patient 5 fell forward out of her wheelchair sustaining facial and head injuries with a displaced nose, bleeding, and pain. This failure caused Patient 5 unnecessary injuries and the inability to maintain her highest practicable level of well-being.This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 230000039 |
Lassen Nursing & Rehabilitation Center |
230009387 |
B |
13-Dec-13 |
IXOQ11 |
5055 |
F 206 CFR 483.12(b)(3) - Policy to Permit Readmission Beyond Bed-Hold A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services. The facility (Facility 1) failed to allow Patient 1 to return to the facility after being transferred to another facility (Facility 2) for evaluation, treatment, and stabilization of aggressive behaviors. On two occasions when Facility 2 called Facility 1 to return Patient 1, Facility 1 refused to accept Patient 1 back into the facility. This failure to accept Patient 1 back to the facility denied Patient 1 of his right to readmission for nursing facility services after his therapeutic leave for stabilization of his behaviors. Patient 1 was admitted to Facility 1 on 10/26/11 with diagnoses that included Diabetes Type II (non-insulin dependent), high blood pressure, dementia (loss of cognitive/reasoning functions) with behaviors, a history of past non-compliance, abnormality of gait, and communication problems. During an interview on 6/8/12 at 11:15 am, Patient 1's public guardian (PG 1) stated Facility 1 had sent Patient 1 to Facility 2, the last part of March, 2012, after an incident with another patient at Facility 1. PG 1 stated Facility 2 was a mental health facility out of State that accepts skilled nursing facility patients, treats them medically until they are stable, and then returns the patient to the original facility. PG 1 stated Facility 2 was not a long term, residential facility. PG 1 stated Patient 1 has been ready to return to Facility 1 but Facility 1 has refused (several times) to readmit Patient 1. PG 1 stated she has been trying to find other placement for Patient 1 and has been unsuccessful to this point and feels Facility 1 should take Patient 1 back until another long term, skilled nursing facility could be found. PG 1 stated she had been calling Facility 1 "at least a couple of times a week" since Patient 1 was ready to return to Facility 1 trying to get them to take him back. Facility 1 refused to accept Patient 1 back at each request. PG 1 stated she received no notification that Patient 1 was being discharged without the opportunity to return after treatment. During an interview on 6/8/12 at 2:45 pm, the Director of Nurse's (DON) for Facility 1 stated Patient 1 had been sent to Facility 2 after an incident with another patient with the understanding that he would not return to Facility 1. When asked if he had that statement in writing the DON stated, "No, it was a verbal agreement." It was explained to the DON that if they had nothing in writing indicating Facility 2 agreed to keep Patient 1, and the fact that Facility 2 was a treatment based hospital and not a long term care facility, Facility 1 would have to take Patient 1 back. It was also explained that they could start the formal discharge proceedings with proper notification and assistance to find another facility after Patient 1's return, but at this time they had accepted Patient 1 for initial care and it was their responsibility to continue that care. Patient 1 was returned to Facility 1 on 6/8/12. During a telephone interview on 6/29/12 at 4 pm, the social services worker (SSW) at Facility 2 stated Patient 1 was admitted to Facility 2 with the understanding they would attempt to find placement in another facility but could not guarantee Patient 1 would not have to go back to Facility 1. SSW stated when they were unable to find another facility to accept Patient 1 she called Facility 1 and explained, Patient 1 was medically stable, had no behaviors, and was ready to come back to Facility 1. SSW stated the first attempt to return Patient 1 to Facility 1 was on 4/30/12, and Facility 1 refused to readmit him related to his "history of previous behaviors." SSW stated Patient 1 remained stable with no behaviors so she again called Facility 1 on 5/14/12, to have Patient 1 return to the facility. She stated she faxed two weeks' worth of progress notes indicating he had no further behaviors, but Facility 1 again refused to readmit Patient 1 related to his previous behaviors. The failure of Facility 1 to accept Patient 1 back into skilled nursing care placed an undue hardship on PG 1 in attempting to find other placement when none was available and kept Patient 1 in Facility 2 in a bed that should have been available for the acute care of another patient in need of treatment for mental health stabilization. Patient 1 had to use Medicare hospitalization days as payment in Facility 2 when he was by regulation allowed to have the first available bed for MediCal in his facility of origin, prior to his transfer.The violation of this regulation had a direct or immediate relationship to the health, safety, or security of patients. |
| 230000039 |
Lassen Nursing & Rehabilitation Center |
230009581 |
A |
13-Feb-14 |
P6GM11 |
6058 |
F 323 483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide adequate supervision and properly functioning safety devices to ensure Patient 6 was safe from elopement. As a result, during the early morning hours of 10/30/12, Patient 6 was able to walk out of the facility and travel four (4) miles before found by law enforcement officers, injured and lying on the highway. Patient 6 was admitted to the facility on 2/26/10 with diagnoses that included dementia (a progressive impairment of intellectual function) and an irregular heart beat.A Minimum Data Set (MDS), a patient assessment tool, dated 9/7/12, assessed Patient 6 as having memory problems. He wandered throughout the facility without assistance. The facility identified that this wandering behavior placed Patient 6 at significant risk for elopement and injury. A nursing care plan, dated 4/23/12, identified that Patient 6 was at risk for elopement and that a Wanderguard (a device that activates an alarm when an unauthorized attempt is made to exit the building) would be in place on Patient 6. On 10/30/12, the Department of Public Health received notification that Patient 6 had eloped from the facility and was found by the Sheriff's Department at 4:08 am that morning. On 10/31/12 at 12:30 pm, Administrative (Admin) Nurse B stated that he had received a phone call from staff on 10/30/12 at 3:40 am, informing him that Patient 6 was missing from the facility. He stated that Patient 6 wore a Wanderguard, and earlier that shift, he had attempted to get out of the building. He further stated that a police officer found Patient 6 rolling around on the ground, on the outskirts of town. "He had scrapes on his face and a broken hand." Admin Nurse B stated that Patient 6's medical condition after his injury was serious enough that he had been transported by the hospital to another hospital for further treatment. On 10/31/12 at 4:50 pm, the local sheriff's department (SD) was contacted. The SD representative stated that there was no report, and that no one from the facility called the department to report Patient 6 missing. When officers spotted him, Patient 6 he was down on the ground, and a medical call was made for an ambulance. The SD representative stated that the dispatch log read, "Man down on side of Highway 36, one hundred yards west of Highway 36/395.....and requested medical assistance." On 10/31/12 at 5 pm, Certified Nursing Assistant (CNA) D was interviewed. She stated, when she went to take Patient 6's vital signs at 3:20 am he was gone. CNA D stated that she notified the charge nurse and continued to search for Patient 6 in all the areas he liked to go. She stated she looked outside, and walked to the local gas station, while the charge nurse was also looking for him.On 3/31/12 at 5:10 pm, CNA E stated that Patient 6 would become restless, pacing, and would go in and out of doors after talking to his wife on the telephone. She stated earlier that night, Patient 6 had activated the door alarm trying to go out of the facility. She stated that when she came back from lunch at 2:48 am, she was unable to find Patient 6. CNA E stated that the charge nurse left the facility on foot to look for Patient 6, came back, and then in her car, went to go look for him. CNA E stated she saw two police cars while she was out of the facility and described Patient 6 to one of the officers. One of the officers informed her that someone had been identified that matched Patient 6's description going out of town on the highway. On 11/1/13 at 3 pm, Licensed Nurse (LN) C was interviewed. She stated she was the charge nurse on the night that Patient 6 had eloped from the facility. She stated that Patient 6 had been restless all night, activating the door alarm, and wanting to go outside. LN C stated at 3 am, Patient 6 was discovered missing. LN C stated she got in her truck and drove down Main Street for about 15 minutes while another CNA went on foot in the opposite direction. She stated shortly afterwards, she received a call from another nurse at the facility stating that law enforcement had found Patient 6. She confirmed that she never called the police/sheriff, and that she did not check Patient 6's Wanderguard every shift. She further stated that she was not sure what door Patient 6 had exited from the facility, but in the past, the kitchen door alarm did not work. Patient 6's medication administration and treatment records were reviewed. There was no documented evidence to show licensed nursing staff checked to ensure Patient 6 was wearing his Wanderguard and that it was functioning properly.On 3/31/12 at 2:30 pm, Admin Nurse B reviewed Patient 6's record and confirmed that there was no documented evidence that Patient 6 was checked every shift by either licensed nursing staff or CNAs to ensure he was wearing the Wanderguard, and that it was working properly. The facility's Resident Elopement policy, revised 12/27/11, required, "If a resident cannot be located, the facility shall notify the resident's responsible party, physician, and local police department or sheriff's department." Also, that, "Additional off duty staff may be called in to assist in the search, if needed." Therefore, the facility failed to ensure: 1) that properly functioning alarm devices were in place and operating, and 2) that there was adequate supervision of Patient 6 to prevent him from walking away. As a result, during the early morning hours of 10/30/12, Patient 6 was able to walk four (4) miles away before falling and injuring himself. He was found by Sheriff's Department officers lying on the highway, with facial abrasions and a broken left wrist. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 230000039 |
Lassen Nursing & Rehabilitation Center |
230010058 |
B |
13-Feb-14 |
P6GM11 |
2994 |
F 223 483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to ensure one of two residents, Resident 12, was free from abuse when Certified Nursing Assistant (CNA) C verbally abused the resident during personal care. This failure resulted in verbal abuse to Resident 12 and emotional distress for her roommate, Resident 9. During an interview on 12/3/12 at 11:50 am, Resident 9 stated that on 11/6/12 she was awakened, maybe around 3 am, by a loud voice in the night. She said that CNA C was speaking, in an angry sounding tone, to her roommate, Resident 12. Resident 9 said, "I believe she (Resident 12) pooped her pants." When CNA C was cleaning Resident 12 CNA C told the resident to "Stop acting like a baby." Resident 9 stated that it made her upset to hear that, and the first thing the next morning she reported the incident to the Social Services Director (SSD). Resident 9's record showed that she was admitted to the facility on 10/26/12 for after care and physical rehabilitation following surgical repair of a fractured hip. Resident 9's Minimum Data Set (a resident assessment tool), dated 11/6/12, showed that she was alert, oriented and had no problem with her memory. During an interview on 12/3/12 at 11:35 am, SSD stated that first thing in the morning on 11/6/12, Resident 9 came and told her about an incident of verbal abuse that occurred during the night between CNA C and Resident 12. SSD stated that she interviewed Resident 12 that same morning and though Resident 12 was talkative, she could not recall the incident. SSD current statements correlated with her written statements, dated 11/6/12 and timed at 8:30 am and 11 am. A review of Resident 12's closed record, on 12/3/12, showed that Resident 12 was admitted to the facility on 10/22/12 with diagnoses that included dementia and confusion. Her MDS, dated 10/29/12, identified Resident 12 required extensive assistance for personal care, and had moderate memory problems, but that she was able to make her needs known. Resident 12 was discharged from the facility on 11/30 12 and not available for interview.During an interview on 12/3/12 at 12:30 pm, the Administrator stated, on 11/6/12 CNA C was suspended for three days while the facility investigated the allegation of verbal abuse. The facility determined that CNA C had verbally abused Resident 12 and CNA C was terminated on 11/9/12.Therefore, the facility failed to ensure Resident 12 was free from abuse when CNA C verbally abused the resident during personal care. This failure resulted in verbal abuse to Resident 12 and emotional distress for her roommate, Resident 9. This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 230000039 |
Lassen Nursing & Rehabilitation Center |
230010059 |
B |
13-Feb-14 |
OCKX11 |
12616 |
F 314 483.25(c) TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to prevent avoidable development of an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough or eschar, dead tissue that is tan, brown, or black in the wound bed. Until enough slough/eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined) pressure ulcer and the progression of right and left buttock skin breakdown by failing to: Develop a written plan of care and provide care interventions, in accordance with recognized standards of care and the facility's Pressure Ulcer Management policy, to prevent the worsening and further development of new pressure ulcers for Resident 1 who was at risk for developing pressure ulcers, due to an existing reddened buttocks, bowel and bladder incontinence, decreased oral intake, and a decline in her ability to care for herself; Recognize risk factors/symptoms of urinary tract infection and dehydration, assess Resident 1's skin, identify new and worsening skin break down, notify the physician of these changes in the resident's condition, and provide effective treatment.These failures resulted in the development and worsening of pressure ulcers on Resident 1's right and left buttocks, and the development of an unstageable pressure ulcer on her coccyx (tailbone). Resident 1 was transferred to an acute hospital where she was evaluated and diagnosed with infection, dehydration and acute kidney failure, requiring aggressive intravenous fluid replacement and antibiotics. Resident 1 was admitted to the facility on 2/22/12. Prior to admission to the facility, she recently had a one week stay (2/13/12 - 2/20/12) in the hospital for the treatment of pneumonia and was discharged home with home health nursing care on 2/20/12 (noted to have clear, intact skin at time of discharge). However, Resident 1 proved to be too debilitated to be cared for at home and she was readmitted to the hospital, then transferred to the skilled nursing facility for physical rehabilitation and completion of antibiotic therapy for treatment of Pneumonia. The facility's Nursing Admission Assessment, dated 2/22/13 and timed at 2:30 pm, showed that Resident 1 was alert and oriented, able to answer questions and make her needs known, but forgetful at times. She was experiencing weakness and diarrhea and urinary urgency with occasional incontinence (can be symptoms of urinary tract infection (UTI) and poses a risk for dehydration). Resident 1 required high flow oxygen continuously and had a fair appetite (poor oral intake poses a risk for dehydration/UTI and malnutrition which contributes to skin breakdown risk). The skin assessment section identified that Resident 1's skin was intact with one area of perirectal redness on the day of her admission.A short term care plan, dated 2/22/12, noted as a "problem," Resident 1's area of perirectal redness. However, the approaches of "Treatment per MD order and observe for signs and symptoms of infection..." did not include care interventions that would prevent further development of skin breakdown or prevent the worsening of pressure ulcers or development of new pressure ulcers, according to the facility's Pressure Ulcer Management policy or recognized standards of care.There was no evidence in the record to indicate that the nursing staff recognized the "redness" as an possible deep tissue injury or that the nurses notified the physician that the skin lesion was present or obtained treatment orders. A care plan, dated 2/22/12, identified the "problems" of bowel and bladder incontinence and the prone to skin breakdown. Planned interventions included checking every two hours, and as needed, for incontinence and providing peri care (care of the perianal area to ensure it remains clean and dry), "monitoring for signs and symptoms of skin problems routinely, redness, etc." and monitoring skin integrity, per facility protocols. An ADL Function care plan, dated 2/22/12, did not include bed mobility in Resident 1's list of self care deficits. The care plan directed staff to reposition routinely, and as needed, and monitor pressure areas for redness.A physician's order, dated 2/23/12 and timed at 5:30 pm, directed, "cleanse perirectal redness with moist towelette. Apply Lanaseptic every day x 14 days." The facility's "Pressure Ulcer Management" policy, revised 8/2007, read, " It is the policy of this facility to ensure that residents skin status is assessed and appropriate interventions are developed and implemented to maintain skin integrity, assist in wound healing and or prevent avoidable skin breakdown in order to attain or maintain the highest practicable physical, mental and psychosocial well-being." "Based on the assessment and identification of risk factors and through the assessment process the following interventions may be considered ... assist with or turn and reposition ... initiate positioning pillows or cushions ... apply pressure reducing devices to bed ... apply pressure reducing devices to chair or seat ...avoid friction and shearing."Neither the 2/22 nor the 2/27/12 skin care plans included these basic first steps in pressure ulcer prevention/care.Nurse's notes for 2/23 and 2/24/12 described Resident 1 as needing the assistance of one to two persons to transfer and toilet, was both continent and incontinent of bowel and bladder, and that incontinence care was done on each shift, and as needed. Nurse's notes for 2/25/12 described Resident 1 as drowsy, incontinent of bowel and bladder, and unable to arouse enough to take her medication or eat meals. Resident 1 was "more awake" on 2/26/12, however, her respiratory status was declining and new orders for breathing treatments and medications were obtained and initiated. On 2/27/12 at 2:50 am, the nurse documented that Resident 1 was sleepy and slow to respond to verbal and physical stimulation. As such, the nurse held Resident 1's medications. The next nurse's note, dated 2/27/12 (no time), described Resident 1 as having increased confusion, that she was alert and orient to person but not to time and place, her speech was unclear, and that she was incontinent of bowel and bladder. An untimed nurse's note and physician order, dated 2/27/12, both read, "Cleanse red area to right buttock...cleanse red area to left buttocks...cleanse black area to coccyx."Three separate "Skin Breakdown Reports," all dated 2/27/12, noted that Resident 1 had the following skin break down: A pressure ulcer to her coccyx of an undetermined stage that measured 4.0 cm long by 3.6 cm wide, and was black with eschar and 100% necrotic tissue; A Stage I left buttock pressure ulcer that measured 8.6 cm long by 8.4 cm wide; and A Stage I right buttock pressure ulcer that measured 4.4 cm long by 4.2 cm wide.On 2/27/12, a skin ulcer care plan was written for three pressure ulcers that Resident 1 acquired since she was admitted to the facility, five days prior. The perirectal redness present on admission had worsened to "Stage I" pressure ulcers on her right and left buttocks, and a new area of breakdown, described as "black" and "unstageable with eschar and necrosis," developed on her coccyx. The cause of the pressure ulcers was documented as "Decreased LOC (level of consciousness)." Licensed nursing staff were to provide treatments as ordered by the physician, assess and document wound healing progress weekly and assess for signs and symptoms of infection, increased necrotic tissue, or no response to treatment, and turn the resident every 2 hours, and as needed. Decreased LOC can be a sign of UTI or Dehydration, but not a cause of a pressure ulcer. A resident who has a decreased LOC, would be less mobile, therefore, require increased interventions to mobilize and relieve/prevent pressure to the ulcer. The facility's Minimum Data Set (MDS) assessment, dated 2/28/12, identified that Resident 1 required extensive assistance from staff for bed mobility, transfers, toileting, and personal hygiene. The MDS identified that the Resident was frequently incontinent of both bowel and urine, and had two Stage I pressure ulcers and one Stage IV pressure ulcer measuring 4.0 x 3.6 centimeters, with necrotic tissue (Eschar-black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges).The National Pressure Ulcer Advisory Panel (NPUAP) defines a Stage I pressure ulcer as intact skin with non-blanchable redness of a localized area usually over a bony prominence. An unstageable pressure ulcer has full thickness tissue loss in which the base of the ulcer is covered by slough or eschar (dead tissue that is tan, brown, or black) in the wound bed. Until enough slough/eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. From Resident 1's admission on 2/22 to 2/27/12, a period of five days, there was no documentation in the record that Resident 1's reddened perirectal area was assessed, or that interventions listed in the facility's Pressure Ulcer Management policy/protocol or current standards of care were implemented by nursing staff to prevent the development of a new unstageable pressure ulcer and worsening of the Resident's right and left buttock skin breakdown. There was no documentation by licensed nurses that described through assessment and evaluation the state of the residents many skin lesions, prior to 2/27/12. As Resident 1's condition deteriorated, between 7/22-7/27/12, she had decreased bed mobility, increased confusion and lethargy, and increased episodes of bowel and bladder incontinence, all which would place the resident at increased risk for skin break down, and could be symptoms of infection/dehydration. There was no documented evidence of increased monitoring or assessment of her skin condition or changes in care plan interventions to prevent the pressure ulcers from developing and worsening. On 10/24/12 at 2:54 pm, a concurrent interview and record review was conducted with the Director of Nursing (DON). Review of an Activities of Daily Living (ADL) Function care plan indicated that the intervention of bed mobility was not check marked as a planned intervention, and risk for skin breakdown or pressure ulcers was not identified. The DON confirmed that a care plan for skin integrity or risk for skin breakdown, that included nursing care interventions to prevent the development of skin breakdown, was not developed to address Resident 1's increased risk for pressure ulcers.Therefore, the facility failed to prevent avoidable development of an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough or eschar (dead tissue that is tan, brown, or black) in the wound bed. Until enough slough/eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined) pressure ulcer and the progression of right and left buttock skin breakdown by failing to: Develop a written plan of care and provide care interventions, in accordance with recognized standards of care and the facility's Pressure Ulcer Management policy, to prevent the worsening and further development of new pressure ulcers for Resident 1 who was at risk for developing pressure ulcers, due to an existing reddened buttocks, bowel and bladder incontinence, decreased oral intake, and a decline in her ability to care for herself; Recognize risk factors/symptoms of urinary tract infection and dehydration, assess Resident 1's skin, identify new and worsening skin break down, notify the physician of these changes in the resident's condition, and provide effective treatment.These failures resulted in the development and worsening of pressure ulcers on Resident 1's right and left buttocks, and the development of an unstageable pressure ulcer on her coccyx (tailbone). Resident 1 was transferred to an acute hospital where she was evaluated and diagnosed with infection, dehydration and acute kidney failure, requiring aggressive intravenous fluid replacement and antibiotics. This violation had a direct relationship to the health, safety, or security of patients. |
| 230000039 |
Lassen Nursing & Rehabilitation Center |
230010144 |
B |
14-Mar-14 |
PLMT11 |
4894 |
F 309 483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEINGEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.The facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for Resident 6 by failing to timely obtain and report laboratory (lab) results, notify the physician of acute changes in the resident's condition, and recognize and ensure timely treatment for infection when Resident 6 was identified to have C. diff (a highly contagious infection that causes severe diarrhea). Nursing staff had not promptly assessed, monitored, or implemented necessary interventions commonly used to control the spread of infection. Nursing staff delayed Resident 6's treatment by not promptly informing the physician of the results from her diagnostic lab testing. These failures resulted in an untreated infection and a delay in the treatment of an infection for Resident 6.Resident 6's record was reviewed. Resident 6 was admitted on 1/20/13 with diagnoses that included falls with injury and dementia. On 1/25/13, a physician ordered stool specimen was collected and submitted to the lab. On 1/26/13, the lab reported to the facility that Resident 6 had C. diff. On 1/28/13, two days later, the facility faxed the lab report to Resident 6's physician and documented, "waiting for response." There was no documented evidence that nursing staff followed up on the fax or communicated with the physician. Resident 6 was not placed in contact isolation and assessment and care planning was not done.On 1/30/13, four days after the identification of the infection, Resident 6's physician ordered treatment, and Resident 6 was placed on contact isolation precautions.A review of the facility's policy titled, "Isolation Precautions" revised 3/2005, was conducted. The policy directed the following: "1. In addition to standard precautions, use contact precautions for specified residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment." On 7/31/13 at 9 am, an interview and concurrent record review was conducted with the Administrator (Admin). The Admin was unable to provide a dedicated policy and procedure for lab management. The Admin stated that there had been a lack of oversight regarding the management of resident laboratory specimens and that no tracking system had been in place. The Admin confirmed that Residents 4, 5, and 6 had not received lab services according to professional standards of practice or as their physicians had ordered, which adversely affected their health and well-being. The Admin confirmed that nursing assessment, documentation, intervention, monitoring, and physician notification regarding resident changes in condition was not followed, per policy.On 9/4/13 at 2:40 pm and 6:15 pm, during interviews, LNs A, C, D, E, and F stated that all laboratory results had been faxed to a locked office in a building outside of the main facility, which the nursing staff had no access to. LN D stated that if a resident's lab results were faxed back during a weekend or holiday, "we had to wait until Monday" to see the results and notify the physicians. LN F stated that she should have initiated change of condition charting and care planning on Resident 6, when the C. diff testing was ordered, instead of five days later when treatment was obtained. LNs A, C, D, E, and F stated that all faxes to physicians require a phone call to ensure the physician received the fax, by the end of the shift, if the physician had not responded and confirmed that was not done for Resident 6.Therefore, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for Resident 6 by failing to timely obtain and report laboratory (lab) results, notify the physician of acute changes in the resident's condition, and recognize and ensure timely treatment for infection when Resident 6 was identified to have C. diff (a highly contagious infection that causes severe diarrhea). Nursing staff had not promptly assessed, monitored, or implemented necessary interventions commonly used to control the spread of infection. Nursing staff delayed Resident 6's treatment by not promptly informing the physician of the results from her diagnostic lab testing. These failures resulted in an untreated infection and a delay in the treatment of an infection for Resident 6.The violation of this regulation had a direct relationship to the health, safety, or security of patients. |
| 230000039 |
Lassen Nursing & Rehabilitation Center |
230010145 |
A |
19-Mar-15 |
PLMT11 |
9630 |
F 309 CFR 483.25 Quality of CareEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for Resident 5 by failing to timely obtain and report laboratory (lab) results, notify the physician of acute changes in the resident's condition, and recognize and ensure timely treatment for infection when Resident 5 had an increased risk for UTI and sepsis, due to an atrophied (decreased in size and function) right kidney. Licensed nursing (LN) staff had not promptly obtained diagnostic lab testing (UA) to ensure timely detection and treatment of infection. LN staff inadequately assessed, documented, monitored, evaluated, and reported (to the physician) Resident 5's changes in condition, and lab testing that should have been available, was not. On two separate occasions, Resident 5 had to be transferred to the hospital for a higher level of care when he became septic in the facility. Resident 5 was admitted on 12/11/12 with diagnoses that included a stroke, chronic renal insufficiency, and an atrophied right kidney. The most recent MDS, dated 6/20/13, reflected that Resident 5's cognition was intact and he was usually continent of his bladder. Resident 5's record was reviewed. On 1/30/13 at 6:35 am, a nursing student documented in the Nursing progress notes that Resident 5 had a fever of 100.3 degrees Fahrenheit (F) and, "nurse aware." There was no evidence of nursing assessment, monitoring, evaluation or intervention related to Resident 5's fever over the next 72 hours. There was no evidence that discussions regarding Resident 5's change in condition had been conducted with his physician and Resident 5's fever was left untreated. On 2/2/13 at 7:30 pm, LN H documented that Resident 5 had a fever of 102.3F, and chills, and was transferred to the emergency room (ER). LN H completed an "Emergency Transfer Communication" form at 8 pm, and left the "reason for transfer" section blank. LN H documented on the form that Resident 5 had a fever "this morning at 6 am of 101.1" and that she had given him "Tylenol" and now his fever was "102.3." There was no evidence that Resident 5's physician had been notified and treatment sought for his fever which had been identified by LN H at 6 am. Review of the local ER (Hospital A) documentation dated 2/2/13 showed that the hospital collected a urine specimen less than two hours later in the ER, Resident 5's urine was tested and he had a UTI with more than 60,000 WBCs, 3+ blood, and 1+ bacteria. The ER physician documented in Resident 5's H&P, dated 2/2/13 at 10:22 pm, that Resident 5 was septic due to pyelonephritis (a kidney infection that developed from infected urine) and his temperature was 104.9F. Resident 5 returned to the facility on 2/5/13, on antibiotics for a UTI. On 2/10/13 at 11:45 am, LN F documented that Resident 5's physician had ordered a UA, to be done "tomorrow" and wrote the order on Resident 5' TAR (Treatment Administration Record, used to substantiate that treatments and other care was provided as ordered). On 2/11/13, LN B circled her initials on the TAR and wrote "UA not obtained." On 2/15/13, four days later, a urine sample was collected (unknown by whom) and submitted to the lab. On 2/18/13, the UA results revealed that Resident 5's urine was turbid (cloudy from bacteria), had a few bacteria, 3+ blood, and more than 60,000 WBCs. An antibiotic was ordered for Resident 5's UTI. Nursing notes over the next week documented that Resident 5 had no adverse reaction to the antibiotic therapy, but lacked a detailed description of his urine (i.e. color, clarity, odor, pain with urination) and assessment and evaluation of the effectiveness of the antibiotic treatment. On 2/25/13, LN A took an order for another UA from Resident 5's physician, but had not put the order on the TAR. On 2/26/13, Resident 5 had completed the antibiotic therapy and LN A documented (no time) that Resident 5, "continues to complain of not feeling well" but had not described his symptoms or notified his physician and the UA was not done. There was no nursing assessment, intervention, or documentation over the next 72 hours related to how Resident 5 was feeling. On 2/28/13, three days after ordered, the urine sample was collected and sent to the lab. On 3/2/13 at 4 pm, LN F documented that she had obtained an order from Resident 5's physician to send him to the hospital for "evaluation and treatment" because he was "shaking." There was no description of Resident 5's condition prior to the unplanned hospital transfer, and the UA results that should have been readily available, were still pending. There was no explanation of what was to be "evaluated" or what "treatment" Resident 5 needed at the hospital. On 3/2/13 at 6:43 pm, just over two hours later, the ER physician documented in an H&P (medical examination) that Resident 5's urine "appears grossly very dirty" and "The patient is very toxic ... barely opening his eyes... appears very septic" and the diagnosis was "severe sepsis" and his temperature was 103.8F. On 9/4/13 at 2:40 pm and 6:15 pm, LNs A, C, D, E, and F were interviewed. LN A stated that she had not recalled that the student nurse reported Resident 5's change in condition to her. LN A stated: "We had problems with student nurses documenting things in the residents' records without informing us" and stated that she had brought that to the DON's attention and he stated to her, "Oh well." LNs A and E stated that part of the problem with collecting specimens late was that nursing staff were not utilizing the 24 hour shift communication log and "we had no tracking system or policy and procedure for lab" and stated they had no way to know when or what lab was due, sent out, or expected back. LNs A, C, D, E, and F confirmed that a "Change in Condition Assessment" should have been started on Resident 5 on 1/30/13, when he had a fever and on 2/26/13, when he complained of still not feeling well, despite being on antibiotics. None of the LNs were able to explain why there was no assessment and documentation on Resident 5, three days prior to both hospital transfers for sepsis. The facility's policy titled, "Change of Condition Management Guideline" dated January 2006, was reviewed. The procedure section directed the following: 1.) "Document change of condition assessment reporting, and interventions in nursing notes." 2.) "License Nurse reports at change of shift." 3.) "License Nurse will place resident on alert charting." 4.) "License Nurse will document resident response and progress to treatment interventions every shift until stabilized." 5.) "Attachment A" listed the following as resident changes in condition: 6.) "Abnormal lab & X-Ray" According to the "American Medical Directors Association (AMDA)" Clinical Practice Guidelines for "Acute Change of Condition (ACOC) in the Long-Term Care Setting", Copyright 2003; "Hospitalization of long term-care patients should be avoided for many reasons. Transfer to the ER or hospital is costly; is disruptive for patients; and can expose patients to many risks...Timely evaluation and intervention is necessary to address ACOCs effectively in the long-term care setting." The following AMDA guidelines are recognized as professional "standards of care": Page 22: "A nurse should evaluate the patient with an ACOC at least once during every shift while the patient is unstable or significantly symptomatic and should document relevant findings in the patient's record. Nurses and other appropriate staff should provide practitioners with enough detailed information to allow them to determine the patient's progress and identify possible complications. At least one meaningful communication (by phone or fax) should occur between the nurse and the practitioner within 24 hours of the onset of ACOC or of identification of the fact that the patient's condition is not stable or improving as anticipated." Page 23, "Staff nurse: Recognize condition change early. Assess the patient's symptoms and physical function and document detailed descriptions of observations and symptoms. Update the charge nurse or supervisor if patient's condition deteriorates or patient fails to improve within expected time frame. Report patient's status to the practitioner as appropriate." Therefore, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for Resident 5 by failing to timely obtain and report laboratory (lab) results, notify the physician of acute changes in the resident's condition, and recognize and ensure timely treatment for infection when Resident 5 had an increased risk for UTI and sepsis, due to an atrophied (decreased in size) right kidney. LN staff had not promptly obtained diagnostic lab testing (UA) to ensure timely detection and treatment of infection. LN staff inadequately assessed, documented, monitored, evaluated, and reported (to the physician) Resident 5's changes in condition, and lab testing that should have been available, was not. On two separate occasions, Resident 5 had to be transferred to the hospital for a higher level of care when he became septic in the facility. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 230000039 |
Lassen Nursing & Rehabilitation Center |
230010343 |
B |
14-Mar-14 |
NXXJ11 |
3975 |
1418.91(a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. The facility failed to report an allegation of abuse and failed to implement its abuse policy for one resident, when a staff member did not report a staff to resident abuse allegation within 24 hours to the California Department of Public Health (CDPH) (Resident 1). This failure had the potential for abuse to not be properly reported, monitored and investigated, placing residents at risk.CDPH received a faxed report from the facility titled, "SOC 341: Report of Suspected Dependent Adult/Elder Abuse" on 12/8/13. This report indicated that Resident 1 had stated during a medical appointment on 12/3/13, that Registered Nurse (RN) 1 had kicked him on 12/1/13. This report indicated that this had been reported to CDPH and to the local Ombudsman (advocacy agency serving residents in long term care facilities) on 12/8/13.Resident 1's record was reviewed on 12/13/13. Resident 1 was admitted to the facility on 5/23/13, with diagnoses that included rehabilitation and dementia. The facility's MDS (Minimum Data Set, assessment tool), dated 12/11/13, described Resident 1 having severe cognitive impairments.During an interview, with the Director of Nursing (DON) on 12/13/13 at 11:40 am, he indicated that License Vocational Nurse (LVN) 2 had knowledge of this accusation from Resident 1 regarding RN on 12/1/13, but had not communicated this to the facility administration until 12/3/13. The DON acknowledged that the allegation of abuse had not been reported to CDPH or the Ombudsman until 12/8/13. The DON acknowledged that this was beyond the required 24 hour reporting period and the facility's abuse policy had not been followed.The facility's policy and procedure titled, "Abuse and Crime Reporting" dated 8/28/13, read, "It is the policy of this facility to report, in accordance with local, state and/or federal laws and regulations, to the appropriate agency, any allegations of and/or suspected conditions of abuse as defined, upon any resident 65 years of age or older or any dependent adult or and to report any reasonable suspicion of crime towards any resident of the facility... All employees, and covered individuals of the facility who observe or have knowledge of an incident of abuse that reasonably appears to be abuse or neglect or is told by an elder or dependent adult they have experienced behavior constituting abuse or neglect or reasonably suspects (objectively) reasonable suspicion based upon facts, is to report the allegation or suspected abuse or neglect to his/her supervisor and Administrator... Any employee, or covered individual who has a reasonable suspicion that a crime has been committed against any resident must report the incident within 24-hours to CDPH and to the local law enforcement agency..." LVN 2's personnel file reviewed on 12/13/13, contained a document titled, "Elder Dependent Adult Abuse Acknowledgment of Training" signed on 8/14/13. This document acknowledged that LVN 2 had been trained in; how and where to report elder and dependent adult abuse, role as mandated reporter, how to complete the SOC 341 form, what to report and other abuse reporting requirements/regulations.LVN 2 was interviewed by telephone on 12/17/13 at 9:05 am, she reported that on 12/1/13, Resident 1 had told her that he had been kicked by RN 1. LVN 2 acknowledged that she should have reported the abuse accusation directly to the DON, Ombudsman and CDPH as soon as she knew about it. LVN 2 further acknowledged that she had not followed the facility's abuse policy when she did not report the abuse allegation within 24 hours as required. Therefore, the facility failed to report an allegation of abuse to CDPH within 24 hours. This violation had a direct relationship to the health, safety, or security of patients. |
| 230000039 |
Lassen Nursing & Rehabilitation Center |
230010390 |
A |
13-Feb-14 |
P6GM11 |
6059 |
F328 483.25(k) TREATMENT/CARE FOR SPECIAL NEEDS 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. The facility failed to ensure Resident 3 received proper and necessary respiratory care and treatment when, during a field trip, Resident 3's oxygen tank ran low and needed to be changed, and the facility staff in attendance were unable to connect the regulator (a device that regulates the amount of oxygen delivered) to a new/full oxygen tank. Resident 3 experienced symptoms of hypoxia and respiratory distress requiring emergency medical treatment from an ambulance crew and was transported to the hospital. Resident 3 was admitted to the facility on 1/19/11 with diagnoses that included congestive heart failure (the heart being unable to move the blood through the body adequately), Chronic Obstructive Airway Disease (COPD-narrowed air passages in the lungs which obstructs her breathing and causes shortness of breath), Bipolar disorder, and tobacco use disorder (chain smoker). A review of Patient 3's Minimum Data Set, (MDS - a resident assessment tool), dated 10/22/12, showed that she could make her needs known, that she was competent to make her own decisions, and as such, was her own responsible party. On 12/3/12 at 11:45 am, Resident 3 stated that in 10/2012, she and a group of about ten patients were taken on a field trip to the local casino for lunch and gambling. When it was time to go back to the facility, the transport van was summoned back to the facility. The van left with plans to return to the casino to transport the residents back to the facility. A few minutes after the van left, the Activities Director (AD) noticed that Resident 3's oxygen tank was running low of oxygen. The resident was receiving continuous oxygen at high rate of flow requiring frequent oxygen tank changes. A new tank was present, but none of the staff in the group knew how to attach the regulator onto the new oxygen tank. An off duty Licensed Vocational Nurse (LVN), who works at the facility, happened to be at the casino with her husband and assisted in putting the regulator on the new oxygen tank. Resident 3 stated that she told one of the staff that she did not feel well and the next thing she remembered was waking up in the ambulance. During an interview on 12/3/12 at 12:30 pm, AD stated that Resident 3 had just gotten over pneumonia and had taken her last antibiotic that morning. AD stated that Resident 3 had been hospitalized twice in 10/2012 with respiratory infections which were not uncommon for her, due to her chronic lung disease. AD stated that Resident 3 had severe respiratory disease and required the use of supplemental oxygen at 5-6 liters per minute, 24 hours a day. Due to the high flow rate, Resident 3 needed a new oxygen tank every few hours and used five to six tanks a day. AD stated that Resident 3 was one of 10 residents who attended a casino outing on 10/9/12. When it was time to leave the casino, the transport van was unexpectedly summoned back to the facility, prior to the residents boarding. Just after the van left, AD noticed that Resident 3's oxygen tank was running low. A new tank was available, however, no one present knew how to put the regulator on the new tank. Resident 3 complained that she did not feel well and an ambulance was called. AD stated that Resident 3 began shaking like she was having a seizure, then lost consciousness just as the ambulance arrived.The ambulance report, dated 10/9/12, showed the ambulance crew arrived at the scene at 1:33 pm, and found Resident 3 sitting in her wheelchair, her skin color was blue (indicating a lack of oxygen), her breathing was angonal (life threatening pattern of breathing), and she was unable to open her eyes or make sounds and movements. The ambulance crew initiated emergency respiratory resuscitation (the use of oxygen and breathing equipment) and at 1:50 pm, transported Resident 3 to the emergency department at the local hospital. Resident 3's condition was initially treated at the local hospital and from there she was flown to a regional hospital for ongoing care. On 12/3/12 at 3:30 pm, a phone interview was conducted with Licensed Vocational Nurse (LVN) A. LVN A stated that she and her husband were having lunch at the casino on her day off. She heard a commotion and realized it was people from the facility where she worked. She went over to them to see if she could help and saw staff fumbling with the regulator, trying to get it on a new oxygen tank. LVN A noticed Resident 3's lips were turning purple and she was starting to lose consciousness. LVN A stated that she was able to get the regulator on the new oxygen tank just as the ambulance arrived. On 12/3/12 at 4:00 pm, after a phone interview with the van driver, each of the five staff members present during the 10/9/12 field trip incident were individually asked if they knew how to change the regulator on the oxygen tank at the time Resident 3's oxygen tank needed to be changed and when Resident 3 became hypoxic: the Administrator stated, "No," the Activities Director stated, "No," Activities Assistants D and E stated, "No," the Janitor stated, "No," and Social Services Director stated, "No." Therefore, the facility failed to ensure Resident 3 received proper and necessary respiratory care and treatment when, during a field trip, Resident 3's oxygen tank ran low needing to be changed and the facility staff in attendance were unable to connect the regulator to a new/full oxygen tank. Resident 3 experienced symptoms of hypoxia and respiratory distress requiring emergency medical treatment from an ambulance crew and was transported to the hospital. These violations presented an imminent danger of death or serious harm to the patient or a substantial probability that death or serious physical harm would result. |
| 230000039 |
Lassen Nursing & Rehabilitation Center |
230010538 |
B |
14-Mar-14 |
PLMT11 |
4629 |
F 323 483.25(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 failed to ensure an environment that was free from accident hazards to prevent an accident with injury for Resident 1 by failing to provide adequate supervision and assistance, ensure that a call light was within reach, and that a pressure sensitive mat alarm was in place to prevent a fall with injury for Resident 1 that resulted in severe left hip and back pain, and transfer to a hospital where she was diagnosed with broken ribs.Resident 1's record was reviewed and admission documentation indicated Resident 1 was admitted to the facility on 9/6/12 with diagnoses that included dementia and a history of falls with a closed head injury.A fall risk evaluation, dated 9/9/12, identified that Resident 1 was a high risk for falls. A fall risk care plan, initiated on 9/9/12, included a goal that Resident 1 would have no falls with injury. The care planned interventions included quarterly, or as needed, fall risk assessments, a fall mat beside the bed, a mat alarm at bed side, to keep the bed in a low position, and keep the electrical bed controls out of reach of the resident.A self-care activities of daily living (ADL) care plan, dated 9/6/12, included an intervention to, "Have call light available and answer promptly."Resident 1's Minimum Data Set (MDS - an assessment tool), dated 9/13/12, identified Resident 1 had both short and long term memory problems and that she was dependent on staff for her toileting needs. The facility had Resident 1 on a toileting program that included night time awakenings several times through the night to assist her to the bathroom.A Change of Condition (COC) note, completed 4/12/13 at 8:30 am, read Resident 1 had a fall, complained of pain in her left hip and back with an intensity of 10/10 (On a scale of 1 to 10, 10 being highest level of pain, severe). The fall risk factors identified on the COC included history of fall, poor safety judgment, cardiac medications, requires assist for toileting and unsteady gait. The additional comments of the COC read, "found on floor next to her bed on left side complained of 10/10 left hip and back pain, stated she thinks her back bone is broke..." Resident 1 was transferred to an acute care facility and determined to have sustained two rib fractures. Resident 1 was interviewed, on 4/24/13 at 11:06 am, and stated, "I do not remember a fall out of my bed, I don't know what I was doing." Resident 1 was observed moving restlessly in her wheelchair and stated, "I want out of here." On 4/24/13 at 11:37 am, Licensed Nurse (LN) C stated she was on duty the day Resident 1 had fallen and was sent to the hospital. LN C stated she responded to the incident when called by a Certified Nursing Assistant (CNA).Resident 1's roommate (Resident 13) had come out to the hall to get a staff person to help. LN C stated she had never seen Resident 1 use her call bell, but the call bell was on when she responded.LN C stated Resident 13 witnessed the fall and told LN C that Resident 1 had to go to the bathroom, got up, tried to grab hold of a privacy curtain and fell into a bedside cabinet that belonged to another roommate. LN C stated Resident 1 did not have a pressure sensitive mat alarm beside her bed at the time, per the care plan. On 4/24/13 at 3:20 pm, Resident 13 stated, as she pointed to her wall calendar next to her bed, that on 4/12/13, Resident 1 woke up early, sometime around 6 am, and stated, "I want to go to the bathroom." Resident 13 stated she was encouraging Resident 1 to use her call bell but that Resident 1 said she could not find it. Resident 13 reported Resident 1's bed was left in a high position and the call bell was dangling down from a side rail out of the reach of Resident 1 (the facility investigation also noted that Resident 1's bed was in the high position). Resident 13 stated she handed Resident 1 the call light and assisted in ringing the bell.Resident 13 stated the call light seemed to be going for a while (about 20 minutes) before Resident 1 got up without assistance and fell. Resident 13 reported she covered Resident 1 with a robe and then needed to leave the room after Resident 1 fell to get staff to help. Resident 13 stated she walked to the nearby Nurse's Station One and four nurses were seated there.The violation of this regulation had a direct relationship to the health, safety, or security of patients. |
| 230000039 |
Lassen Nursing & Rehabilitation Center |
230010540 |
B |
14-Mar-14 |
PLMT11 |
4939 |
F 323 483.25(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 failed to ensure an environment that was free from accident hazards and that provided adequate supervision to prevent an accident with injury for Resident 2 by failing to provide adequate supervision of Resident 2 when she wandered into a therapy gym and had an unwitnessed, avoidable fall and was injured, then had a second unwitnessed, avoidable fall related to the same deficient practice; and Provide an environment that was free from accident hazards, when the therapy gym was left unlocked and Resident 2 was injured on a piece of equipment which lacerated her head and nose and abraised her wrist and; Have an effective system that ensured alarm devices were regularly checked for proper functioning, when Resident 2 sustained two avoidable falls eight days apart, and her wheelchair alarm was not operational, both times. These failures resulted in injuries to Resident 2 (the top right side of her head and the bridge of her nose lacerated and a skin tear to her right elbow). Resident 2 was sent to the Emergency Room where 11 staples were required to close the laceration on her head.Resident 2 was admitted on 3/19/13 with diagnoses that included a history of falls, dementia, and hearing loss. The most recent Minimum Data Set (MDS, an assessment tool), dated 6/25/13, reflected that Resident 2 had severely impaired cognitive skills and required moderate assistance of one person to transfer and ambulate. On 7/30/13 at 12:05 pm, Resident 2 was observed in her wheelchair wearing a self-releasing seat belt (SRSB) which was connected to an alarm on the back of her chair. A CNA (Certified Nursing Assistant) demonstrated that when the seat belt was unbuckled the alarm sounded.Resident 2's record was reviewed. A "Change in Condition Assessment," dated 7/19/13 at 3 pm, revealed that Resident 2 had been found on the floor in the facility's therapy gym with the top right side of her head and the bridge of her nose lacerated and a skin tear to her right elbow. Resident 2 was then sent to the Emergency Room and 11 staples were required to close the laceration on her head.The Interdisciplinary Team Notes (IDT), dated 7/22/13, documented that on 7/19/13, when Resident 2 was alone in the therapy gym and the door was closed, she unbuckled her SRSB, but the "alarm wasn't going off." The IDT recommended that the "staff" monitor the light on the alarm to ensure that it was on and to keep the therapy gym door locked.A "Change in Condition Assessment," dated 7/27/13 at 5 pm, revealed that eight days later, Resident 2 again unbuckled her SRSB, and was found uninjured on the floor in a resident's room and the "alarm was not on."On 7/30/13 at 1:30 pm, an interview was conducted with the Administrator (Admin). The Admin stated the therapy gym was to be locked at all times when staff was not present and confirmed that on 7/19/13, staff had not followed that procedure and "had left the therapy door unlocked." The Admin stated staff had not adequately supervised Resident 2's whereabouts on 7/19/13, when she was found behind a closed door lying on the therapy gym floor bleeding, and again on 7/27/13, when she was found on the floor in a resident's room. The Admin stated staff that were responsible for the monitoring of alarm devices, had not been clearly assigned. The Admin stated both of Resident 2's falls and injury had been directly related to the SRSB alarm not properly functioning, and could have been avoided.Therefore, the facility failed to ensure an environment that was free from accident hazards and that provided adequate supervision to prevent an accident with injury for Resident 2 by failing to provide adequate supervision of Resident 2 when she wandered into a therapy gym and had an unwitnessed, avoidable fall and was injured, then had a second unwitnessed, avoidable fall related to the same deficient practice; and Provide an environment that was free from accident hazards, when the therapy gym was left unlocked and Resident 2 was injured on a piece of equipment which lacerated her head and nose and abraised her wrist and; Have an effective system that ensured alarm devices were regularly checked for proper functioning, when Resident 2 sustained two avoidable falls eight days apart, and her wheelchair alarm was not operational, both times. These failures resulted in injuries to Resident 2 (the top right side of her head and the bridge of her nose lacerated and a skin tear to her right elbow). Resident 2 was sent to the Emergency Room where 11 staples were required to close the laceration on her head. The violation of this regulation had a direct relationship to the health, safety, or security of patients. |
| 230000039 |
Lassen Nursing & Rehabilitation Center |
230011339 |
A |
19-Mar-15 |
PLMT11 |
16382 |
F 309 CFR 483.25 Quality of CareEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for Resident 4 by failing to timely obtain and report laboratory (lab) results, notify the physician of acute changes in the resident's condition, and recognize and ensure timely treatment for infection when: Resident 4 was at an increased risk for urinary tract infection (UTI) and urosepsis (body-wide infection due to infected urine), due to the use of an indwelling catheter (a tube inserted into the bladder for the purpose of urine drainage from the bladder). Licensed nursing (LN) staff had either not collected or incorrectly collected urine, blood, and stool specimens ordered by Resident 4's physician (PMD). LN staff, PMD, another physician (MD), and a physician's assistant (PA) failed to recognize that the UAs had not been completed, failed to ensure lab results were obtained and failed to ensure treatment for Resident 4's UTI. Licensed nursing staff had not recognized that promptly obtaining, evaluating, and reporting diagnostic lab testing was an important intervention in the early detection of infection, and that essential diagnostic laboratory testing results had not been obtained, as ordered. Resident 4's health status subsequently declined, and she was transferred emergently to the local hospital (Hospital A) where her infection and clinical condition was too critical and could not be managed. Resident 4 was then transferred to a larger medical center (Hospital B) for a higher level of care, where she died of septic shock due to urosepsis and the untreated urinary tract infection. Resident 4's record was reviewed on (date). Resident 4 was admitted to the facility on 11/6/12 with diagnoses that included dementia and renal (kidney) insufficiency. The Minimum Data Set (MDS, an assessment tool), dated 11/13/12, reflected that Resident 4's cognition was intact and that she had an indwelling urinary catheter (Foley). On 11/7/12, Licensed Vocational Nurse (LN) A documented in the nursing notes that Resident 4's Foley was draining "cloudy sediment urine" and obtained and noted a telephone order from Resident 4's Primary Medical Physician (PMD) for a Urinalysis with a Culture and Sensitivity (UA or Urine Analysis - requires a sample of urine and tests for the presence of infection the urine, the C&S identifies the type of bacteria causing the infection and which antibiotic(s) will best treat it). The results of the UA were not in Resident 4's record and the facility staff could not find the results elsewhere in the facility. During the subsequent survey, on (date), the facility's contracted laboratory provided data and the record documented the following: Lab data showed: On 11/8/12, nursing staff collected a urine sample from Resident 4 and sent the specimen to the lab. Lab data showed: On 11/9/12, the lab notified LN D (per lab documentation) that the specimen container was not properly labeled with Resident 4's identification, and the UA could not be completed. Lab data showed: On 11/14/12, five days later, a second urine sample was collected and sent to the lab. Record documents: On 11/15/12, Physician A (not the PMD) saw Resident 4, but had not addressed that the UA results, which should have been available, were not and Resident 4's UTI remained untreated. Lab data showed: On 11/17/12, the results from the UA reflected that Resident 4 had a UTI evidenced by an abnormal amount of blood (2+, no blood is normal), a "few" bacteria, and more than 30,000 WBCs (white blood cells are a sign of infection-normal is 0 to 5000). The lab identified that the urine sample was contaminated with "more than three organisms" (a numerous variety of bacteria that come from other sources such as counter tops, hands, and other surfaces) and requested that a clean urine specimen be resubmitted. The C&S portion of the test could not be performed because there were too many bacteria to isolate which specific bacteria caused the infection.Record documents: There was no evidence that Resident 4's physician received the lab results and treatment was not initiated. Lab data showed: On 11/19/12, a third urine specimen was collected by LN B and submitted to the lab. Lab data showed: On 11/23/12, the results from that UA reflected that Resident 4's UTI had worsened showing increased blood (now 3+), bacteria ("many"), and WBCs (6000 to 10,000). The lab report added that the urine specimen was incorrectly submitted in a sterile cup, which had not been refrigerated (to prevent the overgrowth of bacteria), therefore contaminated, and the C&S could not be done. The lab requested that a clean urine specimen be resubmitted. Record documents: There was no evidence that Resident 4's physician had been provided with the results of the UA collected on 11/19/12, and no evidence that another urine sample was collected. Subsequent review of Resident 4's record showed that on 12/17/12, the Physician's Assistant (PA), (for Physician A and not the PMD), saw Resident 4, but had not addressed that the UA results, which should have been available over a month ago, were not and Resident 4's UTI remained untreated. On 1/12/13, the facility's Registered Dietitian requested a Complete Blood Count (CBC- requires a sample of blood which is drawn from the arm, and used to evaluate abnormal levels of blood cells. A high amount of white blood cells (WBCs) indicate an infection and a low amount of red blood cells are a sign of anemia or bleeding), and a Complete Metabolic Panel (CMP- requires a sample of blood drawn from the arm and used to evaluate fluid imbalances such as dehydration and kidney function). CBCs and CMPs are useful to the RD to evaluate if malnutrition, dehydration, kidney failure, or nutrient deficiencies are present and Resident 4 had not had those tests done since admission. LN D faxed the request to Resident 4's physician on 1/12/13. The fax was in Resident 4's physician's orders section of her record and signed by Resident 4's physician (no date), but the orders were not noted by a nurse. On 1/19/13, one week later, LN D documented in Resident 4's nursing notes that those orders had been obtained but they were never carried out and the CBC/CMP was not done. On 1/23/13 at 10 am, a student nurse documented in the nursing progress notes, that Resident 4's skin was "jaundice (yellow-can occur from the toxins that bacteria produce) appearing in color" and had "white sediment" in her urine collection bag. There was no evidence that Resident 4's physician was notified of her urinary status, but was notified by fax (no time indicated) on 1/23/13, that Resident 4 had diarrhea. There was no nursing assessment, documentation, intervention, monitoring, or evaluation for diarrhea, and despite Resident 4's symptoms, it continued to go unrecognized that the UA with a C&S (ordered over two months ago) and the CBC/CMP blood work tests (ordered nearly two weeks ago), were still not done. On 1/24/13, Resident 4's physician responded back by fax and ordered that a stool sample be tested for C&S,WBCs, and enteric pathogens (intestinal bacteria), LN F signed "done" on the fax (no date). The order for the C&S, WBCs, and enteric pathogens was entered on Resident 4's Treatment Administration Record (TAR), but dated 1/27/13, and never signed off as "done." There was no evidence that the test had been done. On 1/27/13, Physician A saw Resident 4 and documented in his History and Physical (H&P-medical examination), "we will get stool studies," but failed to recognize that these tests had previously been ordered on 1/2/13 by the PMD and the results should already been available. Physician A had not addressed that the UA C&S, which should have been done over two months ago, and the CBC/CMP, which should have been done nearly two weeks ago, were still not available. There was no evidence in Resident 4's physician orders, medication and treatment sheets, or nursing notes from the day of admission on 11/6/12, to the day of discharge to the hospital on 1/30/13, that she had received any antibiotic treatment for her UTI. Nursing assessment and documentation reflected no further action to advocate for the treatment of Resident 4's UTI and had not addressed the untreated UTI. On 1/30/13 at 6:05 p.m., LN G documented in the nursing notes that an "ambulance was contacted" and Resident 4 was sent to the local Emergency Room (ER). LN G documented on the "Emergency Transfer Communication" form the reason Resident 4 had to be transferred was because, "Went into Res (resident's) room at 1800 (6 pm) Res laying (sic: lying) in bed ARP (Responsible party) requested mother go to the Hospital for evaluation. Took vitals Res responsive called (Hospital A)." Resident 4's blood pressure was 90/42 at the time of transfer (normal is 120/80). On the "Change in Condition Assessment" form at 6:22 pm (20 minutes later), LN G documented that Resident 4 was now "lethargic (not responsive)" and that Resident 4 had stated something was wrong with her, but that "she (Resident 4)" did not know what. The Change in Condition form specified that the nurse was to "Check resident lab and diagnostic testing ... Describe any abnormal values." LN G wrote a zero (0) with a line (/) through it and failed to recognize that Resident 4 still had an untreated UTI, and a CBC/CMP and stool test for C&S, WBCs, and enteric pathogens still had not been collected and sent to the lab for analysis. Review of the local ER (Hospital A) documentation dated 1/30/13 showed that the hospital collected a urine specimen less than two hours later, which showed 3+ blood, 2+ bacteria, bilirubin 1+ (causes jaundice and skin to yellow), and more than 60,000 WBCs. Hospital A was not able to manage Resident 4's critical condition and she was transferred from there to the major medical center (Hospital B) 90 miles away for a higher level of care, where she died three days later. The physician's Discharge Summary from Hospital B, dated 2/2/13, listed the cause of death as, "Septic shock due to a urinary tract infection, C. diff (an intestinal bacteria), atrial fibrillation (an abnormal heartbeat), leukocytosis (abnormal amounts of leukocytes in the bloodstream-normally found in severe infections such as sepsis), metabolic acidosis (occurs with severe dehydration, kidney failure and sepsis), altered mental status, and acute (sudden onset) kidney failure." On 8/1/13 at 1:30 pm, an interview and concurrent record review was conducted with the facility's contracted laboratory's Laboratory Manager (LM). The LM confirmed that three urine specimens for Resident 4 had been incorrectly submitted to the lab and the facility was notified each time. LM stated that the first specimen was not correctly labeled and was not processed and LN D was notified. The second urine specimen was contaminated evidenced by "numerous bacteria that don't live in humans" and explained that the bacteria found in Resident 4's urine either came from dirty hands, counter tops or other surfaces such as floors, walls, or door knobs. The LM stated that the third specimen submitted was contaminated because it was put in a cup instead of the "specimen tubes with preservatives," that the lab provided to the facility. The LM confirmed that Resident 4 had a UTI and stated that the C&S portion of Resident 4's UA's had not been done because, "there were too many bacteria to isolate the one that was causing her infection, we needed a clean specimen." The LM stated that after the third specimen, "no more urine specimens were submitted" for testing. The LM confirmed that the lab never received a blood sample from Resident 4, to complete a CBC/CMP or a stool specimen to test for C&S, enteric pathogens, or WBCs. On 8/1/13 at 1:45 pm, Resident 4's PMD physician was interviewed. The PMD stated that he was not able to recall the circumstances of Resident 4's laboratory testing and was not aware that he had not received the results from those tests that he had ordered. On 9/4/13 at 2:40 pm and 6:15 pm, concurrent record reviews and interviews were conducted with LNs A, C, D, E, and F (LNs B and G no longer work at the facility). LNs A, C, D, and F, confirmed that they were all involved in Resident 4's care. All of the LNs stated that they were not aware that none of the physician ordered lab had been completed for Resident 4 or that a UTI had been left untreated for over two months. LN A stated that laboratory orders should be written on the resident's TAR, but confirmed that although a "UA" was written on Resident 4's TAR on 11/7/12, only one nurse signed that the UA was done on 11/19/12. LN A stated that all residents' lab results were received on a fax machine which was in a locked office, that the nursing staff never has access to on weekends and holidays. She stated that because they had no access to the fax, the nursing staff never received Resident 4's UA results. LN A confirmed that the LN staff had not followed through and ensured that Resident 4's UA's were collected and reported or that she received treatment for her UTI. During that interview, LN D confirmed that she had faxed the CBC/CMP request to Resident 4's physician and stated, "I take care of all the Dietitians requests." LN D confirmed that when the order came back signed by the PMD, a nurse had not noted the order and could not explain how the order ended up in Resident 4's record when it had not been noted by a nurse. LN D stated, "Our fax room is messy and unorganized and faxes are misplaced all the time." During that interview, LNs A, C, D, E, and F, all stated that they had no lab policy and procedure to follow and no system for tracking which lab was collected or reported to the physicians. LNs A, C, D, E, and F all stated that nurses were to communicate in writing to the next shift any resident changes or new orders on the "24 hour log" (a log book that sits on the nurses desk), but LN A stated, "we don't all use it." LNs A, C, D, E, and F stated that they knew the way they collected and received resident lab reports, "was not working" and asked their Director of Nurses for help, but no new systems were developed. Therefore, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for Resident 4 by failing to timely obtain and report laboratory (lab) results, notify the physician of acute changes in the resident's condition, and recognize and ensure timely treatment for infection when Resident 4 was at an increased risk for urinary tract infection (UTI) and urosepsis (blood poisoning from infected urine), due to the use of an indwelling catheter (a tube inserted into the bladder for the purpose of urine drainage from the bladder). Licensed nursing (LN) staff had either not collected or incorrectly collected urine, blood, and stool specimens that Resident 4's physician had ordered. LN staff, the primary care physician (PMD), another physician (MD), and a physician's assistant (PA) failed to recognize that the UAs had not been completed, ensure lab results were obtained, to ensure treatment for Resident 4's UTI. Licensed nursing staff had not recognized that promptly obtaining, evaluating, and reporting diagnostic lab testing was an important intervention in the early detection of infection, and diagnostic lab testing results that should have been available, but were not available. Resident 4's health status subsequently declined, and she was transferred emergently to the local hospital (Hospital A) where her infection and clinical condition could not be managed. Resident 4 was then transferred to a larger medical center (Hospital B) for a higher level of care, where she died from septic shock due to the untreated urinary tract infection (body wide systemic infection associated with infected urine). These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient. |
| 240000097 |
Legacy Post-Acute Rehabilitation Center |
240009312 |
A |
18-May-12 |
RH0J11 |
8719 |
REGULATION VIOLATION: CFR 483.25 Accidents (h) The facility must ensure that- (2) Each resident receives adequate supervision and assistance devices to prevent accidents.On August 8, 2007, an unannounced visit was made to the facility to investigate a complaint regarding an incident of alleged injury of unknown origin. Based on the information obtained during the investigation, the facility failed to identify the need for adequate, close, frequent supervision to ensure that Resident A was free from falls and injuries due to falls.Resident A was transferred from the acute care hospital with an order for a waist restraint in bed, due to the resident's confusion and risk for falls and injury. The facility failed to ensure that Resident A received adequate supervision to prevent the resident's fall and injury. On August 8, 2007, Resident A's health record identified Resident A as a 92 year old female, who was admitted to the facility on July 25, 2007 with diagnoses that included urinary tract infection (UTI), atrial fibrillation (irregular heart heat), hypertension (elevated blood pressure) and anxiety. Documentation showed that Resident A lived at home prior to her admission to the facility. Resident A was brought to a general acute care hospital by ambulance on July 21, 2007, with fever and palpitations in her chest. She was admitted to the hospital for treatment of atrial fibrillation and UTI. On July 25, 2007, she was transferred to the skilled nursing facility for rehabilitation.The hospital transfer record, dated July 25, 2007, indicated that Resident A was confused and needed a soft restraint secondary to a risk for falls. The admission orders for Resident A, dated July 25, 2007, included Plavix 75 mg (milligrams) by mouth daily, and aspirin 325 mg by mouth daily (both medications thin the blood). In addition, orders included Ativan 1 mg by mouth, every six hours, as needed for anxiety, manifested by "fidgeting."In addition, the physician ordered the use of side rails up, times two, for safety and poor balance, and a waist restraint, while in bed, to prevent self injury. The Resident Admission and Assessment Form, Behavior/Cognitive/Safety Assessment section, dated July 26, 2007 at 3:00 AM, described Resident A as alert, confused, forgetful, and "able to verbalize certain needs and desires." The admission assessment also indicated that Resident A needed assistance with bathing, grooming, toileting, and eating, and had weakness of her extremities (arms and legs). The Physical Therapy Evaluation, dated July 27, 2007, indicated that prior to being admitted to the facility, Resident A lived with a companion and used a forward wheel walker for walking and activities. The Physical Therapist (PT) documented, "Patient (Resident) displays impaired strength, balance and mobility, placing her at risk for falls and/or injury." The Nursing Care Plan for Resident A included a care plan, dated July 26, 2007, for potential for injuries related to fall risk, secondary to poor safety awareness, poor balance, body weakness, decreased level of consciousness, and confusion. Interventions included restraints as ordered, side rails up, times two, and a waist belt physical restraint.However, there was no documented evidence found in the health record to indicate that the facility determined an adequate level of supervision required to keep Resident A safe and prevent falls or injuries, based on the resident's cognitive impairment, behaviors, fall risk, and the need for physical restraints, which would include an assessment of the least restrictive measures needed to meet the resident's safety needs. A review of Nurse Assistant Notes-PM (evening) Shift, dated July 27, 2007, revealed that a Certified Nurse Assistant (CNA) documented Resident A was alert, confused, disoriented, noisy and agitated, and was dependent on staff for transfers, mobility, and ambulation (walking). Documentation showed that Resident A's side rails were in the up position. There was no documentation that Resident A had a waist restraint on at the time. On July 28, 2007 at 12:00 AM (midnight), a Licensed Vocational Nurse (LVN 1) documented, in the Nurse's Notes, that Resident A was awake, alert, confused, and made two attempts to try and get out of bed. LVN 1 also documented that Resident A's roll belt (waist restraint) was "intact for safety." However, there was no documentation to indicate the reason for the resident's two attempts to get out of bed unassisted. In addition, a review of the Medication Records, dated July 2007, indicated that LVN 1 gave Ativan 1 mg by mouth to Resident A for "fidgeting" on July 28, 2007 at 12:00 AM (midnight).On July 28, 2007 at 6:00 AM, LVN 1 documented in the Nurse's Notes that Resident A was, "Found on floor adjacent to bed with bilateral side rails still up. Waist restraint found still attached to patient's waist. Left tie unattached to bed with right tie loosely attached to bed. Patient alert, awake, verbally responsive and continues to be confused to time, place, and situation." Resident A had "left temporal swelling and approximate dime size laceration...right posterior (back side) head contusion (bruise caused when blood vessels are damaged or broken as a result of a blow to the skin) with swelling noted..." On July 28, 2007 at 7:25 AM, a day shift licensed nurse documented, in the Nurse's Notes, that she came into Resident A's room and assessed the resident. The licensed nurse documented that the left side of Resident A's head was "soaked with bright red blood" and a "hematoma (an abnormal localized collection of blood in which the blood is usually clotted or partially clotted and is usually situated within an organ or a soft tissue space)" was noted.On July 28, 2007 at 7:30 AM, documentation in the Nurse's Notes indicated that paramedics were called.On July 28, 2007 at 7:40 AM, documentation in the Nurse's Notes indicated that staff obtained a physician's order to transfer Resident A to an acute care hospital; paramedics arrived to the facility; Resident A was transported to a general acute care hospital. A review of Resident A's acute care hospital medical record revealed that Resident A complained of a headache and was unable to track an object with her eyes, while in the Emergency Department. Documentation revealed that Resident A was having trouble breathing and was subsequently intubated (a breathing tube was inserted into her airway to help her breathe) on July 28, 2007 at 12:30 PM, in the Emergency Department.Resident A's acute care hospital diagnoses included altered level of consciousness and subdural intracranial hemorrhage (bleeding into the space between the brain cover and the brain that can put increased pressure on the brain, and may progress to coma and even death). On August 1, 2007, Resident A was discharged from the acute care hospital to another skilled nursing facility [Facility 2]. Documentation showed that Resident A was transferred in a comatose state. Resident A was admitted under the care of hospice, "For comfort measures and end of life care."On August 9, 2007, Resident A died. A review of the death certificate for Resident A, dated August 13, 2007, included a description of the resident's fall in the skilled nursing facility [Facility 1], which included Resident A striking her head during the fall. The death certificate listed the resident's "Cause of Death" as, "(A) Subdural Hematoma" and "(B) Blunt Force Head Injury." Documentation obtained from the resident's skilled nursing facility stay [Facility 1], indicated that the facility was aware of the resident's risk for falls and injuries. However, the facility failed to determine the reason for the resident's two attempts to get out of bed unassisted. Rather, the licensed nurse administered an anti-anxiety medication, which had known, possibly unsafe side effects, including dizziness, drowsiness, blurred vision and sudden low blood pressure. As a result, Resident A got out of bed a third time, fell, sustained injuries to her head and died 12 days later. Therefore, the facility failed to ensure that Resident A, a restrained resident, with known confusion, forgetfulness, high risk for falls, and who was given medication with known, possibly unsafe side effects, received adequate supervision to prevent her fall and injury, which lead to the death of Resident A.These facility failures presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. |
| 240001749 |
Ladeney Home |
240009549 |
B |
16-Oct-12 |
XKRY11 |
10266 |
REGULATION VIOLATION: Title 42 483.460 Conditions of Participation: Health care services. (c) Standard: Nursing services. The facility must provide clients with nursing services in accordance with their needs. These services must include - (3) For those clients certified as not needing a medical care plan, a review of their health status which must - (i) Be by a direct physical examination. and (c) Standard: Nursing services. The facility must provide clients with nursing services in accordance with their needs. These services must include - (4) Other nursing care as prescribed by the physician or as identified by client needs.The facility failed to ensure that Client A was assessed by the RN (registered nurse) after the client fell out of his bed on June 22, 2012 at approximately 12:10 AM. After the fall, Client A and exhibited pain when moved. X-rays obtained on July 10, 2012 revealed a "sub capital fracture of the femoral neck."The facility also failed to notify the physician when a pressure sore developed on the client's right hip and when drainage was present in the wound. On June 29, 2012, the primary care physician (PMD) ordered x-rays to be done of both hips due to the client's continued pain; however, the x-rays were not done until July 10, 2012. The x-ray results were reported to the facility on July 12, 2012. The results were, "sub capital fracture of the femoral neck" (This was a complete fracture through the highest part of the thigh bone at the hip) of the left hip. This resulted in a delay of treatment for Client A, who was hospitalized 20 days after his fall from bed, and required a surgical hip replacement. In addition, upon arrival to the general acute care hospital, Client A was determined to have a Stage III pressure ulcer (full thickness tissue loss, may expose subcutaneous fat, and slough-dead skin, may be present), on his right hip which required a wound care specialist to surgically debride it (remove dead skin layers), and which cultured positive for methicillin resistant staphylococcus areaus- MRSA-a contagious bacterial infection), which placed Client A in isolation. The failure of the RN to perform a physical assessment, obtain x-rays in a timely manner, and identify the wound on the right hip as a pressure ulcer, resulted in Client A being placed at risk for unnecessary pain and infection. On July 24, 2012 at 8:45 AM, an unannounced visit was made to the facility to investigate a complaint regarding Client A being hospitalized with a fractured left hip. Client A was a 50 year old male admitted to the facility on April 18, 1968 originally, and re-admitted on October 1, 2011, with diagnoses to include: severe mental retardation (IQ < 20); epilepsy (convulsions); anemia (low red blood cell count which carry oxygen to tissues and organs throughout the body); right lower extremity edema; and arthritis. Client A had been ambulatory, with assistance at times until approximately January 2012 when he began to have increased arthritis pain in his knees. The most recent Individual Service Plan (ISP) dated January 19, 2012, listed his behaviors as "picking at sores" and "tendency in past to wander off." Client A was able to speak only a few words. The staff was to perform active assistive range of motion (ROM) exercise of lower extremities "2x/day". Client A was incontinent of bowel and bladder. On June 22, 2012 at 8:45 AM, the QMRP (qualified mental retardation professional) documented the following. "At 6:30 AM [used DCS 1's (direct care staff's name] notified me that while he was bringing [used Client A's name] to the table for breakfast, [Client A's name] appeared to be in pain. I investigated and [used DCS 2's name] night shift staff stated that around 12:10 AM, she heard a noise in [Client A's name] room, and when she went in [Client A] had fallen out of bed. [DCS 2' s name]stated that the 4:00 PM to midnight staff was getting into his car when she called him back to help assist in putting [Client A] back into his bed, and checked for bruising...DCS 2 notified RN concerning [Client A's name] appearing in pain and RN stated to give [Client A] Tylenol." On June 22, 2012, DCS 2 documented, "[Client A's name] fell from bed at 12:10 and this morning he was in pain so could not go to school." On June 22, 2012 at 9:00 AM, the RN documented, "[Client A's name] seen smaller second boil almost heal but area around first looking red. MD notified and Bactrim DS BID x10 days (an antibiotic to be given twice a day) ordered will start this evening. [Client A's name] also fell out of bed during the night. DCS reported acting as if in pain. Tylenol ordered and administered earlier this AM. At this time resting comfortably. DCS will continue to monitor." A second entry for June 22, 2012 at 5:00 PM indicated, "Phone call to DCS reported that [Client A's name] was doing well." During an interview with the RN at 10:30 AM, she was unable to locate any documentation to indicate that she had done a full body assessment following the incident of Client A's fall to determine the possible source of his pain and his unwillingness to get up to go to his day program, which was unusual for him. There was no documented evidence that the RN assessed the client for a possible head injury, assessed for range of motion and/or shortening and external rotation of his lower extremities. The RN implemented a plan of care on June 22, 2012, to "monitor for signs of injury after fall from bed". Interventions included, "DCS to notify RN of any changes in functioning level, decreased movement and increased fatigue."On June 25, 2012, three days after Client A fell, the RN documented,[Client A's name] acting as usual." However, at 9:30 AM, the RN documented, "Phone call from DCS this AM reporting he thought Client A was having pain, had some difficulty standing. Seen at this time doing well. Stood for a while crying, slightly shaky, possible arthritis will continue to monitor." There was no documentation that the physician was called to share this change in Client A's behavior, which included signs and symptoms of pain.On July 2, 2012 at 8:30 AM, the RN documented Client A having nasal congestion. In that note she indicated that the PMD had seen Client A "on June 29, 2012 for regular evaluation. Bilateral hip x-rays ordered to evaluate arthritis." A review of the physician's orders showed that no order for x-rays had been written. In addition, a review of the x-ray showed the x-ray was obtained on July 10, 2012. This was 11 days after it was ordered, and 20 days after Client A fell. The X-ray was faxed to the facility; the PMD was notified on July 12, 2012 at 12:30 PM that Client A had fractured his left hip. The physician ordered Client A to be sent to the general acute care hospital (GACH) for further evaluation and treatment. A review of the documentation at the GACH dated July 12, 2012 at 2:45 PM included Client A's admitting diagnoses as: "Left hip fracture secondary to mechanical fall; normocytic anemia; epilepsy; chronic osteoarthritis of knees and hips; chronic right lower extremity edema; chronic lower extremity knee contractures (legs drawn up towards body) and a Stage III decubitus ulcer (pressure sore) on the right hip measuring 1 cm x 1 cm (1 cm = 2.54 inches)." Client A underwent surgery to replace his left hip, surgical debridement of his right hip pressure ulcer (removal of dead or damaged tissue). Client A received intravenous (in the vein) pain medications to keep him comfortable. Due to his urinary incontinence, an indwelling catheter had to be inserted to protect both the surgical wound on the left hip and pressure ulcer on the right hip. Client A's right hip was cultured and found to have MRSA. As a result, Client A was placed in contact isolation to prevent cross-contamination with other patients. Client A was not able to return to his home due to his medical needs. A review of the wound assessment, which included a photograph obtained on admission to the GACH on July 12, 2012 at 6:20 PM, showed a 0.5 cm x 0.5 cm (centimeter) wound. The center of the wound had yellow slough, surrounded by a 1 cm area of reddened skin on what was identified as the right lateral hip. During a telephone interview with the RN on July 25, 2012 at 8:45 AM, she was asked about the pressure ulcer on Client A's right hip. She stated he had a boil and they had given him various oral antibiotics. The RN stated, "It would start to heal and then there would be a second boil." In addition, the RN was asked if she had discussed the use of a topical ointment and a dressing due to the client being incontinent and lying on that area. She said, "No". On July 25, 2012 at 9:15 AM, the PMD was interviewed and shown the picture of the wound as it appeared on admission to the GACH where it had been labeled a pressure sore versus a boil. After reviewing the interventions done at the GACH for the wound, the PMD was asked if what was present in the photograph was the "boil" he had been treating for the past two months on Client A's right hip. He stated, "I can't say for certain without seeing it, but can only say that looks like the location where he had the boil." During the same interview, the physician was asked about the client's fall. The physician stated when a fracture is suspected, clients are immediately sent to the emergency room for an evaluation. When asked if the nurse had called the morning of the fall and told him the client was having pain on range of motion, would he have ordered x-rays at that time, the physician stated, "Yes". The facility RN failed to do a full physical assessment on Client A after he fell, and failed to ensure x-rays were done as ordered which resulted in a delay in treatment for a hip fracture. The facility RN failed to identify that the area on Client A's hip was caused by pressure from his preference to lye on his right side, and failed to notify the PMD when the wound developed drainage while the client was receiving antibiotics. This resulted in Client A developing an infection at the site with MRSA that required surgical debridement. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility clients. |
| 240000747 |
LANCASTER HOUSE |
240010526 |
A |
07-Mar-14 |
EFB211 |
11337 |
REGULATION VIOLATION: WIC 483.460 Nursing Services - Facility Practices and Guidelines 483.460 Nursing Services - Facility Practices (c) The facility must provide clients with nursing services in accordance with their needs. 483.460 Nursing Services - Guidelines (c) The facility must provide clients with nursing services in accordance with their needs. (3) For those clients certified as not needing a medical care plan, a review of their health status which must - (1) Be by a direct physical examination. FINDINGS: On March 26, 2013 at 8:10 AM, an unannounced visit was made to the facility to investigate a complaint regarding the death of a client (Client A). 1. The facility's registered nurse (RN) failed to identify a change of condition in Client A, or notify the physician when his symptoms of vomiting with constipation started on March 15, 2013. 2. The facility's registered nurse failed to physically assess Client A when his condition continued to deteriorate ending with Client A's death on March 16, 2013. Client A was a 52 year old male admitted to the facility on July 7, 2011, with diagnoses to include: profound intellectual disability (IQ<20); Micro-encephalus (head circumference is smaller than normal); osteoarthritis (degenerative disease of the joints); blind and seizure disorder (convulsions). Client A was able to verbalize his needs in one to three word sentences, was non-ambulatory but could propel himself in his wheelchair. Client A had a behavioral plan related to being resistive to going to bed and using the toilet. The client was on a regular, heart healthy, ground-texture diet and he fed himself without problems. On March 15, 2013, Client A developed vomiting, excessive fatigue, loss of appetite and constipation; all but the vomiting continued through March 16, 2013. On March 16, 2013, at approximately 8:33 PM, emergency medical response (EMS) was summoned to the home and Client A was pronounced dead at 9:21 PM.During a review of the clinical record for Client A on March 26, 2013 at 9:30 AM, the direct care staff (DCS 1) had documented that on March 15, 2013, "[Client A] was throwing up at school but no temp [temperature]. I put [Client A] on toilet and he seemed constipated. He had a small BM [bowel movement]. I called [RN 1] at 3:55 PM and she said to give him a suppository and wait 3 hours. If no results, give enema. Small BM at 7:00 PM, gave him an enema with no results. Called [RN 2] at 8:50 PM, after 1 hour 50 minutes, she said, 'give plenty of fluids and call her in the morning."During an interview with RN 1 on March 26, 2013 at 9:15 AM, she stated, "[Client A] always had a great appetite, that was so unusual for him not to want to eat."In further interview with RN 1, at 9:45 AM on March 27, 2013, she advised that a physical examination by the RN staff should have been done on Client A after she and RN 2 had been made aware of Client A vomiting twice on March 15, 2013 at the day program, being constipated, not eating, requesting to go to bed and having fatigue.During an interview with RN 2, on March 27, 2013 at 9:00 AM, she was asked if she was the regular RN assigned to the home. RN 2 responded, "No, I was on call for all 20 houses." RN 2 was asked to review a nursing note she had written, dated March 15, 2013.In RN 2's note she had documented the following: "At 8:15 PM staff reported no results to Fleets enema. Order to give client extra fluids and follow up in the morning with the results." When asked if she had assessed the client, to rule out a fecal impaction (stool that a person cannot pass that has to be manually evacuated), or notified the physician that Client A had vomited, been constipated, had no results from the enema and wasn't eating, she stated, "no."During the same interview with RN 2, she acknowledged that she should have gone to the facility and performed a physical assessment on Client A when she had been made aware by DCS 2 that he had not been eating, was constipated, and had received a suppository with small results and an enema with no results.The facility Policy & Procedure (P&P) entitled, "Change in a Client's Condition or Status," dated June 2002, was reviewed with RN 1 and RN 2 on March 27, 2013. The P&P indicated under the section titled, "Policy Statement" that the facility would "...promptly notify the client, his or her attending physician, and representative (sponsor) of changes in the client's medical/mental condition and/or status..." the sub-section, "Policy Interpretation and Implementation", #2, indicated "The registered nurse will go to the facility and assess the client based on the urgency of the medical situation...The registered nurse will document in the medical record his/her assessment of the client..."Both RN 1 and RN 2 confirmed a physical assessment of Client A should have been done when they were made aware that he had vomited twice, had gagged and spit out food, wasn't eating, was constipated even after both suppository and enemas had been given, and had requested to go to bed because of unusual fatigue.
Review of the clinical record dated March 16, 2013 for the 7:00 AM - 2:30 PM shift, DCS 1 had documented that Client A had eaten only 1/2 cup of canned pears for breakfast and refused lunch. He had one small and one medium watery BM.
Further review of the clinical record dated March 16, 2013, DCS 1 had further documented at 10:30 AM that Client A was unusually quiet, gagged and spit out his breakfast and asked to be put to bed, which he normally resisted. The same behavior occurred at lunch, Client A asking to go to bed. DCS 1 noted, "He was more tired and sleepy than usual." DCS 1 had documented that Client A's symptoms had been discussed with RN 1 at the start of her shift, and RN 2 after lunch.A March 16, 2013 Interdisciplinary Note by DCS 2 indicated that after she arrived for her 2:30 PM - 9:00 PM shift, she found Client A in bed, which was unusual. DCS 2 documented that she got Client A up for dinner and took his temperature which was 96.4. Client A took two bites of dinner and requested to go back to bed. He allowed her to shower him and put him to bed without his usual resistance. The Interdisciplinary Note further indicated, "At about 7:30 PM the second staff [DCS 3] was in [Client A's] room changing his diaper. He had another BM. At this time... the other staff called on me to check on [Client A], saying he was not breathing normal. I then checked on [Client A] and he was sweating and cold to touch. I then immediately called the nurse [RN 2]. She [RN 2] said to call the doctor. I then called the FM [Facility Manager] after paging the doctor, by this time it was 7:40 PM. While waiting for the doctor to call back I continued to check on client. He was breathing shorter and I was not uncomfortable that he was in any distress. He was still talking. I then went back to charting for other clients. At 8:15 PM, I went to check on [Client A] and at this time he was not responding to my voice or touch. I immediately called for other staff. At about 8:20 PM, I called 9-1-1."Further review of Client A's Interdisciplinary Notes for March 16, 2013 showed the only vital signs that had been taken for Client A was a temperature at 4:50 PM that read 96. 4.
During an interview with DCS 2 on March 27, 2013 at 8:30 AM, she stated that the doctor had not called back on March 16, 2013, and confirmed that there was at least a five minute interval between finding Client A without a pulse and cardiopulmonary resuscitation (CPR) being initiated. When asked if RN 2 had requested vital signs (temperature, pulse, respiration, and blood pressure) be taken, or had asked what his vital signs had been during the shift, she stated, "No, she never asked. I just took his temperature earlier, I don't know why."
During an interview with DCS 2 on March 27, 2013 at 8:45 AM she confirmed she found Client A on March 16, 2013 at 8:15 PM, unresponsive and without a pulse.
During an interview with RN 2 on March 27, 2013 at 9:00 AM, she was shown the note she had written dated March 15, 2013. The note did not indicate it was a late entry but the note included data for both March 15 and 16, 2013. The note further documented; "On March 16, 2013 morning staff reported client has small watery BM and notified staff to monitor and notify RN and MD. On March 16, 2013 at 7:30 PM, staff reported client was cold to touch, shallow breathing and sweating. RN instructed staff to call MD. At approximately 9:30 PM staff calls and notified that client passed away."
During the same interview with RN 2, she was asked if she had gone to the home and done an abdominal or respiratory assessment of Client A given his declining condition. She stated, "No I don't see so good at night to drive." When asked if she had called the staff back to be updated on Client A's condition and the physician's response, she shook her head to indicate "no." When asked if she had advised the staff to obtain vital signs prior to calling the MD she stated, "No they tell me they are normal." RN 2 was shown the only documented vital signs taken on March 15, 2013 were as follows:
a. 3:20 PM Temperature=97.8
b. 5:55 PM B/P 139/95 (normal 120/80) and pulse 109 (normal 60-100). No respirations or temperature was taken
c. 8:40 PM B/P 143/99, pulse 113, and temperature 97.7
d.March 16, 2013 (sometime between 2:30 PM and 5:30 PM) temperature was 96.4.
On March 27, 2013, during a review of the facility's policy and procedure (P&P) for the Registered Nurse's Job Description dated July 2, 1997, the P&P indicated, "The Registered Nurse will carry a beeper at all times. The beeper is used so staff can notify the nurse of any client change of condition...There may be times that the client's change of condition warrants the nurse to go to the facility to attend to the client."
Client A's death certificate was reviewed on May 20, 2013; the death certificate indicated the document was signed by the attending physician on March 20, 2013.
During an interview with the on call physician on March 27, 2013 at 10:00 AM, he was asked if he had signed the Death Certificate. He stated, "I did and put a diagnosis of "Cardiopulmonary arrest, secondary to respiratory arrest, etiology unknown. I thought I had to sign it." When asked if he had been made aware of Client A's vomiting, not eating, constipation even after a suppository and enema, requests to go to bed, "cold sweats", and irregular respirations, he stated, "I did get a page from the home on March 16, 2013 but the [phone] number they put in was wrong. It was some residence. I was not aware of the vomiting or other issues until after the fact of signing the Death Certificate."
The facility RN's failure to do a physical assessment and to notify the physician when Client A's symptoms were indicative of a change of condition, resulted in a delay in medical treatment.
Therefore, the facility RNs' failure to go to the home and perform a physical assessment of Client A when she was notified that Client A's symptoms had progressed, resulted in a lack of medical intervention and the death of Client A.
This facility's failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would |
| 240001000 |
LILLIAN HOUSE |
240012416 |
B |
30-Jun-16 |
0OMR11 |
7061 |
Regulation Violation: Title 22 76875(a)(2)(3)(b) (a) Facilities shall provide registered nursing services in accordance with the needs of the clients for the purpose of: (2) Development and implementation of a written plan for each client to provide for nursing services as a part of the individual service plan, consistent with diagnostic, therapeutic and medication regimens. (3) Review and revision, as necessary, of the nursing services section of the individual service plan at least every six months. (b) The attending physician shall be notified immediately of any sudden and/or marked adverse changes in signs, symptoms or behavior exhibited by a client. The facility failed to ensure the Registered Nurse (RN) physically assessed Client 1, developed and implemented a plan of care and notified the physician (MD), when Client 1 experienced a change of condition as evidenced by coughing and wheezing on February 3, 2016 and a low blood pressure on February 4, 2016. During a review of the clinical record for Client 1, on May 2, 2016, the Admission and Discharge Record indicated Client 1 was admitted to the facility on XXXXXXX with diagnoses, which included profound intellectual disability (significant delay in intellectual development and functioning) and seizure (uncontrolled electrical activity in the brain). Continued review of the clinical record reflected Client 1 expired at the facility on XXXXXXX 2016. A review of the RN (Registered Nurse) Notes' latest entry dated February 4, 2016 at 11:00 PM, indicated "Client found unresponsive by staff; 911 called; CPR (cardiopulmonary resuscitation) performed but client passed." There were no other entries documented in the RN notes since XXXXXXX, 2016 (eight days prior to the date Client 1 passed away). A review of the Interdisciplinary Notes' latest entry, dated February 4, 2016, no time indicated, by a PM (afternoon) Direct Care Staff (DCS 1), indicated the client "was given hourly vital signs observation due to his coughing and wheezing when breathing after coughs." A review of Client 1's Vital Signs Record dated February 4, 2016 at 3:35 PM, showed Client 1's systolic blood pressure (amount of pressure in the arteries when the heart contracts) was 80 and the diastolic blood pressure (amount of pressure in the arteries when the heart is at rest) was 60. Client 1's blood pressure was improving from 4:30 PM to 7:30 PM. Client 1's blood pressure at 7:30 PM showed 100/85. There is no entry at 8:30 PM. A telephone interview with the Registered Nurse (RN 1), was conducted on May 2, 2016 at 2:35 PM. She said on February 4, 2016 at approximately 9:50 PM, a Direct Care Staff (DCS 3) found Client 1 unresponsive. She said DCS 2 called 911 and DCS 3 initiated CPR. RN 1 said the paramedics arrived and took over the care. She stated that Client 1 passed away. RN 1 further stated on February 4, 2016, at approximately 3:00 PM, DCS 2 took Client 1's blood pressure and noted it was abnormally low. RN 1 said she notified the Primary Care Physician (PCP 1) of the low blood pressure, and PCP 1 ordered to "push fluid" and monitor vital signs (data included blood pressure, body temperature, heart rate, and respiratory rate) every one hour. RN 1 confirmed she did not document the communication she had with PCP 1 and did not document the physician's order of "push fluid" and monitor vital signs every one hour. A review of the physician's orders indicated there was no order to push fluid documented. During a phone interview with DCS 3, on May 2, 2016 at 3:00 PM, she stated she worked the nocturnal shift (starting at 10:00 PM). DCS 3 said she came to the facility on February 4, 2016 at approximately 9:50 PM, and checked on Client 1 on her first round. DCS 3 said he was in his bed with his eyes closed while DCS 2 was changing him. DCS 3 said he looked pale and his lips were whitish. DCS 3 stated she immediately knew something was wrong with the client (Client 1) because from her experience of taking care of him for years, he would always have his tongue sticking out when he laid in bed. DCS 3 said his tongue was not sticking out at this time. She summoned DCS 1 for help and instructed to call 911 when she initiated CPR on the client. She said DCS 2 remained with her. When asked if she had asked whether DCS 2 noticed the client's unresponsiveness while he was changing the client, she stated DCS 2 told her he thought the client "was sleeping." During an interview with the Program Manager (PM), on May 2, 2016 at 4:15 PM, he confirmed DCS 1 and DCS 2 were no longer employed at the facility. A review of Client 1's clinical records was conducted with the PM on May 2, 2016 at 5:30 PM. The PM confirmed there was: 1. No documented evidence to show the licensed nurse assessed Client 1 for a change in respiratory pattern (cough and wheezing) on February 3, 2016 (one day prior to the client's passing). 2. No documented evidence to show the client's cough and wheezing had resolved on February 3, 2016. 3. No documented care plan addressing the cough and wheezing on February 3, 2016. 4. No documented evidence to show RN 1 notified the primary care physician on February 3, 2016 when DCS 1 noted a change in Client 1's respiratory pattern and on February 4, 2016 when DCS 1 noted Client 1's low blood pressure. 5. No documented evidence to show RN 1 obtained a telephone physician's order to manage the low blood pressure. During a telephone interview with Client 1?s Primary Care Physician (PCP), on May 3, 2016 at 9:55 AM, he stated he did not remember if the nurse had reported any change of condition for Client 1 on February 3 or February 4, 2016. The PCP stated he was notified when the client passed away. During a phone interview with RN 1, on May 12, 2016 at 3:20 PM, she stated on February 3, 2016, at approximately 9:00 PM, DCS 1 called her and reported Client 1 had coughed and wheezed three to four times throughout the shift. When asked if she or any licensed nurse had physically assessed the client, she stated no. When asked if there was any documented evidence to show a licensed nurse assessed the client?s change in respiratory status and notified the physician. She stated it was not done. The facility's Policy and Procedure titled, "Notification of Client Change of Condition", dated September 2012, indicated "...3. The RN will be responsible for making all notification of changes to the physician. 4. Before notifying the physician, the RN may observe and assess the overall condition utilizing physical assessment and chart review. 7. All attempts to notify the physician and the client's representative will be noted in the client's charts..." The facility failed to ensure the provision of nursing services according to client needs when the RN failed to observe and assess the client?s overall condition, notify Client 1?s physician of the change of condition, and update the plan of care to address the client?s change of condition. These violations had a direct or immediate relationship to the health, safety or security of patients. |
| 240000097 |
Legacy Post-Acute Rehabilitation Center |
240012597 |
B |
26-Sep-16 |
6GRL11 |
6060 |
REGULATION VIOLATION 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility staff failed to provide safety precautions for Patient 1. On March 5, 2016, while a staff was providing care to Patient 1, the staff was unsure of how much assistance the patient needed. Patient 1 fell out of bed, sustained a facial injury, swelling to her right cheek and facial pain. An observation of Patient 1 on April 18, 2016 at 1:30 PM, the patient was lying in bed with eyes closed. Patient 1 was observed to have a tracheotomy (a surgically made hole that goes through the front of the neck and into the windpipe). Patient 1 was non-verbal and in a vegetative state (a state of brain dysfunction in which a person shows no signs of awareness). A review of Patient 1's clinical record, indicated the patient was admitted to the facility on XXXXXXX with diagnoses that included chronic respiratory failure (the inability of the respiratory system to oxygenate the blood), obesity (excessive body fat) and in a persistent vegetative state. A review of the Minimum Data Set (MDS-a facility comprehensive assessment tool) Functional status (the measure of a person's ability to perform activities of daily living (ADLs) independently), dated January 3, 2016, indicated Patient 1 was assessed to be total dependent (full staff performance) and had total impairment on both upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). Patient 1 required total assist with all of her ADLs activity. A review of the nursing progress note, dated March 5, 2016 at 8:15 PM, the "Initial Change of Condition for a witnessed controlled fall" indicated, "the CNA (Certified Nurses Assistant) reported that she was changing the patient, she was too heavy, and she began to fall from the bed...Right cheek red, ice applied." A review of the nursing progress note, dated March 6, 2015 at 3:12 AM, indicated monitoring for witnessed fall, "redness and slight edema noted to right cheek, ice pack wrapped in towel and applied to cheek for 15 minutes." A review of the nursing progress note dated March 6, 2015 at 9:32 AM, indicated, "Norco (a narcotic medication used to treat pain) tablet 5-325 MG (milligrams), 1 tablet via G-tube (A gastrostomy tube also called a G-tube- is a tube inserted through the abdomen that delivers nutrition and medication directly to the stomach) given due to facial grimacing, swelling at the right cheek and body movement." A review of the nursing progress note dated March 6, 2016 at 6:30 PM, documented, "medicated x 1 for pain due to swelling on right face." During an interview with CNA 1 on April 20, 2016 at 10:10 AM, she stated on March 5, 2016 Patient 1 was lying in bed. "I went in to change her [Patient 1], this was the first time I cared for her." CNA 1 stated, "I went to change her diaper, I rolled the patient to the side, she was heavier than I thought and she started to slip off the bed." Furthermore CNA 1 stated Patient 1 slipped off the bed, her face was pushed into the side table by her bed causing the swelling on her cheek. CNA 1 stated Patient 1 fell off the bed. When asked how does she know how much assistance the resident's need, CNA 1 was not able to explain. During a review of the "Legacy Morse Fall Risk Scale", (assessment for determining fall risk), dated December 29, 2015, indicated Patient 1 had a total score of 50. A "score of 45 and higher represents a high risk for falls." The instructions on the Legacy Morse Fall Risk Scale indicated ... used to determine fall risk factors and target interventions to reduce risk." A review of Patient 1's care plan entitled, "Fall Risk", initiated on July 7, 2014, related to decrease safety awareness, PVS (persistent vegetative state), anxiety and seizures showed interventions which included, ?Complete a fall risk assessment on admission and quarterly or with changes of condition/decline." There was no documented evidence to indicate how to reduce falls for Patient 1. During an interview with the Assistant Director of Nurses (ADON) on April 18, 2016 at 3:30 PM, the ADON verified there was no intervention to reduce falls for Patient 1 prior to the fall incident on March 5, 2016. The ADON verified Patient 1 had a high fall risk score of 50. The ADON stated, "Every resident is assessed for their fall risk and should have an individualized care plan to reduce the risk." The ADON stated Patient 1 was a total care. Patient 1 was dependent on staff for bed mobility and all of her ADLs activity. When asked regarding how the staff determines how much assistance the patients need, the ADON stated, It is up to the CNA's and it is patient specific. The ADON then added, "When you look at a patient, you can tell if the patient is required for a one or two person assist, I think, it's based on the size of the patient and the size of the CNA." A review of the facility policy and procedure titled, "Fall Prevention Program", dated June 2015, indicated, "All residents' environments shall remain free of accident hazard as is possible and all residents will receive adequate supervision and assistive devices to prevent accidents. All resident shall be assessed for being at risk for falls. Any resident identified as being 'at risk' for falls shall have an individual plan of care that included intervention to prevent falls from occurring." In Procedure "Fall Prevention Interventions", 1. As the resident's needs are identified, resident specific interventions will be implemented? " The facility failed to implement their fall prevention policy. Patient 1 required fall risk precaution due to patient decreased safety awareness, persistent vegetative state, anxiety and seizures. On March 5, 2016, while receiving care, Patient 1 fell from the bed, sustained a facial injury, swelling to her right cheek and facial pain. These violations had a direct relationship to the health, safety or security of the patient. |
| 910000035 |
Lotus Care Center |
910008955 |
B |
27-Jan-12 |
2GYZ11 |
11081 |
F 323 ?483.25 (h) Accidents. The facility must ensure that- (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The Department received a fax complaint from a former staff that alleged she was fired for notifying the police after a patient (Patient A) wandered out of the facility and went missing and could not be located.On October 27, 2010, an unannounced complaint investigation was conducted. Based on observation, interview, and record review, the facility failed to: 1. Supervise and monitor Patient A, who had a diagnosis of altered level of consciousness with a decreased mental functioning and psychosis and wandering behavior that was not care planned, who went missing.These failures resulted in Patient A?s involvement in five physical altercations within three months including three with injuries, and a fall which resulted in the patient limping and wandering out of the facility unsupervised and missing for over 13 months. A review of the facility?s investigation report indicated Patient A went missing on October 2, 2010. According to the report, the patient went missing around 7:20 p.m. on the evening shift. The staff searched for the patient unsuccessfully and notified the police. According to follow-up reports, dated October 4 and October 22, 2010, the facility contacted all the acute care hospitals in the area, continued to physically search the area, and posted flyers. Patient A remained missing. During an observation on October 27, 2010, at 2:50 p.m., the facility?s metal door leading from the building into a patio area and the south-side metal door leading from the patio towards the street access were opened. The facility was having a roof repaired and the construction workers were seen entering and exiting the facility grounds through the two metal doors. On October 27, 2010, at 3 p.m., during an interview, the certified nursing assistant (CNA 1) stated the facility?s doors were opened then due to the construction work on the roof and she stated normally the doors are closed, but unlocked. CNA 1 stated she worked the day shift of October 2, 2010, the day Patient A was discovered missing from the facility. CNA 1 stated she clocked out at 3 p.m. and Patient A was observed still sitting by the nursing station. CNA 1 stated at 8 p.m. she received a call at home from CNA 2 indicating Patient A could not be found. CNA 1 stated the patient was confused.A review of Patient A?s Admission Face Sheet indicated the patient was a 65 year-old male who was admitted to the facility on June 24, 2010. The patient?s diagnoses included organic brain syndrome (decreased mental function due to a medical disease, other than a psychiatric illness), and psychosis (loss of contact with reality).According to a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated July 5, 2010, indicated Patient A was Spanish speaking only and had short and long-term memory problems. The patient?s cognitive skills for daily decision-making were moderately impaired with poor decision-making skills and required supervision. According to the MDS, the patient required limited assistance with walking, bed mobility, personal hygiene, and dressing. Patient A?s primary mode of ambulation (walking) was with the use of a walker. A review of a ?Licensed Nurses Progress Note? dated June 25, 2010, and timed at 2 a.m., indicated the patient was wandering along the hallway attempting to open the facility?s main door. According to the nurse?s note, the patient then attempted to enter each room he approached, but had to be re-directed to his own room, but the patient was refusing to enter his own room because his roommate was yelling. A review of another ?Licensed Nurses Progress Note? dated June 26, 2010, timed at 3-11 p.m. shift, indicated Patient A was wandering around the facility and was re-oriented by the staff to environment and use of the call bell. A review of the patient?s care plans revealed there was not any plan of care to address the patient?s confused wandering behavior. Another entry in the ?Licensed Nurses Progress Note? dated July 10, 2010 and timed at 11p.m.-7 a.m. shift, indicated the patient was observed fighting with his roommate (not identified) in the bathroom. According to the nurse?s note, Patient A was unable to verbalize what happened during the incident and was transferred to another room. According to a Licensed Nurses Progress Note, dated July 17, 2010 and timed at 9:05 a.m., Patient A was unable to verbalize what happened during the physical altercation with another patient (not identified) on the patio. The note indicated Patient A sustained a ?swollen, bruised black left eye? after the altercation. A review of a ?Licensed Nurses Progress Note? dated August 3, 2010 and timed at 8:30 p.m., indicated Patient A fell to the floor after being punched by another patient. The note indicated Patient A was disoriented and had neck and facial scratches. According to another entry in the ?Licensed Nurses Progress Notes? dated August 20, 2010 and timed at 9:35 p.m., Patient A had another altercation with a female patient (not identified), in which the staff intervened and broke-up the fight. A review of a Licensed Nurses Progress Note, dated August 31, 2010, and timed at 10 a.m., indicated Patient A was observed limping and when asked by staff what happened, the patient stated he fell down the day before, but was unable to say how he fell. Another Licensed Nurses Progress Note, dated September 7, 2010 and timed at 3:35 p.m., indicated Patient A was involved in a fight with another patient (not identified) and sustained redness to the right side of his face. There was no plan of care to address Patient A?s need for close supervision. A ?Licensed Nurses Progress Note? dated October 2, 2010 and timed at 7 p.m.-7a.m. shift, indicated the police was called at 7:20 p.m. and arrived at the facility at 8 p.m. because Patient A was missing. On October 27, 2010, at 3:42 p.m., during an interview, the director of nurses (DON) stated when a patient was discovered missing, the administrator, doctor, resident's family, police, and herself should be notified. The DON was asked if an elopement risk assessment was done for Patient A and the DON stated the assessment is only done for those patients with a history of elopement from another facility. The DON stated Patient A had no elopement risk assessment done on admission or thereafter, although the nursing staff was documenting the patient was confused and would wander around the facility. On October 27, 2010, at 4:30 p.m., during an interview, Employee 1 stated she was on duty the day Patient A was discovered missing (October 2, 2010). Employee 1 stated she clocked out from work at approximately 6:30 p.m. to 7 p.m. She stated as she was getting into the car, she saw Patient A exit the facility?s north metal gate leading into the parking lot and street access area. Employee 1 stated she instructed the patient to go back inside the facility and she waited until the patient entered the south metal door, which leads into the facility grounds and patio area.During an observation, on October 28, 2010, at 9:15 a.m., the facility?s north and south gates leading into the parking lot in front of the building to the sidewalk were unlocked and open. A total of six patients were seen in front of the building unsupervised.On October 28, 2010 at 10:05 a.m., CNA 4 stated the facility?s south door was not locked and is left open because the facility was not a locked facility. CNA 4 stated the facility did not have any wandering patients, meaning patients do not leave the facility without staff knowing where they are.On October 28, 2010, at 10:25 a.m., during an observation and interview, the DON stated that the south door was opened because a patient likes to walk around in circles. The DON stated she was not concerned with the gate being unlocked because, ?This is not a locked facility and we do not have wandering patients.? On November 10, 2010, at 3:40 p.m., during an interview, CNA 5 stated she was on duty on October 2, 2010, the day Patient A was discovered missing. CNA 5 stated she saw Patient A sitting near the nurses? station at approximately 6:30 p.m. However, at 8 p.m., CNA 5 stated when she was preparing to give out snacks, Patient A was no longer sitting near the nurses? station. CNA 5 stated then the staff started searching for Patient A. On November 10, 2010, at 3:50 p.m., during an interview, CNA 3, who was assigned to care for Patient A the evening the patient went missing, stated she was on a break when the snacks were being passed at 8 p.m. and was informed Patient A went missing at approximately 7:30 p.m. On February 8, 2011, at 10:42 a.m., CNA 1 stated Patient A was always confused and dependent upon the staff for everything. A patient (Patient B) was observed outside of the facility?s gated area at the curbside of a main street unsupervised. CNA 1 observed Patient B standing at the curbside with his walker and stated the patient had periods of confusion, but walks to the corner and back to the facility. CNA 1 was asked about the facility?s lack of supervision. CNA1 stated CNAs assigned to patients who sit outside the facility were responsible to check their patients every five minutes.A review of Patient B?s Admission Face sheet, indicated the patient was a 59 year-old male admitted to the facility on August 19, 2009. The patient?s diagnoses included altered mental status with a history of alcohol abuse. According to a Resident Assessment Protocol Summary (RAPS), dated August 30, 2010, indicated cognitive loss, ADL functioning, psychological well-being, falls, and receiving psychotropic medications were all triggered as concerns for Patient B, but yet he was sitting outside the facility?s gated area unsupervised. On February 8, 2011 at 10:45 a.m., CNA 4 stated CNAs are to make rounds every two hours to check the whereabouts of their assigned patients. CNA 4 stated, ?It is our responsibility to know where our assigned patients were.? On February 8, 2011, at 4 p.m., during an interview, the facility?s assistant administrator stated Patient A had not returned to the facility and had not been found. The assistant administrator was asked to provide the facility?s policy and procedure regarding supervision and safety for confused patients, but failed to do so.As of November 16, 2011, at 2:50 p.m., according to the facility?s social service designee (SSD), during a telephone interview, Patient A?s whereabouts had not been located and the patient had not returned to the facility. The facility failed to: 1. Supervise and monitor Patient A, who had a diagnosis of altered level of consciousness with a decreased mental functioning and psychosis and wandering behavior that was not care planned, who went missing. The above violation had a direct or immediate relationship to the health, safety, or security of Resident A. |
| 910000328 |
LONGWOOD MANOR CONVALESCENT HOSPITAL |
910009048 |
B |
28-Feb-12 |
MWYJ11 |
6554 |
72601(a) Title 22, Divison5, Chapter 3, Article 6-72601 (a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter 1, Division 17, Part 6, Title 24, California Administrative Code and requirements of the State Fire Marshal.On February 15, 2012, at 2:20 p.m., an unannounced visit was made to the facility to investigate a complaint regarding ongoing alterations to the facility without permits and/or approvals from the Office of Statewide Health Planning and Development (OSHPD). The licensed capacity of the facility is 198 beds. The facility failed to comply with the requirements from OSHPD, the authority of having jurisdiction for alteration and construction work in healthcare facilities by: 1. Renovations and alterations to case work, range and sink without permits or approval from OSHPD. 2. Installation of data/phone cabling in various areas that had been placed in service without required permits, plan approval, inspection, testing or approvals from OSHPD. 3. Installation of water heaters placed in service with permits or approval from OSHPD. 4. Installation of new or replacement HVAC air handler appliances without permits or approval from OSHPD. 5. Installation and alterations to the fire alarm system without required review, permits or approval from OSHPD. 6. Installation of kitchen hood suppression system was without required review, permits or approvals from OSHPD. 7. Installation of electrical alterations and/or additions completed and placed into service without required review, permits or approvals from OSHPD. 8. Installation of cordless phone stations in fire resistive exit access corridor walls without OSHPD plan approval, inspection, or approvals.9. Installation of large unsprinklered patio cover structures attached to the facility without required review, permits or approval from OSHPD. 10. Installation of security surveillance system and wall mounted televisions without required review, permits or approvals from OSHPD. 11. Recovered or re-roofed area (more than 100 square feet) without required review, permits or approvals from OSHPD. 12. Fire resistive assemblies have been disassembled or altered.During a tour of the facility on February 15, 2012, 2:20 to 3:30 p.m., the Evaluator observed the following: A. Renovations and alterations to casework, range and sink without permits or approval from OSHPD. B. Installation of data/phone cabling in various areas that had been placed in service without required permits, plan approval, inspection, testing or approvals from OSHPD. C. Installation of water heaters placed in service with permits or approval from OSHPD. D. Installation of new or replacement HVAC air handler appliances without permits or approval from OSHPD. E. Installation and alterations to the fire alarm system without required review, permits or approval from OSHPD. F. Installation of kitchen hood suppression system was without required review, permits or approvals from OSHPD. G. Installation of electrical alterations and/or additions completed and placed into service without required review, permits or approvals from OSHPD. H. Installation of cordless phone stations in fire resistive exit access corridor walls without OSHPD plan approval, inspection, or approvals.I. Installation of large unsprinklered patio cover structures attached to the facility without required review, permits or approval from OSHPD. J. Installation of security surveillance system and wall mounted televisions without required review, permits or approvals from OSHPD. K. Recovered or re-roofed area (more than 100 square feet) without required review, permits or approvals from OSHPD. L. Fire resistive assemblies have been disassembled or altered.During an interview with Employee A at the time of the observation, he stated the installation and alterations in the above said items were completed anywhere from 2 months to 3 years ago. He stated he was unaware if the alterations or installation of work had been reviewed or approved by OSHPD. During an interview with the Employee B, she stated that she could not provide any documented evidence that there was OSHPD review or approval for the alterations or installation of the above mentioned work. A review of an OSHPD field visit report dated November 14, 2011 from an OSHPD area compliance officer and a field visit report dated February 13, 2012 by an OSHPD fire marshal inspector, both identified the alterations and unapproved equipment that were installed and placed into service without the required inspection, review, permits or approvals from OSHPD. In addition, according to the fire marshal report, there were no permits obtained by the facility for any work or alterations since 1991. The facility failed to comply with the requirement from the Office of Statewide Health Planning and Development, the authority having jurisdiction for alteration and construction work in healthcare facilities by: 1. Renovations and alterations to casework, range and sink without permits or approval from OSHPD. 2. Installation of data/phone cabling in various areas that had been placed in service without required permits, plan approval, inspection, testing or approvals from OSHPD. 3. Installation of water heaters placed in service with permits or approval from OSHPD. 4. Installation of new or replacement HVAC air handler appliances without permits or approval from OSHPD. 5. Installation and alterations to the fire alarm system without required review, permits or approval from OSHPD. 6. Installation of kitchen hood suppression system was without required review, permits or approvals from OSHPD. 7. Installation of electrical alterations and/or additions completed and placed into service without required review, permits or approvals from OSHPD. 8. Installation of cordless phone stations in fire resistive exit access corridor walls without OSHPD plan approval, inspection, or approvals.9. Installation of large unsprinklered patio cover structures attached to the facility without required review, permits or approval from OSHPD. 10. Installation of security surveillance system and wall mounted televisions without required review, permits or approvals from OSHPD. 11. Recovered or re-roofed area (more than 100 square feet) without required review, permits or approvals from OSHPD. 12. Fire resistive assemblies have been disassembled or altered.These violations had a direct relationship to the health, safety, and security of all patients of the facility. |
| 910000328 |
LONGWOOD MANOR CONVALESCENT HOSPITAL |
910009049 |
B |
08-Mar-12 |
None |
3611 |
Class B Citation 72601(a) Title 22, Divison5, Chapter 3, Article 6-72601 (a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter 1, Division 17, Part 6, Title 24, California Administrative Code and requirements of the State Fire Marshal. On February 15, 2012, at 2:20 p.m., an unannounced visit was made to the facility to investigate a complaint regarding ongoing alterations to the facility without permits and/or approvals from the Office of Statewide Health Planning and Development (OSHPD). Based on observation, interview and record review, the facility failed to comply with the requirements from OSHPD, the authority having jurisdiction for alteration and construction work in healthcare facilities by: 1. Installing an emergency generator and associated ATS (automatic transfer switch)/ appurtenances installed and placed into service without permits or approval from OSHPD. 2. Installing incorrect and/or deficient panels, raceways and receptacles associated with unapproved emergency generator. 3. Installing receptacles in patient care areas and sleeping rooms not listed as ?Hospital Grade? without permits or approval from OSHPD. During a tour of the facility on February 15, 2012, 2:20 to 3:30 p.m., the Evaluator observed the following: A. Installation of emergency generator and associated ATS (automatic transfer switch)/ appurtenances installed and placed into service without permits or approval from OSHPD. B. Installation of incorrect and/or deficient panels, raceways and receptacles associated with unapproved emergency generator. C. Installation of receptacles in patient care areas and sleeping rooms (especially sub-acute rooms) not listed as ?Hospital Grade? without permits or approval from OSHPD. During an interview with Employee A at the time of the observation, he stated that the facility had the emergency generator and other associated emergency components, and the emergency plugs for approximately 10 years. He stated he was unaware if there was any OSHPD review or approval. During an interview with the Employee B, she stated that she could not provide any documented evidence that there was OSHPD review or approval for the emergency generator and related components designated for the sub-acute unit. A review of an OSHPD field visit report dated November 14, 2011 from an OSHPD area compliance officer and a field visit report dated February 13, 2012 by an OSHPD fire marshal inspector, both identified the unapproved generator and related components (ATS and emergency plugs) that were installed and placed into service without the required inspection, review, permits or approvals from OSHPD. In addition, according to the fire marshal report, there were no permits obtained by the facility for any work or alterations since 1991. The facility failed to comply with the requirement from the Office of Statewide Health Planning and Development, the authority having jurisdiction for alteration and construction work in healthcare facilities by: 1. Installing an emergency generator and associated ATS (automatic transfer switch)/ appurtenances installed and placed into service without permits or approval from OSHPD. 2. Installing incorrect and/or deficient panels, raceways and receptacles associated with unapproved emergency generator. 3. Installing receptacles in patient care areas and sleeping rooms not listed as ?Hospital Grade? without permits or approval from OSHPD. These violations had a direct relationship to the health, safety, and security of all patients of the facility. |
| 910000053 |
LAS FLORES CONVALESCENT HOSPITAL |
910009194 |
B |
29-Mar-12 |
9CI011 |
14501 |
72527(a)(5) Patient?s Rights (a) Patients have the right enumerate 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: (5) to receive all information that is material to an individual patient?s decision concerning whether to accept or refuse any proposed treatment or procedure. The disclosure of material information for administration of psychotherapeutic drugs or physical restraints or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function shall include the disclosure of information listed in Section 72528(b). 72527(a)(23) Patient?s Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (23) To be free from psychotherapeutic drugs and physical restraints used for the purpose of patient discipline or staff convenience and to be free from psychotherapeutic drugs used as a chemical restraint as defined in Section 72018: Chemical Restraint; Chemical restraint means a drug used to control behavior and used in a manner not required to treat the patient?s medical symptoms, except in an emergency which threatens to bring immediate injury to the patient or others. If a chemical restraint is administered during an emergency, such medication shall be only that which is required to treat the emergency condition and shall be provided in ways that are least restrictive of the personal liberty of the patient and used only for a specified and limited period of time.72528(a)(b)(1)(2)(3)(4)(5)(6)(c) Informed Consent Requirements (a) It is the responsibility of the attending physician to determine what information a reasonable person in the patient?s condition and circumstances would consider material to a decision to accept or refuse a proposed treatment or procedure. Information that is commonly appreciated need not be disclosed. The disclosure of the material information and obtaining informed consent shall be the responsibility of the physician. (b) The information material to a decision concerning the administration of a psychotherapeutic drug or physical restraint, or the prolonged use of a device that may lead to the inability of the patient to regain use of a normal bodily function shall include at least the following: (1) the reason for the treatment and the nature and seriousness of the patient?s illness. (2) The nature of the procedures to be used in the proposed treatment including their probable frequency and duration. (3) The probable degree and duration (temporary or permanent) of improvement or remission, expected without such treatment. (4) The nature, degree, duration and probability of the side effects and significant risks, commonly known by the health professions. (5) The reasonable alternative treatments and risks, and why the health professional is recommending this particular treatment. (6) That the patient has the right to accept or refuse the proposed treatment, and if he or she consents, has the right to revoke his or her consent for any reason at any time. (c) Before initiating the administration of psychotherapeutic drugs, or physical restraints, or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function, facility staff shall verify that the patient?s health record contains documentation that the patient has given informed consent to the proposed treatment or procedure. The facility shall also ensure that all decisions concerning the withdrawal or withholding of life sustaining treatment are documented in the patient?s health record. On December 16, 2011, during a recertification survey, Patient A was chosen as a sample patient. All aspects of his care were examined, including his medication administration. During the survey, Patient A?s responsible party, informed the Surveyor that the patient was exhibiting new behaviors, such as shaking and jerking, which had not been present before his admission to the facility. The patient?s responsible party was concerned and stated the patient was not behaving like himself.Based on observation, interview and record review, the facility?s nursing staff failed to: 1. Ensure Patient A?s responsible party was provided information/material necessary to make an informed decision concerning the use of psychotherapeutic medication administration.2. Ensure Patient A was not administered psychotherapeutic drugs (Ativan [used for anxiety] Seroquel [used for psychosis]) without indication for use and/or for the purpose of patient discipline or staff convenience as defined in Section 72018; Chemical Restraint: Chemical restraint means a drug used to control behavior and used in a manner not required to treat the patient?s medical symptoms. 3. Obtain and/or verify that an informed consent was obtained prior to the administration of psychotherapeutic medication. These deficient practices placed the patient at risk for side effects associated with the use of antipsychotic medication (drowsiness, restlessness, muscle spasms, shakiness [tremor], dry mouth, blurring of vision, agitation, lethargy, irritability).A review of Patient A's Admission Records indicated he was a 79 year-old male, who was admitted to the facility on December 8, 2011, with diagnoses including right subdural hemorrhage (a collection of blood on the surface of the brain) status post (following) craniotomy (a surgical operation in which a bone flap is temporarily removed from the skull to access the brain) and dementia (a serious loss of cognitive ability) with behavioral disturbances. Physician's Orders, dated December 8, 2011, indicated Patient A was to receive Seroquel 50 milligrams (mg) two times daily, and then another order indicated the patient was to receive Seroquel 100 mg two times daily, both for psychosis related to dementia, manifested by resistance to care and combativeness. An Antipsychotic Medication Record, dated December 2011, indicated Patient A received Seroquel 100 mg once on the 8th, 9th and 18th and two times daily from the 10th through the 17th. Continued review of the Antipsychotic Medication Record, dated December 8 to 18, 2011, indicated Patient A was to be monitored every shift for side effects associated with the use of Seroquel such as; tardive dyskinesia (facial and tongue movement ), cognitive/behavior impairment (decreased mental status), akathisia (inability to sit still), and parkinsonism (tremors, drooling and rigidity). Records of monitoring indicated Patient A had no side effects from the use of Seroquel, from December 8 to 8, 2011, although the patient was observed by the Surveyor and the patient?s responsible party on December17and 18, 2011, shaking and jerking. Licensed Personnel Progress Notes, dated December 9, 2011, at 12:00 p.m., indicated Patient A refused to take oral medication; and spit the pills out. Documentation indicated Patient A struck out at nurses when they attempted to assist him with care. A call was placed to the psychiatrist. Physician?s Orders, dated December 9, 2011, indicated Patient A was to receive Ativan 1 mg two times daily, as needed, for anxiety, manifested by irritability. An Antianxiety Medication Record, dated December 2011, indicated Patient A received Ativan 1 mg on the 10th and 13th of December.Licensed Personnel Progress Notes, dated December 10th and 13th indicated no written documentation of Patient A's anxiety and/or irritability; although as needed medication (Ativan) was administered, to him, on those dates.A Physician's Order form for Seroquel, dated December 8, 2011, and another one for Ativan, dated December 9, 2011, had an informed consent section attached. The informed consent section, indicated to check either the patient or responsible party as the person the physician obtained the informed consent from. Neither the patient nor the responsible party section was checked.A Facility Verification of Resident Informed Consent to Psychotherapeutic Drugs, dated December 8, 2011, indicated the area for the patient/decision maker?s signature was signed by the physician.Instructions on the form indicated, it is recommended, not required, that the patient?s decision maker sign in the appropriate space below. If the patient or the decision maker does not wish to sign this document or if the decision is obtained via telephone, the facility staff may document the treatment decision by printing the name of the decision maker followed by the facility staff signature, title and date in the appropriate space below.On December 17, 2011, at 12:45 p.m., during an interview, the Director of Nursing (DON) stated informed consents for psychotherapeutic medication should be completed fully by the physician and nursing staff prior to administration of psychotropic medication. The DON stated obtaining an informed consent was the responsibility of the physician but it could have been easily verified by the nursing staff, since the patient?s responsible party was in the facility daily and was very involved in the patient?s care. Regarding change of conditions, the DON stated it was the responsibility of the nursing staff to monitor, assess, document and report any change of condition or new behaviors of patients. On December 17, 2011, at 5:45 p.m., Patient A was observed by his responsible party and the Surveyor. The patient was in his room, sitting up in bed, attempting to eat dinner without assistance. He was observed missing his mouth and spilling food on his clothing because his hand was shaking and his upper body was making jerking movements. The patient's responsible party stated he had never done that before. She was concerned and wanted to know why the new behavior was occurring. On December 18, 2011, at 4:00 p.m., during an interview, Patient A's responsible party again stated she was concerned with new behaviors the patient was displaying (shaking, jerking movements, overly sedated) and again emphasized he had not behaved that way when he resided with her. She stated the patient was not behaving in his usual manner and wanted to know if he was taking any new medications she might not be aware of. At that time, she was informed that the patient was receiving Seroquel and Ativan, which were antipsychotic medications. She stated Patient A had never taken those medications before, no one had asked her permission to give the medications to him and she had not been aware that he was receiving them. The responsible party stated it was wrong to give Patient A psychotropic medication without first discussing it with her.She emphasized she had not spoken to the patient?s physician or the nursing staff and had not given anyone permission to prescribe or administer the medication to the patient. According to the Geriatric Dosage Handbook, Including Clinical Recommendations and Monitoring Guidelines, 12th Edition, pg. 1330 Quetiapine (Seroquel) an Antipsychotic Agent, AtypicalUse: Treatment of schizophrenia; treatment of acute manic episodes associated with bipolar disorder (as monotherapy or in combination with lithium or Valproate) Warning/Precautions [U.S. Boxed Warning]: Patients with dementia-related behavioral disorders treated with atypical antipsychotics are at an increased risk of death compared to placebo. Quetiapine is not approved for this indication. Monitoring Parameters, mental status, abnormal involuntary movement scale (AIMS). According to the Geriatric Dosage Handbook, Including Clinical Recommendations and Monitoring Guidelines, 12th Edition, pg. 908 Lorazepan (Ativan) Anxiolytic, sedative/hypnotic Use: Management of anxiety disorders or short-term relief of the symptoms of anxiety or anxiety associated with depression. Unlabeled/Investigation Use: Ethanol detoxification; treatment of insomnia, psychogenic catatonia, partial complex seizures, agitation. A facility policy on Informed Consents, dated August 9, 2011, indicated an informed consent is defined as the voluntary agreement of a patient or a representative of an incapacitated patient to accept a treatment or procedure after receiving information. The facility shall verify the patient or his/her surrogate has given informed consent to the proposed treatment or procedure prior to the initiation of psychotherapeutic drugs.Patient A was admitted to the facility on December 8, 2011. He was prescribed and administered antipsychotic medication without appropriate indication for use, for the convenience of staff and/or to control the resident?s behavior as prescribed for psychosis related dementia, manifested by resistance to care and combativeness, and anxiety, manifested by irritability. Antipsychotic medications were administered to the patient prior to and without obtaining an informed consent; per the patient?s responsible party, she did not know the patient was receiving the medication. Observation and interview indicated Patient A?s behavior of shaking and jerking were new, however, written documentation did not indicate these new behaviors were monitored/assessed. Therefore the facility failed to: 1. Ensure Patient A?s responsible party was provided information/material necessary to make an informed decision concerning the use of psychotherapeutic medication administration.2. Ensure Patient A was not administered psychotherapeutic drugs (Ativan [used for anxiety] Seroquel [used for psychosis]) without indication for use and/or for the purpose of patient discipline or staff convenience as defined in Section 72018; Chemical Restraint: Chemical restraint means a drug used to control behavior and used in a manner not required to treat the patient?s medical symptoms. 3. Obtain and/or verify that an informed consent was obtained prior to the administration of psychotherapeutic medication. These violations presented a direct or immediate relationship to the health, safety, security, or welfare of the patient. |
| 910000053 |
LAS FLORES CONVALESCENT HOSPITAL |
910009196 |
A |
29-Mar-12 |
JIJL11 |
12930 |
72523(a) Patent Care Policies and Procedures (a) written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objective are achieved. 72547 (a)(5)(B) Content of Health Records (a) A facility shall maintain for each patient a health record which shall include: (5) Nurses' notes which shall be signed and dated. Nurses' notes shall include: (B) Meaningful and informative nurses' progress notes written by licensed nurses as often as the patient's condition warrants. However, weekly nurses' progress notes shall be written by licensed nurses on each patient and shall be specific to the patient's needs, the patient care plan and the patient's response to care and treatments. 72547(a)(6) Content of Health Records (a) A facility shall maintain for each patient a health record which shall include; (6) Temperature, pulse, respiration and blood pressure notations when indicated. On May 29, 2009, at 4:30 p.m., an unannounced visit was made to the facility to investigate a complaint that Patient A expired while en route to a general acute hospital (GACH), following a report that he was failing because of pneumonia and the nurses did not know how to administer oxygen. Based on interview and record review, the facility?s nursing staff failed to: 1. Ensure the facility?s policy and procedure for ?Emergency Transfer to Acute Care Hospital? was implemented. Patient A was observed with difficulty breathing and abnormal vital signs; blood pressure 89/60 (normal range 120-139/80-89), apical pulse 40 (the heart rate when measured with a stethoscope placed over the heart [normal range 60-100 beats per minute]), respirations 25 (normal range 15-20 breaths per minute), and an oxygen saturation rate (a measure of how much oxygen the blood is carrying) of 64 % [normal range 95-100%]). The nursing staff called the patient?s physician to obtain an order to transfer him to a GACH instead of calling for emergency services (911), as the facility?s policy indicated. 911 was called more than 4 hours after the patient was initially observed with abnormal breathing and vital signs and later expired at the GACH. 2. Document pertinent information for Patient A, who had a change in condition, to include assessment/monitoring of his quality of breathing (labored, shallow, agonal [gasping breaths], etc?), auscultation of lungs, vital signs, skin color, temperature, ability to speak, interventions and response to interventions.3. Obtain and document Patient As vital signs when he was observed with difficulty breathing and as his condition changed. Documentation of Patient A?s vital signs began at 4:35 p.m., an hour and 35 minutes after he was observed with compromised breathing. No other vital signs were documented prior to his transfer to the GACH at 7:35 p.m., 3 hours and 35 minutes after he was initially observed with difficulty breathing. On May 16, 2009, at 3:00 p.m., Patient A was observed with difficulty breathing. The physician was notified of the patient's change of condition; however, no vital signs were documented until 4:35 p.m., (1 hour and 35 minutes after finding the patient?s breathing compromised). Upon notifying the physician of the patient?s condition, the physician ordered the patient to be monitored. Documentation indicated no monitoring of the patient (vital signs, breathing, color, general condition), was done, as ordered. Documentation at 4:35 p.m., indicated the physician ordered Patient A transferred to a GACH, however, the transportation service refused to transfer the patient because of his abnormal vital signs; blood pressure 89/60, apical pulse 40, respirations 25 and an oxygen saturation rate of 64%. Per documentation 911 was called at 5:30 p.m., however, the emergency services report indicated they were not dispatched to the facility until 7:17 p.m., over 4 hours after the patient was initially observed with abnormal breathing, and 2 hours and 47 minutes after the physician ordered the patient transferred to the GACH. A review of Patient A's Admission Record indicated he was an 84-year old male, who was admitted to the facility on April 30, 2009, with diagnoses that included pneumonia and rhinitis (inflammation of some internal areas of the nose), Alzheimer?s disease, dementia and psychosis. Licensed Personnel Progress Notes, dated May 16, 2009, at 3:00 p.m., indicated Patient A's physician was called to inform him of the patient's difficulty breathing, a message was left on the physician?s answering service, oxygen was administered to the patient, at two liters per minute (lpm) through a nasal cannula (a device used to deliver oxygen to a patient in need of respiratory help). There was no documented evidence the patient?s condition was assessed to include his respiratory status, vital signs or response to the oxygen that was administered. Licensed Personnel Progress Notes, dated May 16, 2009, (no time documented), indicated the physician returned the facility?s call. He was informed of the patient's condition and stated to monitor the patient and call for any further changes. Licensed Personnel Progress Notes, dated May 16, 2009, at 4:30 p.m., indicated Patient A's physician returned the facility?s call and stated to send the patient to the GACH. There was no written documentation that Patient A was being monitored. Licensed Personnel Progress Notes, dated May 16, 2009, at 4:35 p.m., indicated an ambulance service was called to transfer Patient A. Documentation indicated the patient's vital signs were as follows: B/P 89/60, apical pulse 40, respirations 25, and oxygen saturation rate of 64%. Documentation at 4:35 p.m., indicated the ambulance service refused to transfer the patient, however, there was no documented evidence that 911 was called so Patient A could receive immediate care and transfer to a GACH.Licensed Personnel Progress Notes, dated May 16, 2009, at 5:30 p.m., indicated again, the ambulance service refused to transport Patient A due to his decreased vital signs, 911 was then called. Nursing documentation of the patient's condition, as reported by the fire department, indicated altered level of consciousness (ALOC), vital signs not viable, oxygen saturation rate of 64% and lungs clear.A Los Angeles County Fire Department Emergency Medical Service Report Form, dated May 16, 2009, indicated they were dispatched to the facility at 7:17 p.m., they arrived at the facility at 7:22 p.m., they reached the patient at 7:23 p.m., left the facility, with the patient, at 7:35 p.m., arrived at the GACH, with the patient, at 7:41 p.m., and transferred the patient's care at 7:43 p.m. The emergency services report times did not match nursing documentation, which indicated 911 was called at 5:30 p.m. An Emergency Physician Record, dated May 16, 2009, indicated on arrival to the GACH, Patient A had a decreased mental status, agonal breathing and was unresponsive. His blood pressure was 0, heart rate was left blank, respirations were 4 and his temperature was 93.1.The patient was pronounced dead at 8:20 p.m., due to cardiopulmonary arrest (cessation of heartbeat and cardiac function). On May 29, 2009, at 5:30 p.m., during an interview, Licensed Vocational Nurse 1(LVN 1) stated, at 3:00 p.m., she made her rounds and observed Patient A was not behaving like himself. He wasn't perky as usual and would not respond to any questions. He would usually respond yes or no when he was asked yes or no questions. LVN 1 stated she left a message with the patient's physician to report the patient was breathing abnormally.On December 8, 2011, at 12:55 p.m., during a telephone interview, the Director of Nursing (DON) stated patient documentation is done at least weekly, however, if there was a change of condition, documentation should be done as often as the patient?s condition warranted, to monitor for changes. She stated if a patient's vital signs were abnormal and the patient's condition indicated he was in distress then 911 should be called for immediate assistance and transfer, the physician would be notified later. On December 8, 2011, at 4:15 p.m., during a telephone interview, LVN 1 stated she recalled taking Patient A's vital signs more than once but did not document them. She stated she did not recall if she reported to the physician the patient's actual vital signs when she called to report the patient was having difficulty breathing. She stated the physician told her to transfer the patient, if he had told her to call 911 she would have done so. When asked why she called the physician instead of 911, when the patient's breathing and vital signs were abnormal, she stated it was her understanding their (the facility) policy was to get an order from the physician prior to transferring a patient.On January 10, 2012, at 9:10 a.m., during a telephone interview, Patient A?s physician stated, he vaguely remembered the patient, and could not recall the details of the day in question (May 16, 2009). He stated if a patient was in distress and his vital signs indicated an emergent situation, the nurses should call for paramedics and inform him later. On January 10, 2011, at 10:02 a.m., during a telephone interview, the Dispatch Supervisor, of the ambulance service, stated on May 16, 2009, they received a request for service from the facility, at 1823:49 (6:23 p.m.). The facility reported they had a patient in distress and wanted to know how long before they (the ambulance service) could come. The dispatch supervisor stated, per documentation she read from, the facility was told it would be approximately 45 minutes before they would arrive, if the patient was in distress, they should call 911. A facility policy and procedure on Emergency Transfer to Acute Care Hospital, not dated, indicated a resident (patient) is transferred to an acute care hospital to receive necessary, immediate care that is not available to the long-term care facility. Call for ambulance or 911 transfers as indicated. A facility policy and procedure on Charting and Documentation, not dated, indicated the purpose of charting and documentation was to provide: a complete account of the resident's (patient?s) care, treatment, and response to care, signs and symptoms as well as the progress of the patient?s care. It is a tool for measuring the quality of care provided to the patient and a legal record that protects the patient, physician, nurse and the facility. Chart all pertinent changes in the patient?s condition, reaction to treatments, medication, etc..., as well as routine observations. Chart as often as necessary and as the need arises. A facility policy on Documentation Requirements, not dated, indicated under Licensed Progress Notes; document the specific time and date the problem was identified. Include observations about the condition of the resident (patient), any complaints; any other pertinent details should be included in the entry. Under Licensed Progress Notes-Physician Notification; document the specific time and date the physician was contacted about the patient?s condition. Therefore the facility?s nursing staff failed to: 1. Ensure the facility?s policy and procedure for ?Emergency Transfer to Acute Care Hospital? was implemented. Patient A was observed with difficulty breathing and abnormal vital signs; blood pressure 89/60 (normal range 120-139/80-89), apical pulse 40 (the heart rate when measured with a stethoscope placed over the heart [normal range 60-100 beats per minute]), respirations 25 (normal range 15-20 breaths per minute), and an oxygen saturation rate (a measure of how much oxygen the blood is carrying) of 64 % [normal range 95-100%]). The nursing staff called the patient?s physician to obtain an order to transfer him to a GACH instead of calling for emergency services (911), as the facility?s policy indicated. 911 was called more than 4 hours after the patient was initially observed with abnormal breathing and vital signs and later expired at the GACH. 2. Document pertinent information for Patient A, who had a change in condition, to include assessment/monitoring of his quality of breathing (labored, shallow, agonal [gasping breaths], etc?), auscultation of lungs, vital signs, skin color, temperature, ability to speak, interventions and response to interventions.3. Obtain and document Patient As vital signs when he was observed with difficulty breathing and as his condition changed. Documentation of Patient A?s vital signs began at 4:35 p.m., an hour and 35 minutes after he was observed with compromised breathing. No other vital signs were documented prior to his transfer to the GACH at 7:35 p.m., 3 hours and 35 minutes after he was initially observed with difficulty breathing. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 910000053 |
LAS FLORES CONVALESCENT HOSPITAL |
910009321 |
B |
23-May-12 |
6LQ911 |
9937 |
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). On July 22, 2009, at 3:45 p.m., an unannounced complaint visit was made regarding a patient, who was transferred to the general acute care hospital (GACH), with unstageable decubiti (areas of damaged skin and tissue that develop when sustained pressure cuts off circulation to vulnerable parts of the body), to her right buttocks, right ear, and both heels.Based on interview and record review the facility failed to ensure Patient A?s existing decubitus ulcers did not deteriorate and prevent development of new decubitus ulcers by failing to: 1. Ensure Patient A, who was readmitted to the facility with multiple decubitus ulcers, had physician?s treatment orders for each decubitus ulcer site. Patient A was assessed upon admission with decubitus ulcers to her heels, sacral and left buttock.2. Ensure Patient A?s skin was assessed in accordance with the facility?s policies to prevent development of a new ulcer/sore to Patient A?s right ear lobe.A review of Patient A?s Admission Records indicated she was readmitted to the facility on June 27, 2009, from the GACH with diagnosis of decubitus ulcers to the sacrum (a large triangular bone at the base of the spine) and heels. According to the Minimum Data Set (MDS), a standardized comprehensive assessment of the patient?s problems and conditions dated July 3, 2009, Patient A?s cognitive skills for daily decision-making were moderately impaired. She had a functional limitation in range of motion (ROM) to one side of her neck with partial loss of voluntary movement. The patient was also assessed as requiring extensive assistance to being totally dependent on staff with all activities of daily living, and had two Stage II [partial thickness skin loss involving first and second layer of skin (epidermis and dermis)], one Stage III [full thickness skin loss involving damage or necrosis (dead tissue) of subcutaneous tissue], and two Stage IV [full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure] decubitus ulcers. The Admission Nursing Assessment, body diagram, dated June 27, 2009, indicated Patient A was admitted with the following decubitus ulcers: 1. Right heel measured 4x4 centimeters (cm), red/black color in the center. 2. Left heel measured 4x5 cm, red/black center. 3. Sacral measured 9x2 cm with yellow color wound bed. 4. Left buttocks, site 1 1x0 cm, and site 2 1x1.5 cm. Licensed Personnel Progress Notes dated June 27, 2009, indicated Patient A was readmitted to the facility with necrotic heels, a reddened left buttock, and a reddened sacrum. A review of the Admission Physician?s Orders dated June 27, 2009, indicated there were no physician?s orders obtained for the treatment of Patient A?s admitting decubitus ulcers. A Care Plan dated June 27, 2009, indicated Patient A had Stage IV decubitus ulcers to both heels and a Stage III sacral decubitus ulcer. The patient?s goal was to have the wound decrease in size or heal completely within 30 days. The approaches included to provide treatments as ordered, however, there were no treatment orders obtained for the decubitus ulcers. On June 29, 2009 (two days after Patient A was readmitted to the facility), the following physician?s treatment orders were obtained: 1. Right heel pressure ulcer Stage IV; cleanse with normal saline, pat dry, apply Santyl ointment (an enzyme that breaks down collagen in damaged tissue) and cover with a dry dressing daily, for 30 days. 2. Left heel pressure ulcer Stage IV; cleanse with normal saline, pat dry, apply Santyl ointment and cover with a dry dressing daily, for 30 days. 3. Sacral pressure ulcer Stage III; cleanse with normal saline, pat dry, apply Santyl ointment and cover with a dry dressing daily, for 30 days. However, there were no written or transcribed physician?s treatment orders for Patient A?s left buttock decubitus ulcers, site 1 and site 2. A review of the Treatment Record dated June 2009, indicated the treatment to both of Patient A?s heels, and to her sacrum did not begin until June 29, 2009. The treatment record did not indicate treatment was done to the left buttocks, site 1 and site 2, which were identified on the Admission Nursing Assessment dated June 27, 2009. The Skin Integrity Sheets dated June 29, 2009, the date the physician?s treatment orders were obtained (two days after the patient was assessed with multiple decubitus ulcers) indicated the following: 1. Sacral Stage II ulcer measured 10x14 cm, which had increased in size from 9x2 cm on June 27, 2009.2. Left heel Stage IV, measured 5x6 cm which had increased in size from 4x5 cm on June 27, 2009.3. Right heel Stage IV, measured 4x4 cm. (no change from June 27, 2009, readmission assessment) Further review of the Skin Integrity Sheets dated June 29, 2009, indicated no written documentation, assessment, or treatment of the left buttock decubitus ulcers, site 1 and site 2, that were assessed and documented on the Admission Nursing Assessment dated June 27, 2009. A Licensed Personnel Progress Note dated July 13, 2009, at 12:20 p.m., indicated a certified nursing assistant (CNA) reported Patient A felt hot. Her vital signs were: temperature 102.4, pulse 68, respiration 19, and blood pressure 118/68. At 1:00 p.m., the patient?s condition worsened, vital signs were: temperature 102, pulse 132, respiration 40 and blood pressure 90/50, the paramedics were called and the patient was transferred to the GACH. A photograph obtained from the GACH dated July 13, 2009, indicated a sore on Patient A?s right ear. There was no assessment that included measurement. However, the photograph showed the sore covered the bottom portion of the patient?s right ear lobe. It was approximately 1 to 2 inches in length and reddened yellow at the tip of the wound with what appeared to be slough [yellow to white tissue: that may be stringy or thick and may appear as a layer over the wound bed. Slough is an indicator of wound inflammation/infection and must no longer be present on the wound before healing can occur]. A review of the facility Skin Treatment Sheets and Treatment Records from June 29, 2009, through July 12, 2009, indicated no written documentation or assessment that Patient A had an ulcer/sore on her right ear and was being treated. A review of Patient A?s Medical Records indicated one Weekly Body Check List, dated June 14, 2009. There was no other written documentation found indicating weekly skin checks were conducted by the licensed nursing staff or that skin checks were conducted by the CNAs on patient shower days from June 27, 2009, when the patient was readmitted to the facility through July 13, 2009, when she was transferred.On July 28, 2009, at 10:00 a.m., during an interview, the director of nurses (DON) stated the licensed nurses conduct weekly skin assessments of all the patients in the facility, the treatment nurse does a weekly skin assessment of patients with wounds that were already identified and CNAs do skin checks of all patients on their shower days. She stated the forms are supposed to be completed and given to her, but she could not find the skin assessment forms for Patient A.A review of Patient A?s Medical Record, with the DON, indicated no written documentation of weekly skin checks by licensed nurses or certified nursing assistants (CNAs) on the patient?s shower days. On August 4, 2009, at 11:25 a.m., during a telephone interview, Licensed Vocational Nurse 1 (LVN 1) stated he could not assess over 100 patients each week by himself, and the facility had a system in place to ensure the patient?s skin was being monitored. He stated licensed nurses conduct weekly skin assessments of all patients, and the CNAs monitor the patient's skin during their shower days. They are supposed to document and report any skin problems to him, and he assesses the skin of patients with identified skin issues. According to the facility?s Skin Inspection/Assessment policy and procedure (no date) it is the policy of the facility to routinely check residents (patients) for changes in skin integrity and promptly report identified changes to the physician. The CNAs will perform visual inspections of the patient?s body during daily care each shift and to monitor for and promptly report to the licensed nurse the following information: bruises, red areas, open area, skin tears, rashes, changes in skin texture (feeling of the skin). Upon notification, licensed nurses will assess and promptly report changes to the physician. In addition to CNA observation, licensed nurses will complete skin assessments weekly during weekly summary completion and as needed. Appearance of skin shall be recorded on the weekly summary form. If the resident is receiving wound care the treatment nurse will also complete necessary documentation on the appropriate forms. The facility failed to ensure Patient A?s existing decubitus ulcers did not deteriorate and prevent development of new decubitus ulcers by failing to: 1. Ensure Patient A, who was readmitted to the facility with multiple decubitus ulcers, had physician?s treatment orders for each decubitus ulcer site. Patient A was assessed upon admission with decubitus ulcers to her heels, sacral and left buttock.2. Ensure Patient A?s skin was assessed in accordance with the facility?s policies to prevent development of a new ulcer/sore to Patient A?s right ear lobe.The above violation had a direct relationship to the health, security and safety of Patient 1. |
| 910000035 |
Lotus Care Center |
910009911 |
A |
18-Jun-13 |
56UC11 |
14574 |
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. (B) Development of an individual, written patient care plan which indicates the care to be given. the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. These findings were identified during an un-announced recertification survey started on March 18, 2011. Based on observation, interview, and record review, the facility failed to: 1. Identify and develop an individualized written care plan of Patient 6?s diagnosis of mental retardation. 2. Review, evaluate, and update the plan of care when Patient 6 had an actual fall. 3. Reassess the patient after an actual fall and identify problems that lead to the fall. 4. Implement interventions/corrective measures as indicated in Patient 6?s plan of care for falls. 5. Provide close supervision/monitoring and assistance to Patient 6 to prevent further occurrences of falls, as stipulated in his plan of care. These deficient practices resulted in Patient 6 falling on August 9, 2010, and sustaining right hip and wrist fractures, and a subdural hematoma (blood gathered within the outermost area enveloping the brain); being transferred to a general acute care hospital (GACH); being admitted into an intensive care unit, and undergoing orthopedic surgery to repair the fractures. Patient 6 stayed in the hospital for a total of 14 days, requiring medication for pain every day. The clinical record for Patient 6 was reviewed on March 19, 2011. According to the Admission Face Sheet, Patient 6 was a 67 year-old male, admitted to the facility on May 1, 2007. The patient?s diagnoses included chronic altered level of consciousness (ongoing measure of arousability other than normal, ranging from lethargy to coma), ETOH (alcohol) abuse, seizure disorder (a brain disorder that disturbs the normal patterns of the brain), difficulty walking, abnormal posture, and muscle weakness. According to the Face Sheet, Patient 6 was responsible for himself.The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated July 5, 2010 (prior to the patient's fall with injury), indicated the patient had some difficulty with his cognitive skills for daily decision-making in new situations only. The MDS indicated Patient 6 required supervision, oversight, and cueing for his activities of daily living, including transfers, walking on and off the unit, dressing, eating, toileting, and personal hygiene. The patient required physical assistance with transfers for bathing. According to the MDS, the patient was unsteady while standing, but was able to rebalance himself. His mode of locomotion was with a cane, walker, and/or a crutch. He was continent (had control) of bowel and bladder, had a seizure disorder, muscle weakness, and unsteady gait. The MDS indicated the patient complained of moderate back pain less than daily and had no falls in the past 180 days. The patient had experienced recent weight loss, was taking antipsychotic, anti-anxiety, and antidepressant medications daily. The MDS stipulated Patient 6 required reorientation/cueing for mood, behavior, and cognitive loss. A review of the general acute care hospital?s (GACH) History and Physical (H/P), dated April 21, 2010, indicated Patient 6 suffered from "mild mental retardation (an intellectual functioning level that is well below average with significant limitations in daily living skills)." A H/P from the skilled nursing facility (SNF), dated April 30, 2010, indicated the patient ?does not have the capacity to understand and make decisions." A review of a Physician's Progress Record, dated July 5, 2010, indicated the patient had diagnoses of chronic altered level of consciousness with mild mental retardation. However, a PAS/PASARR Level 1 Screening Document (pre-admission screening and resident review, for the mentally ill and individuals with mental retardation) from the SNF did not reflect the physicians? diagnosis of mental retardation. Also, during an interview, on March 19, 2011, at 4 p.m., the administrator stated he was not aware of Patient 6's diagnosis of mental retardation. There was no care plan in the clinical record to address the patient?s diagnosis of mental retardation. A review of a Fall Risk Assessment from the SNF, dated April 25, 2010, indicated Patient 6 had intermittent confusion, one-two falls in the past three months, was chair-bound and required restraints; also required assist with elimination, had poor vision, had a balance problem while standing and walking and required the use of assistive devices. The patient was assessed to have a high risk for falls, but the assessment failed to identify the patient?s additional risk factors such as seizure disorder and the anti-seizure, antipsychotic, antidepressant and anti-anxiety medications the patient was receiving. The assessment form indicated the patient was to be re-assessed at a minimum of every 90 days (quarterly). However, there was no other fall reassessment after April 25, 2011, until the patient fell again with serious injuries on August 8, 2010, 120 days after the Fall Assessment. There was no documented evidence the facility attempted to identify problems leading to Patient 6?s fall. A care plan titled, "Risk for Falls" dated April 25, 2010, indicated Patient 6 had poor safety awareness, weakness, history of falls in the last six months, seizure disorder, and was receiving psychotropic, anti-seizure, and antihypertensive medications daily. The staff?s interventions included to assist the patient with mobility and transfers as needed. This was not implemented for Patient 6. Another care plan titled, "Risk for Injury" dated April 25, 2010, indicated the patient's risk for injury was related to poor balance, lack of awareness, medications, problems with understanding others, memory recall, gait disturbance, and loss of coordination. Among the generic (pre-printed) staff approaches/interventions selected was to "assist patient as necessary." This was not followed. A Licensed Nurses Progress Note, dated June 28, 2010, timed at 10:40 a.m., indicated Patient 6 fell out of bed and was found on the floor by a certified nurse assistant (CNA). The patient complained of left elbow pain, which was relieved after 30 minutes. Further review of the clinical record revealed there was no documented evidence the patient?s primary physician was notified of the patient?s fall. The facility?s undated policy and procedure titled, "Care Plan" indicated care plans are to be reviewed, at a minimum, once every 90 days and whenever necessary, either as a result of a significant change in patient's status and condition, or if discontinued. According to the patient?s care plans for risk of falls and injuries, the care plans were not reviewed or revised after the patient's fall on June 28, 2010, per the facility?s policy. A review of the Daily Certified Nurse Aide (CNA) Notes, dated from August 1 through 9, 2010, for the evening (P.M.) shift, with no specific time, indicated the patient's mobility and ambulation needs required "Supervision/Cueing."Another Licensed Nurses? Progress Note, dated August 9, 2010, indicated at approximately 6:10 p.m., the patient had a fall outside of the facility. The patient was found on the ground by CNA 7. The patient was assisted back to the room via wheelchair. The note indicated the patient had an abrasion (superficial damage to the skin) over his right eye with slight bleeding. According to the note, the patient stated he was walking around the facility when he experienced dizziness and pain to both of his lower extremities and then he fell and struck the right side of his head on the ground. According to the note, the attending physician was notified and the patient was transferred to a GACH. On March 19, 2011, the facility's investigative report regarding Patient 6?s fall was requested. The report dated August 9, 2010, indicated the patient was found on the ground outside the facility by a CNA, and had sustained an abrasion over his right eye. The report indicated the patient's ambulation privilege was "limited without assist." The undated Interdisciplinary Patient Safety Investigation and Intervention report, indicated Patient 6 fell "outside the facility" at 6:10 p.m., and that the incident could best be attributed to "unsteadiness" and "related to the patient?s change in condition" (but did not explain the change in condition). There was no documentation a staff member was present with the patient to provide supervision, cueing, and to assist as necessary to prevent falls and injuries as indicated in the patient?s MDS and plan of care. When the patient was found, he was not using any assistive device, such as a cane, walker, or wheelchair, as indicated in the MDS. CNA 7, who found Patient 6 on the ground outside of the facility, was not interviewed by the facility, nor did CNA 7 complete a narrative report describing the incident as per the facility?s policy. On March 29, 2011, at 4:40 p.m., during a telephone interview, CNA 7 stated she found Patient 6 after his fall on August 9, 2010. She stated a staff member (unidentified), was leaving the facility around 6 p.m. to go home, called the nurse's station and reported to the charge nurse that Patient 6 was in front of the facility, walking on the sidewalk by himself. The charge nurse instructed CNA 7 to go and assist Patient 6. CNA 7 stated that when she arrived at the sidewalk in front of the facility, Patient 6 was lying on the ground on his right side. CNA 7 called Staff 10 (a charge nurse) for help, then went to the patient's room to get his wheelchair and returned the patient to his room. CNA 7 stated the patient had difficulty walking and used his wheelchair to get around. She stated she was not assigned to the patient that day and could not explain why the patient was walking outside the facility by himself and was not using his wheelchair. Patient 6 was then transported to the GACH. The licensed nurse (Staff 10), who was on duty at the time of the incident and who completed the incident report, was no longer employed by the facility and was not available for an interview. A review of the GACH?s H/P, dated August 10, 2010, indicated Patient 6 had right hip and wrist fractures, a subdural hematoma, and Dilantin toxicity. (Dilantin is an anti-seizure medication; toxicity can cause confusion, abnormal gait, decreased blood pressure that could further lead to dizziness, and seizures). The patient's Dilantin blood level was elevated at 50.8 microgram per milliliter (Mcg/ml/therapeutic reference range is 10.0 - 20.0 Mcg/ml.) The patient was transferred to the Intensive Care Unit to await surgery. A review of the Operative Report, dated August 13, 2010, indicated a preoperative diagnosis of inter-trochanteric fracture (occurring between the top of the femur and lower bony prominence of the hip) of the right hip. The operation performed was an open reduction and internal fixation (ORIF- a surgical procedure to repair a fractured bone using plates and screws or a metal rod) with a Smith-Nephew locking nail, on August 13, 2010. There was no documentation in the clinical record regarding treatment for the right wrist fracture and subdural hematoma. Patient 6 was re-admitted to the SNF facility on August 23, 2010. A review of the MARs from September 2010 to March 2011, indicated the patient continued to complain of right leg pain with a severity of 6-7 on a pain scale of 1-10 and required pain medication, Vicodin ES (extra strength/ a highly addictive opioid pain reliever) 7.5 mg/750 mg, one tablet almost on a daily basis. A review of a Joint Mobility Assessment, dated August 24, 2010, indicated the patient's limitation to his right hip was minimal (75-100%) and was causing the patient pain. During an observation on March 19, 2011, at 10 a.m., Patient 6 was seen lying in bed. The patient stated that he was having pain in his right hip. The patient stated his hip hurt all the time and he thought he had injured it in a fall, but could not remember what happened. A review of the facility?s undated policy and procedure titled, Fall Prevention and Reduction, indicated if and when falls occur, the facility shall implement corrective measures to reduce the incidence of falls. The policy indicated plans of care shall include interventions for provision of monitoring and supervision of patient to prevent fall incidents which should be revised and updated whenever a patient experiences an actual fall. The policy also indicated care plans for patients identified to be at high risk for falls should identify impaired cognition, impaired physical functioning, certain medications and diagnoses. Patients identified to be at greater risk for falls or further falls should be monitored closely to prevent further occurrences of falls. The facility failed to ensure this policy and procedure was implemented for Patient 6.The facility failed to: 1. Identify and develop an individualized written care plan of Patient 6?s diagnosis of mental retardation. 2. Review, evaluate, and update plan of care, when Patient 6 had an actual fall. 3. Reassess the patient after an actual fall and identify problems that lead to the fall. 4. Implement interventions/corrective measures as indicated in Patient 6?s plan of care for falls. 5. Provide close supervision/monitoring and assistance to Patient 6 to prevent further occurrences of falls, as stipulated in his plan of care. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for Patient 6. |
| 910000057 |
LOS PALOS CONVALESCENT HOSPITAL |
910010141 |
B |
13-Sep-13 |
9TC311 |
7568 |
F323 CFR 483.25(h) ? Accidents The facility must ensure that the resident environment remains as free of accident hazards as possible: and each resident receives adequate supervision and assistance devices to prevent accidents. On June 29, 2009, at 12:05 pm., an unannounced visit was conducted to investigate an entity reported incident (ERI) to the Department. The ERI indicated the certified nursing assistant (CNA 1) reported that Resident 1 complained of leg pain when she was put to bed after her shower. An X-ray taken revealed the resident had a displaced fracture of the left distal tibia and fibula (a fracture involving the bones in the lower leg that had moved from the usual site). Based on observation, interview, and record review, the facility nursing staff, CNA 1, who was from a nursing registry, failed to ensure Resident 1 was transferred safely using an assistance device (Vander lift or Hoyer lift [mechanical lift]). CNA 1 failed to follow instructions to ask for assistance and to use an assistive device to transfer Resident 1 from the shower chair to bed. This resulted in Resident 1 sustaining a displaced fracture to the left distal tibia and fibula on June 11, 2009.Resident 1?s admission record revealed she was admitted to the facility on March 6, 2002, with diagnoses that included dementia (progressive deterioration of intellectual functions), history of right hip fracture, and osteoporosis (thinning of the bones, with reduction in bone mass). The Minimum Data Set (MDS) an assessment and care screening tool, dated July 11, 2008, indicated Resident 1 had short and long term memory impairment, was capable of making concrete requests and responded adequately to simple direct communication with distinct intelligible words. The MDS also indicated the resident was totally dependent on staff for bed mobility, transfer with one person assist, locomotion, dressing, eating, toilet use, personal hygiene and bathing. The resident had functional limitation of both arms and feet with partial loss of voluntary movement, and severe lower extremities plantar flexion (movement of the foot that flexes the foot or toes downward toward the sole) contracture (a permanent tightening or shortening of a body part). The primary mode of locomotion was a wheelchair. A care plan for physical functioning dated January 16, 2009, reviewed on April 16, 2009, indicated Resident 1 had alteration in physical functioning and required total assistance with bed mobility, transfer, locomotion, walking, dressing, eating, toilet use, personal hygiene and bathing secondary to impaired cognition and weakness. The goal included for the resident to be assisted with transfers as needed without injury daily for 90 days. The approaches included to assist with transfers as needed. The care plan did not address how the resident would be moved/transferred between surfaces including to or from bed, chair, or a wheelchair.The Licensed Nurse?s Notes dated June 11, 2009, at 3:30 pm during the change of shift rounds, revealed a licensed vocational nurse (LVN 1) documented Resident 1 was moaning and the left leg was bruised with slight discoloration.At 4 pm., LVN 2 documented that CNA 2 reported the resident had skin discoloration on the left lower leg with verbalized pain when the leg was touched or moved. LVN 2 documented the leg was warm, reddened, and swollen. The resident was medicated for pain and the attending physician was notified of the resident?s condition. A Stat (at once) X-ray of the left pelvis, left femur, left tibia fibula and left foot was ordered and carried out and an ice pack was applied to the left lower leg. The X-ray result indicated a displaced fracture of the left distal tibia and fibula. The attending physician was notified at 8 pm. with an order to transfer the resident to a general acute care hospital (GACH) for evaluation. The resident was transferred to the GACH by ambulance at 8:45 pm.The Discharge Summary note from the GACH dated June 16, 2009, indicated Resident 1 was admitted on June 11, 2009, underwent closed reduction surgery (the correction of a fracture), and application of a short left leg cast. Resident 1 was readmitted back to the skilled nursing facility on June 16, 2009, with a cast on her left leg.A review of the facility?s Investigative Report dated June 16, 2012, indicated CNA 1, who was from a nursing registry (temporary staff), ?improperly? handled Resident 1 when the resident was transferred back to bed after the shower. The investigation documentation was not specific as to what was improper about the transfer. On June 29, 2009, at 12:45 p.m., Resident 1 was observed in bed. She was alert, verbally responsive and stated that her left leg was sore. She had a left leg cast below the knee to the foot. During an interview, the resident stated she could not remember if she hit her leg on the chair when she was transferred back to bed by the CNA. During an interview on June 29, 2009, at 12:50 p.m., CNA 3 (permanent 7 am-3 pm CNA) stated Resident 1 required 2 persons assist for transfer, and she usually used the Vander lift to transfer Resident 1. During an interview on June 29, 2009, at 1:50 pm., the Director of Nursing stated Resident 1 was transferred by two persons from the bed to the shower chair.However she was transferred back to bed by CNA 1, without getting assistance, and there was a possibility the resident?s leg got twisted and broke during the transfer. During a telephone interview on June 29, 2009, at 2:15 pm., regarding the June 11, 2009, incident, CNA 1 stated Resident 1 was transferred from the bed to the shower chair with the help of another CNA. However after the shower, CNA 1 stated she decided to transfer the resident back to bed by herself, since the resident was tiny and light. She also stated the resident did not complain of pain prior to the shower; she started complaining of pain after she was back in bed, which was reported to the charge nurse.During an interview on June 29, 2009, at 3 pm., the restorative nursing assistant (RNA 1) who was the team leader on June 11, 2009, stated CNA 1 was given instructions that Resident 1 needed 2 persons assist or a Hoyer lift (Vander lift) for transfer and was instructed to call another CNA for assistance. During an interview on June 29, 2009, at 3:05 pm., CNA 2 stated she was there when the team leader gave instructions to CNA 1 pertaining to Resident 1?s needs for transfer and shower. She was called by CNA 1 for assistance when the resident was transferred from the bed to the shower chair, however CNA 1 did not ask for assistance when she transferred the resident back to bed after the shower. The facility?s undated Registry Protocol indicated the team leader for licensed registry staff, the nursing supervisor or the DON is responsible for providing an initial facility orientation to the registry staff. Orientation will include, but is not limited to resident acuity, special needs and instruction. However, CNA 1 did not follow the instruction given to her by the team leader. The facility nursing staff CNA 1 , who was from a nursing registry, failed to ensure Resident 1 was transferred safely using an assistance device by failing to follow instructions to ask for assistance and to use an assistive device to transfer Resident 1 from the shower chair to bed. This resulted in Resident 1 sustaining a displaced fracture to the left distal tibia and fibula on June 11, 2009.The above violations had a direct relationship to the health, safety, and security of Resident 1. |
| 910000053 |
LAS FLORES CONVALESCENT HOSPITAL |
910010700 |
B |
14-May-14 |
RNUF11 |
6940 |
72311 Nursing Service - General (a)(1)(A)(3) (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include 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. (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. On December 8, 2010, at 8:15 a.m. a complaint investigation was conducted regarding an allegation of non-ambulatory patient who sustained a distal tibia and fibula fractures (broken bone in the lower leg). Based on interview, and record review, the facility failed to: 1. Ensure Patient 1 was continuously assessed for pain after she was identified with lower leg fracture, and receive pain medication. 2. Ensure Patient 1?s attending physician and/or medical director was notified promptly of the X-ray result. On November 23, 2010 at 1:30 p.m., the licensed nurse documented Patient 1 was moaning with facial grimacing when repositioning was attempted. The patient was noted to have swelling to her right knee, femur (upper bone of the leg), fibula (outer lower leg bone) and the skin was warm to touch. The physician was notified at 2 pm and an order was obtained for right leg X-ray. At 9 pm the X-ray result indicated distal tibia (larger bone of leg extending from knee to the ankle), and fibula fractures. On November 24, 2010 at 8:30 a.m., the physician was notified of the X-ray result and the resident was transferred to a general acute care hospital (GACH), 11.5 hours after the patient was identified with fractures. A review of the Medication Record, dated November 24, 2010 at 1 a.m., indicated Tylenol 10 grains (GR) was given orally at 1 a.m., for pain exhibited by facial grimacing. On November 24, 2010, the Resident Transfer Record, indicated before transfer to the GACH, Tylenol extra strength was administered. A total of 11.5 hours had passed before the first medication was given after the patient was identified moaning and with facial grimacing, and eight hours had passed before the second medication was administered at 9 a.m., the following morning. A review of Patient 1's admission record indicated an 86 year old female admitted to the facility on March 16, 2010, with diagnoses including advanced dementia (cognitive and intellectual deterioration), diabetes mellitus (high blood sugar) and had contractures (abnormal shortening of muscle tissue) on her lower extremities.The Minimum Data Set (MDS) a standardized assessment and care screening tool, dated March 26, 2010, indicated the patient?s cognitive skills for daily decision-making were moderately impaired. According to the MDS the patient was non-ambulatory, and required extensive assistance with two person physical assistance for bed mobility, transfers, and was totally dependent on staff for dressing, personal hygiene, bathing and eating. The patient had functional limitation in range of motion on one side of her upper extremity, and impairment to both sides of her lower extremities. In the Licensed Personnel Progress Notes, dated November 23, 2010 at 1:30 p.m., the licensed nurse documented Patient 1 was moaning with facial grimacing when repositioning was attempted. The patient was noted to have swelling to her right knee, femur, fibula and her skin was warm to touch. At 2 p.m., the physician was called and ordered a ?STAT? (as soon as possible) X- ray. A review of the X-ray report dated November 23, 2010, taken at 6:42 p.m., indicated fractures to the distal tibia and fibula.The Licensed Personnel Progress Notes, dated November 23, 2010, at 3 p.m., and 9 p.m., and on November 24, 2010, at 7 a.m., indicated a message was left on the physician's answering machine. On November 24, 2010, at 8:30 a.m., the physician returned the call and ordered to transfer Patient 1 to the GACH.There was no documented evidence that the facility medical director was called when the patient?s attending physician did not return the facility calls. Additionally, there was no documentation the patient was continuously assessed for pain and received pain medication as needed.A review of the physician?s orders for pain, dated March 16, 2010, indicated to give Tylenol 10 grain (Gr) by mouth every four hours for mild body pain, scale 0 to 5 (5 highest). A review of the Resident Transfer Record, dated November 24, 2010 (no time), indicated the patient had pain and was grimacing upon touch and the pain was 4 on a scale of 5, Tylenol extra strength was given at 9 a.m. A review of the GACH admission notes, dated November 24, 2010 at 10:32 a.m., indicated Patient 1?s pain scale was 4. A review of the GACH X-ray report dated November 24, 2010, at 11:04 a.m., indicated a history of trauma, and there was a non-displaced spiral fracture ( the bone has been twisted apart and the line of break is helical [spiral-shaped]) of the distal tibial shaft.During an interview on December 8, 2010 at 10 a.m., with the director of nurses (DON), she stated the licensed nurses called the physician three to four times who did not respond, but told the nurses the medical director should have been notified. A review of Patient 1's care plan for at risk for spontaneous fractures, dated March 16, 2010, and updated September 16, 2010, indicated to x-ray as ordered and notify the physician promptly of significant results. However, the care plan indicated to provide gentle care, but did not include two staff to assist with transfers, and bed mobility. According to the Licensed Personnel Progress Notes, on November 23, 2010, the only documented assessment of the patient was at 1:30 p.m., when swelling and pain was identified on repositioning. On November 24, 2010 at 8:30 a.m., there was a transfer order to the GACH, and to administer Tylenol for pain.A review of the patient?s plan of care for risk of episodes of pain, updated September 2010, indicated to monitor level of pain according to pain scale, and give the patient the medications as ordered, and notify physician if the medication was ineffective.The failure of the facility to: 1. Ensure Patient 1 was continuously assessed for pain after she was identified with lower leg fracture, and receive pain medication. 2. Ensure Patient 1?s attending physician and/or medical director was notified promptly of the X-ray result. The above violation had a direct relationship to the health safety or security of Patient 1.The facility failed to: 1. Notify the physician/ medical director promptly of the fractures.2. Provide pain medications promptly. 3. Conduct continual assessments of the patient and document in the medical record. |
| 910000053 |
LAS FLORES CONVALESCENT HOSPITAL |
910010701 |
B |
14-May-14 |
RNUF11 |
3694 |
F225 483.13(c)(2)The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) On December 8, 2010 at 8:15 a.m., a complaint investigation was conducted regarding an allegation of a non- ambulating patient who sustained a distal tibia and fibula fracture (broken bone in the lower leg). Based on interview, and record review, the facility failed to report an injury of unknown origin to the Department of Public Health within 24 hours. A review of Patient 1's admission records indicated she was admitted to the facility on March 16, 2010, with diagnoses including contracture (abnormal shortening of muscle tissue) of the lower extremities and diabetes mellitus (high blood sugar). A review of the Minimum Data Set (MDS), a standardized assessment, and care screening tool, dated March 26, 2010, indicated the patient?s cognitive skills for daily decision making were moderately impaired, and the patient had short and long term memory problems. Patient 1 required extensive assistance with two person physical assistance for bed mobility, transfers and was totally dependent on staff for dressing, personal hygiene, bathing and eating. The patient had functional limitation in range of motion on one side of her upper extremity, and impairment to both sides of her lower extremities. In the Licensed Personnel Progress Notes, dated November 23, 2010 at 1:30 p.m., the licensed nurse documented Patient 1 was moaning with facial grimacing when repositioning was attempted, and was noted to have swelling to her right knee, femur, fibula and felt warm to touch. At 2 p.m., the physician ordered a "STAT"(as soon as possible) x-ray.A review of the x- ray report, dated November 23, 2010, done at 6:42 p.m., indicated fractures to the distal tibia and fibula. A review of the hospital x- ray report, dated November 24, 2010 at 11:04 a.m., indicated a history of trauma, and there was a non -displaced spiral fracture of the distal tibia shaft (the bone twisted apart and the line of break is spiral shaped) During an interview on December 8, 2010 at 10 a.m., the director of nurses (DON) stated she did not report Patient 1's fractures to the Department of Public Health because she was not sure it was required.A review of the facility's Investigative Form, dated November 22, 2010, indicated the incident was of unknown origin, and there was no witness to the incident.According to a review of the facility's policy and procedure titled, Reporting/Investigating Resident Accidents/Incidents, dated January 2000, all injuries of unknown source will be reported to appropriate agencies as outlined in facility's policy titled, "Reporting Abuse to State Agencies and other Entities/Individuals. A review of the Administrative Manual policy for Unusual Occurrence Reporting, dated September 22, 2007, indicated the facility shall notify the Department of Health Services, (Department of Public Health) (DPH), Licensing and Certification, and local health officer by telephone, confirmed in writing or fax, of all unusual occurrences within 24 hours. Unusual occurrences are not limited to falls with fractures or other injuries that are considered avoidable, and other injuries that affect health and safety as identified by the facility and DPH as requiring reporting.The facility failed to notify the Department of Public Health of Patient 1's unwitnessed injury of unknown origin. |
| 910000057 |
LOS PALOS CONVALESCENT HOSPITAL |
910010894 |
A |
08-Aug-14 |
CV5W11 |
12562 |
F314 483.25 (c) Pressure Sores Based on the comprehensive assessment of a resident, the facility must ensure that (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual?s clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.On March 26, 2014 at 8 a.m., during a recertification survey, an investigation was conducted to investigate an allegation that Resident 1?s family member was not informed of the resident?s pressure ulcer until the morning when the resident was transferred to the general acute care hospital (GACH) emergency room (ER). Based on interview, and record review, the facility failed to ensure the resident received necessary treatment and services to prevent new sores from developing and prevent infection by failing to: 1. Ensure the licensed nurse assessed the new identified pressure sore (redness and/or break in skin usually from prolonged pressure), the assessment was documented in the resident's clinical record and communicated to the incoming licensed nurses for continuing assessment and treatment. 2. Ensure the licensed nurse informed the physician of the new pressure sore for further intervention and treatment orders.On February 26, 2014 at 11:30 p.m. certified nursing assistant 1 (CNA 1) notified licensed vocational nurse 1 (LVN 1) of skin redness to Resident 1's left lower buttock. LVN 1 cleaned the area with normal saline, applied cream to the site and covered the site with a dry 4 x 4 gauze dressing, however, LVN 1 forgot to notify the physician and the incoming licensed nurse. On February 28, 2014, (48 hours after the initial identification of the skin redness to the resident's left lower buttock), Resident 1 was identified with left buttock deep tissue injury (DTI [an injury to a underlying tissue below the skin's surface that results from prolonged pressure in an area of the body]) which measured 6.5 centimeters length (cm) x 6 cm width. The resident was transferred to the GACH for evaluation and was admitted with diagnoses of infected pressure sore and sepsis (presence of bacteria, other infectious organism in the bloodstream with spread throughout the body).A review of Resident 1's admission record indicated the resident was readmitted to the facility on March 19, 2014, with diagnoses that included pressure sores (open area in the skin), dementia (cognitive and intellectual deterioration), Parkinson's disease (a disorder of the brain that leads to shaking and difficulty with walking, movement, and coordination), and had a gastrostomy tube (a tube that is placed directly into the stomach for administration of food, fluids, and medications). The Minimum Data Set (MDS) a standardized resident assessment and care screening tool, dated December 14, 2013, indicated the resident sometimes made self-understood and had the ability sometimes to understand others. The resident's cognitive skills for daily decision-making were moderately impaired. The resident required extensive physical assistance with two staff for bed mobility, and was totally dependent on two staff for transfers, bathing, and toilet use. The MDS indicated Resident I was at risk of developing pressure ulcers and had a Stage 1 (skin redness) on one site, and a Stage II (partial thickness skin loss) on another site. A review of documentation by the facility's wound consultant dated February 21, 2014, indicated Resident 1 had a chronic wound on the right lower extremity and a recurrent wound on the right hip. The wound assessment indicated wound #1 right, lateral malleolus (right side of the ankle), Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure sore, measured 1.7 cm by 1.8 cm with 0.3 cm depth. There was no description given regarding the right hip wound. A review of documentation by the facility's wound consultant dated February 28, 2014, indicated the wound consultant was asked to see the resident for an opinion on how to manage the resident's wounds. The documentation indicated the following wounds: Wound #1 Right, Lateral Malleolus pressure sore, note indicated that it was not examined at this time. Wound #4 Scrotum, suspected DTI, initial wound encounter, measured 1.5 cm by 2.5 cm. Wound #5 Coccyx (tail bone), suspected DTI, initial wound encounter, measured 5 cm by 3 cm. Wound #6 Left Ischium (left lower buttock), suspected DTI, initial wound encounter, measured 6.5 by 6 cm. The periwound (surrounding skin) presented with signs and symptoms of infection. The documentation indicated given the severity of DTI, would strongly recommend further evaluation and treatment in higher level of care to GACH.A review of the Situation Background Assessment Request/Recommendation (SBAR) Nurse/Physician Communication Tool and Progress Notes, dated February 28, 2014, indicated the left ischium DTI, measured 6.5 cm by 6 cm, coccyx measured 5 cm by 3 cm DTI, and scrotum measured 1.5 cm by 5 cm DTI. The request/recommendation was to transfer the resident to the GACH for wound evaluation.A review of the GACH Admission Note, dated February 28, 2014, at 1728 (5:28 p.m.) indicated Resident 1 was referred from the nursing home to the emergency room for evaluation of the large wound on his left buttock. The emergency department course indicated the wound appeared to be obviously infected and the resident's blood pressure was low. The differential diagnosis included infected decubitus ulcer (pressure sore), septic shock (a life-threatening severe form of sepsis that usually results from the presence of bacteria and their toxins in the bloodstream), severe sepsis syndrome, pneumonia, urinary tract infection (UTI [infection of one or more structures in the urinary system]), and dehydration (loss of fluid exceeds amount of fluid intake). The resident was given a saline bolus (a rapid infusion of intravenous fluid or medication that is usually administered to correct a life-threatening condition) x 3 liters and was admitted to the GACH. A review of the GACH History and Physical, dictated on March 1, 2014, indicated the left hip pressure sore was approximately two inches with a black necrotic (dead tissue) center and large amount of erythema (redness) around the wound. The assessment indicated possible wound infection and sepsis. Resident 1 was initially hypotensive (low blood pressure was 80/52 [normal range 120/80]). A plastic surgery consult was requested and antibiotics (medication used to treat infection) were started. The resident was admitted to GACH for 19 days and returned to the skilled nursing facility on March 19, 2014. The Discharge Summary from the GACH indicated the number one discharge diagnoses were sepsis secondary to infection of decubitus (pressure sores) of buttock, and number two were multiple pressure sores. During an interview with CNA 1 on April 2, 2014, at 7:10 a.m., she stated on February 26, 2014 around 11:30 p.m., during care of Resident 1 she observed a reddened area to the resident's left buttock. Certified nursing assistant 1 stated she notified LVN 1. During an interview with LVN 1 on April 2, 2014, at 7:30 a.m., he stated CNA 1 notified him on February 26, 2014, during the 11 p.m. to 7 a.m. shift about Resident 1's reddened abrasion (an area on the skin, that has been damaged by scraping or rubbing) site about a quarter size to the left lower buttock. LVN 1 stated he cleaned the area with normal saline, applied cream to the site and covered the site with a dry 4 x 4 gauze dressing. LVN 1 stated he forgot to call the physician to obtain treatment orders and did not inform the oncoming licensed staff (day shift) of the new site, and the responsible party. LVN 1 stated he was very busy that night and did not chart in the resident's clinical records. It slipped his mind. On his return to work on February 28, 2014, 11 p.m. to 7 a.m. shift, (48 hours after he last saw the resident's left buttock) he was informed Resident 1 was transferred to the GACH.During an interview on April 3, 2014 at 9 a.m., CNA 11 stated that he was assigned only on February 27, 2014, to Resident 1 on the day shift. A bed bath was given and remembered a white dressing was in place to the buttocks. During an interview with CNA 2 on April 3, 2014 at 7:45 a.m., she stated on February 28, 2014, Resident 1 had a bowel movement. CNA 2 stated she noticed on the resident's left buttock a quarter size black purplish center and reddened skin around the opening and she notified the licensed nurse.During an interview with LVN 20 on April 2, 2014, at 10 a.m., he stated CNA 2 notified him on February 28, 2014, of an open wound on Resident 1's left buttock. LVN 20 stated the inside of the wound was dark and reddish, measuring approximately 4.5 cm x 5 cm. He stated the wound consultant was at the facility and was consulted. During an interview with registered nurse (RN) 24 on April 3, 2014, at 2:30 p.m., RN 24 stated LVN 1 did not report the new pressure site on the resident's left lower buttock on February 26, 2014.A review of the Treatment Record from February 1 to 28, 2014 indicated the resident was only receiving treatment to his right lateral ankle (santyl and polysporin powder daily [topical antibiotics]) and to his right hip area for skin maintenance daily and as needed (A&D ointment).A review of the facility's Quality Assurance Report dated February 28, 2014, indicated sudden onset left hip ulcer (left lower buttock), DTI, identified with the following findings: 1. No report from the licensed nurse who identified the pressure sore initially. 2. Treatment and dressing were applied, but the physician, DON and treatment nurse were not notified 3. A ?Body Check ? was not submitted every shift by the CNA. During an interview and record review of Resident 1's clinical records with the DON on April 1, 2014 at 3:50 p.m., there was no documentation for February 26, 2014, about the new pressure site. The DON stated the site was a Kennedy Terminal ulcer (an unavoidable skin breakdown or skin failure that occurs as part of the dying process), however did not comment why LVN 1 did not call the physician, and did not communicate with the incoming staff the new pressure sore, and document his findings.A review of a plan of care for risk skin problem, dated March 7, 2013, indicated to notify the physician of any significant changes in skin condition.A review of the facility's policy and procedure titled, Wound Care (no date), indicated the purpose was to provide guidelines for the care of wounds to promote healing. Verify there is a physician's order for the procedure, review the care plan to assess for any special needs of the resident. The following information should be recorded in the resident's medical records: type of wound care given, date and time wound care was given, any change in condition, an assessment (wound color, size, drainage, etc, and report other information in accordance with facility policy and professional standards of practice. A review of the facility's policy and procedure titled, Charting and Documentation, dated April 3, 2014, indicated all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All incidents, accidents, or changes in the resident's condition must be recorded. Documentation of procedures and treatments shall include care-specific details and shall include a minimum: The date and time/treatment was provided, notification of family, physician, or other staff if indicated, and signature and title of the individual documenting.The facility failed to ensure the resident received necessary treatment and services to prevent new sores from developing and prevent infection by failing to: 1. Ensure the licensed nurse assessed the new identified pressure sore (redness and/or break in skin usually from prolonged pressure), the assessment was documented in the resident's clinical record and communicated to the incoming licensed nurses for continuing assessment and treatment. 2. Ensure the licensed nurse informed the physician of the new pressure sore for further intervention, and treatment orders.The above violations presented either imminent danger that death or serious harm would result to Resident 1. |
| 910000053 |
LAS FLORES CONVALESCENT HOSPITAL |
910011287 |
A |
06-May-15 |
SS9Y11 |
4622 |
42CFR 483.25(h) Accidents F323 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.Based on interview and record review, the facility failed to ensure the correct number of staff transferred Resident 1. The facility assessed Resident 1 as being totally dependent on staff for transfers. This resident who required two staff or more for physical assistance, was transported out of bed and to the shower room by only one staff member. Certified Nursing Assistant (C.N.A.) 5 used the Hoyer lift to transfer the resident from the bed without the assistance of another staff, Resident 1's left foot struck the door frame of the resident's room which resulted in a fracture of the resident's left fourth toe. On June 6, 2014 at 1:20 p.m. an unannounced visit was conducted regarding an Entity Reported Incident (ERI). According to the ERI on April 17, 2014, at approximately at 10:15 a.m. while Resident 1 was being transported to shower room CNA 5, accidentally bumped the resident?s left foot. CNA 5 noticed blood coming from resident's left foot and immediately called for a charge nurse to come assess the resident?s left foot. The charge nurse identified a laceration on the left foot, 4th toe, and the physician was notified. An x-ray was ordered and the results received later that evening, indicated "fracture at the base of the left fourth toe; the remainder of the left foot appears grossly intact." A review of Resident 1's, admission records indicated Resident 1 was readmitted to the facility on April 15, 2014, with diagnoses that indicated late effect cerebrovascular disorder (circulation of blood to the brain causing limited or no blood flow) and diabetes mellitus (a disorder in which there is no control of blood sugar).According to the Minimum Data Set (MDS) Resident Assessment and Care Screening Tool, dated April 22, 2014, the resident was moderately impaired in cognitive skills for daily decision making, and was totally dependent on staff for transfers and required the physical assistance of two or more staff for transfers.In the Licensed Personnel Progress notes, dated April 17, 2014 at 10 a.m., the licensed nurse documented the CNA 5 bumped Resident 1's fourth toe nail on the left foot which caused an open wound with a moderate amount of bleeding. The documentation indicated pressure was applied until the bleeding stopped. At 11 a.m. the physician was notified of the open wound on the left foot, fourth toe. The physician ordered the application of triple antibiotic ointment, (a medication that destroys or slows down the growth of bacteria) and a dry dressing to the open wound, x-ray of the left foot, and a podiatry (a branch of medicine devoted to the disorders of the foot) consultation.The x-ray report, dated April 17, 2014, indicated a fracture at the base of the left fourth toe. During an interview on June 6, 2014, at 2:10 p.m., CNA 5 stated he used the Hoyer lift by himself to take Resident 1 to the shower room. As he wheeled the resident through the resident's room doorway the resident's left foot hit the door frame. CNA 5 stated he did not notice the resident's left foot was bleeding until he got to the shower room. During further interview CNA 5 acknowledged the use of the Hoyer lift required a second staff person physical assistance. During an interview with Staff Developer on June 6, 2014, at 2:15 p.m., she stated CNA 5 was given a verbal warning for not having a second staff person to assist while transferring the resident with the Hoyer lift.A review of CNA 5?s employee file revealed CNA 5 attended an in-service of body mechanics, lifeline/transfers/lifts on August 28, 2013. The facility policy and procedure titled, "Total Mechanical Lift" dated, January 1, 2012, indicated the requirement that at least two people are present while the resident is being transferred with the mechanical lift.The facility failed to ensure the correct number of staff transferred Resident 1. Resident 1 assessed as being totally dependent on staff for transfers, and required two staff or more for physical assistance, was transferred out of bed by one staff. Resident 1's left foot struck the door frame of the resident's room which resulted in a fracture of the resident's left fourth toe. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 910000067 |
Lawndale Healthcare & Wellness Centre, LLC |
910012871 |
A |
27-Jan-17 |
DHEN11 |
14689 |
F309
CFR 483.25, Quality of Care
Each resident must receive and the facility must provide the necessary care and
services to attain or maintain the highest practicable physical, mental and psychosocial
well-being, in accordance with the comprehensive assessment and plan of care.
F281
CFR ?483.20 (k)(3)
The services provided by a facility must ?
(i)Meet the professional standards of quality; and
(ii) Be provided by qualified persons in accordance with each resident?s written plan of care
Based on observation, interview and record review, the facility failed to ensure LVN 1 immediately initiated CPR for one of 14 sampled residents, Resident 9, who was found unresponsive, breathless and pulseless, in accordance with the facility's policy and professional standards of care. This resulted in a delay in the initiation of CPR and caused Resident 9, to not receive the full benefit of CPR (Cardio pulmonary resuscitation) to affect her chance of survival. Consequently, the resident did not survive and expired. Additionally, the facility's licensed nurses LVN 1, 4, 5, 6, RN 1 and the DSD failed to demonstrate knowledge regarding the proper protocol for the initiation of CPR. This deficient practice has the potential to result in a delay in the response time and provision of necessary care during a life threatening/emergent situation and has the potential to result in not honoring the resident's wishes to be resuscitated (Full code), which could cause anxiety to the family and not afford the resident the chance to survive.
According to the nurses notes dated 10/28/16 at 3:00 p.m., Resident 9 was sitting in a wheelchair by her bedside in stable condition and not in any form of distress. At 5:00 p.m., the Hospice Nurse arrived and assessed the resident. Resident 9 had a cough with congestion without rales, rhonchi, shortness of breath or pain. Resident 9 was using 2 liters of oxygen via nasal cannula. At 6:00 p.m., the resident had dinner, and then went to bed because she appeared to look tired. At 7:00 p.m., Resident 9 was observed sleeping using 2 liters of oxygen without wheezing or shortness of breath. At 7:30 p.m., Resident 9 was observed sleeping and her chest was observed as rising and falling. At 7:55 p.m. LVN 1 observed the resident with a drooping face and seemed to be unresponsive. LVN 1 checked the resident?s pulse, shook the resident but the resident remained unresponsive.
During an initial tour of the facility on 10/28/16, at 7:55 p.m., it was observed by the survey team that the paramedics arrived to the facility, entered Resident 9's room and took over CPR efforts on Resident 9. The survey team entered the facility on 10/28/16 at 5:00 p.m.to conduct an annual survey during overtime hours.
According to the admission record, Resident 9 was a 63 year-old female, who was admitted to the facility on XXXXXXX 16, from a general acute care hospital (GACH). The resident had diagnoses which included chronic airway obstruction (COPD - a recurring chronic and permanent disease of the lungs that restrict normal breathing), chronic respiratory failure with hypoxia (oxygen deficiency where oxygen fails to reach body tissues) and heart failure (the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs).
A review of the full Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 8/22/16, indicated Resident 9 was able to express her ideas and wants, had clear speech, and was able to understand others. According to the MDS, the resident's memory was moderately impaired but she had the ability to recall certain words such as sock, blue and bell. The MDS indicated Resident 9 was receiving oxygen therapy. The MDS indicated Resident 9 had a POLST, that the item selected on the POLST is to ?Attempt resuscitation/CPR?, ?full treatment?, and provide long-term artificial nutrition, including feeding tubes.? The resident was on continuous oxygen.
The Physician Orders for Life-Sustaining Treatment [(POLST)- a physician order that outlines a plan of care reflecting a resident's wishes concerning care at life's end] dated 7/24/16, indicated Resident 9 wished an attempt of cardiopulmonary resuscitation (CPR) and full treatment for prolonging life by all medically effective means. There is no evidence the POLST was modified after Resident 9 was admitted to hospice.
A physician's order dated 7/28/16 indicated Resident 9 was a full code and was to be administered oxygen two liters per nasal cannula as needed for shortness of breath or wheezing. According to the hospice assessment, care plan and orders dated 8/10/16 the resident was placed on oxygen 3 liters per minute, continuously. According to the hospice narrative notes the resident was hospitalized on 7/15/16 with labored breathing and a diagnosis of respiratory failure. The resident refused to use a bipap (a machine that helps people breathe more easily during sleep) machine and continued to decline with increased generalized body weakness, she became non-ambulatory with severe dyspnea [difficult or labored breathing], oxygen dependent and increased anxiety.
Resident 9 had a care plan developed on 7/28/16, for ineffective airway clearance, with interventions that included: assess as an indication of respiratory distress as shortness of breath (SOB), wheezing, coughing and notify the doctor accordingly. Elevate the head of the bed as indicated for SOB to help with breathing. Give oxygen inhalation as indicated, and give breathing treatment as ordered. According to the nurses? notes dated 10/28/16 at 6pm, the resident looked tired. According to the History and Physical (H&P) dated, 7/29/16, Resident 9 had shortness of breath on exertion and had the capacity to understand and make decisions.
The physicians order also indicated Resident 9 was admitted to hospice on XXXXXXX 16. The care plan did not change once Resident 9 was admitted into hospice.
A review of the hospice nurses' notes dated 10/28/16, at 4:20 p.m., indicated Resident 9 was sitting in her wheelchair alert, oriented and coherent. The resident had a productive cough with slight congestion and unlabored breathing.
A review of the nurses notes 10/28/16, at 7:55 p.m., indicated on 10/28/16, at 4:30 p.m., Resident 9 was sitting in her wheelchair in no form of distress. At 5:00 p.m., the hospice nurse assessed the resident and obtained an oxygen saturation reading of 92 % (normal range 88-92 for COPD diagnosis). The resident denied shortness of breath. According to LVN 1 at 6 p.m., the resident looked tired and was assisted back to bed. At 7 p.m., the resident was asleep. At 7:55 p.m., Resident 9's face was drooping and she seemed unresponsive and had no pulse. LVN 1 then shook the resident and tried to wake her, but the resident remained unresponsive. LVN 1 then ran towards the nurse?s station and called for everyone's attention. LVN 1 informed the charge nurse to grab the crash cart. The DON called 911 and the rest of the nursing team started CPR. The paramedics arrived to the facility and took over CPR. Resident 9 was transferred to a GACH.
On 10/28/16 at 8:15 p.m., the DON was questioned regarding Resident 9's activity prior to the paramedics' arrival. The DON stated twice that LVN 1 ran to the nurse?s station to inform her that Resident 9 was not breathing. There was a working call button in the room
During an interview on 10/28/16, at 8:30 p.m., LVN 1 stated at 6:30 p.m., Resident 9's oxygen saturation level was assessed as 87%. LVN 1 documented that the resident?s O2 sat was 87% on the declaration form and she verbalized this information during an interview.
The resident was receiving 2 liters of oxygen. A review of the resident's Hospice flowsheet indicated the previous resident's oxygen saturation levels were as follows:
1. 8/10/16, 8/11/16 and 8/27/16. The resident's oxygen saturation measured 96 %, while on 2L of oxygen therapy-
2. On 9/25/16, the resident's oxygen level measured 92% -
3. On 10/19/16 the resident's oxygen level measured as 95%-
According to the University of Michigan, for most COPD patients, the oxygen saturation goal is range between 88-92%. On 10/28/16 the hospice nurse documented the resident?s oxygen saturation of 92%. The oxygen saturation levels were only recorded on the dates mentioned above.
During an interview with LVN 1 on 10/28/16, at 7:45 p.m., LVN 1 stated she observed the resident to be unresponsive and not breathing due to the color of her face and her mouth was twisted. LVN 1 shook the resident, called out her name and checked her radial pulse but the resident remained unresponsive. LVN 1 ran right away to the nurses' station to call for help. LVN 1 obtained an emergency kit (E-kit-an emergency medication kit used in long term facilities) and returned to the resident's room. LVN 1 stated that CPR was initiated for Resident 9 by LVN 2. When LVN 1 was asked why she did not start CPR efforts herself when Resident 9 was found to be non-responsive, she stated that she had run to get help and to retrieve the crash cart.
During an interview on 10/28/16, at 9 p.m., the DON stated that she was called by LVN 1 who stated to her that Resident 9 did not look good. The DON was asked how she looked and the staff became aware that the resident was in distress. The DON stated LVN 1 ran to the nurse?s station to inform the staff. When the DON was asked who initiated CPR? She stated LVN 2 initiated CPR.
During a tour of the facility on 10/28/16 at 9:54 p.m., the Director of Staff Development (DSD) was observed standing in a corner on the south side of the patio reading the facility's CPR policy. He quickly folded the policy and placed the policy in his pocket. The role of the DSD is to ensure the accuracy of staff education.
During an interview on 10/28/16 at 8:05 p.m. and 10 p.m., LVN 2 stated he was alerted that Resident 9 was not breathing. When he arrived to Resident 9's room there was no licensed staff physically touching the resident at that time. LVN 2 observed the resident to be breathless and initiated CPR with chest compressions. LVN 1 and the DON had entered the room after his arrival. LVN 7 entered the resident's room with the crash cart.
During an interview on 10/28/16 at 10:15 p.m., RN 1 was asked when a resident is found unresponsive and breathless what should be done, RN 1 stated she would make sure that the resident is not a full code, get the crash cart and then initiate CPR.
During an interview on 10/28/16, at 10:25 p.m., the Director of Staff Development (DSD) was asked when a resident is found unresponsive and breathless what should be done? The DSD stated he would call for help, obtain the crash cart, check the resident vital signs (measurements taken that indicate the status of the body's life-sustaining functions which includes body temperature, blood pressure, pulse (heart rate), and respiratory rate), hold the resident's shoulders and shout "are you ok", wait for the crash cart, proceed with taking the vital signs and if the resident does not respond then start CPR immediately.
During an interview on 10/29/16, at 11:10 a.m., LVN 5 was asked when a resident is found unresponsive and breathless what should be done. LVN 5 stated she would check the resident's vital signs, call a Code Blue, call out for help, check the resident's medical record to ensure if the resident is a DNR or a full code, then initiate CPR.
During an interview on 10/29/16, at 12:20 p.m., LVN 6 was asked when a resident is found unresponsive and breathless what should be done. LVN 6 stated yell for help, stay with the resident, when help arrives they would be able to determine the code status of the resident, then start CPR. LVN 6 stated that waiting for the code status of a resident during an emergency would be done in a timely manner in less than a minute if possible.
During an interview on 10/29/16 at 12:35 p.m., the DON was asked when a resident is found unresponsive and breathless what should be done. The DON stated she would shake the resident a little bit, check for a pulse, if resident is pulseless then check the resident?s medical record to see if the resident is a DNR or a full code, obtain the crash cart and then perform CPR. The DON was asked how does the nursing staff determine which residents have a DNR or a full code status during an emergency. The DON stated the nursing staff would have to look in the resident's medical records and check for a POLST form before performing CPR. The DON was asked what would happen if a resident does not have a POLST in their medical records? The DON stated residents who do not have a POLST in their medical record are automatically considered a full code. The DON further stated if a licensed nurse is unable to locate a resident's POLST the nurse would call the family and instruct another licensed nurse to perform CPR, while attempting to call the family.
During an interview on 10/29/16 at 12:41 p.m., the DON stated Resident 9 had expired at the GACH on XXXXXXX16.
The facility's policy dated 8/01/15, and titled ?Cardiopulmonary Resuscitation" indicated
CPR is instituted in cases of recognized cardiac and/or pulmonary arrest until medical emergency personnel are available to take over the resuscitation efforts. The first facility personnel to arrive and find a resident with any of the above conditions will identify whether there is cardiopulmonary or respiratory arrest by shaking the person and calling out their name; respond to the resident immediately and send available staff to call a code blue; commence one person CPR, according to current practice; check the resident's airway for breathing and circulation and begin CPR; if alone, perform resuscitation for one minute before leaving the resident to call for help. (This policy does not include the most recent changes from the American Heart Association).
According to the Vocational Practice Act 2518.6 Performance Standards; a licensed vocational nurse shall safeguard the patient's health and safety by actions that include maintaining current knowledge and skills for safe and competent practice.
The facility failed to ensure LVN 1 followed the policies and procedures for CPR on Resident 9, who was unresponsive, breathless and in need of immediate emergent care, and was a full code, and failed to ensure LVN 1, 4, 5, 6, RN 1 and the DSD were properly trained on when to initiate CPR according to the facility?s policies and procedures..
The above violations presented a substantial probability of death or serious physical harm to Resident 1. |
| 920000032 |
LAKEVIEW TERRACE SPECIAL CARE CENTER |
920009102 |
B |
17-Oct-13 |
GZCQ11 |
7155 |
CCR Title 22 Section 72311(a) (2) (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Based on observation, interview, and record review, the facility failed to ensure that Patient A did not leave the facility Absent Without Leave (AWOL) and did not implement the patient?s care plan for one to one monitoring [(1:1) one staff to one patient ratio]. Patient A was able to leave AWOL from the facility four times, two times while on 1:1 monitoring for safety. On August 26, 2011 at 2:30 p.m., an unannounced visit was made to the facility to initiate an investigation of an entity reported incident (ERI) regarding Patient A, who went AWOL three times from this locked facility (a facility that is secured to prevent patients from leaving unsupervised).On December 5, 2011, another visit was made to the facility in response to an additional ERI received by the department that Patient A went AWOL for the fourth time.According to the admission information, Patient A was readmitted to the facility on December 14, 2010, with diagnoses that included schizoaffective disorder. The physician's order dated December 14, 2010, indicated Patient A was to receive Ambien 10 milligrams (mg) at bedtime as needed for sleeplessness. The order also indicated the patient was to receive Ativan every four hours as needed for agitation manifested by becoming restless and disorganized. On February 25, 2011, the order indicated the patient was to receive Risperidone 4 mg at bedtime for thought disorder manifested by paranoid responses to internal stimuli; Clonazepam 1 mg twice a day and at bedtime (used to treat certain types of seizures. It is also used to treat panic disorder), and Remeron 15 mg at bedtime for depression symptoms manifested by self-isolation and low self-esteem. The Interdisciplinary Team (IDT) Meeting notes dated June 1, 2011, indicated a discussion that Patient A had been on 1:1 monitoring since leaving the facility without permission on May 16, 2011. Patient A did not make any attempts or verbalize a desire to leave the facility since returning on May 17, 2011. The IDT recommended discontinuing the 1:1 monitoring during the 7 a.m. to 3 p.m. shift, add hourly checks on the 7 a.m. to 3 p.m. shift, and continue the 1:1 monitoring on the 3 p.m. to 11 p.m. and the 11 p.m. to 7 a.m. shifts.The Minimum Data Set (MDS - a standardized comprehensive assessment of the patient's problems and conditions) dated June 20, 2011, indicated Patient A had clear speech, usually understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of the message but comprehends most of the conversation).The Interdisciplinary Progress Notes dated August 10, 2011, indicated that during the 2 p.m. hourly checks, Patient A was not in his room. Staff were made aware and searched inside the rooms and bathrooms, and outside the facility grounds. However, Patient A was not located and facility staff members were sent out to the community to search for him. The Police Department was notified as well as the patient's conservator. On August 11, 2011, at 10:05 a.m., Patient A was returned to the facility accompanied by family and two police officers. Patient A told the staff he climbed over the fence. The IDT recommended the patient be placed on 1:1 monitoring on all three shifts and will not be eligible in the future to have any shifts discontinued for monitoring. The IDT Progress Notes dated August 20, 2011 at 9:40 p.m., indicated CNA 1 (certified nursing assistant) monitoring Patient A allowed him some privacy by closing the door to his room. When CNA 1 checked on Patient A, he was not in the room. Staff members were notified that the patient was missing. Rooms, bathrooms, outside facility grounds, and the nearby neighborhood were searched, but they were unable to locate Patient A. On the same day at approximately 10:30 p.m., Patient A was located by the staff and he returned to the facility voluntarily.On August 20, 2011, a care plan was established for Patient A's risk for injury related to leaving the facility AWOL. The approach plan included 2:1 monitoring for safety until the next IDT meeting on August 22, 2011. The IDT meeting on August 22, 2011, notes indicated the resident was put back on 1:1 monitoring and no access to personal items without staff supervision.On August 26, 2011 at 2:30 p.m., an observation outside the facility revealed a 10-foot fence with a 4 foot over-hang, and the other part of the fence was 12 feet high with a 3 foot over- hang. The fences surrounded the patio and the building. There was an approximate 10 foot drop down the side of the hill.On August 26, 2011, at 3:15 p.m., during an interview, the Evaluator asked Patient A how he was able to leave from the facility while on 1:1 monitoring. He said the person who was supposed to be watching him was sitting at the nurses' station.He said he walked right by her and exited the door that led to the patio. Patient A also said he left because he felt uncomfortable being in the facility and 1:1 monitoring was too much pressure. He then climbed over the fence and jumped. He stated it only took him two minutes. The patient had superficial scratches that were healing on both legs. Patient A said he obtained the scratches from a stick when he was walking around.During an interview with the Administrator on August 26, 2011 at 4 p.m., she said Patient A was supposed to be on 1:1 monitoring. The person that was monitoring him stepped away and the patient used that opportunity to elope. The Administrator also said all of the staff had been given in-service training that 1:1 monitoring means never leaving the patient?s side.On November 18, 2011, the department received an ERI that Patient A was found missing from the facility on November 17, 2011. The report indicated the CNA assigned to do 1:1 monitoring with Patient A, went to the nurses? station for a moment and left Patient A in his room. When the CNA returned to the resident's room, he was gone. A community search was initiated and the police were called. At the time of the report the resident had not been located. According to the facility's policy, One-to-One (1:1) Resident Monitoring (undated) means one staff member supervising/providing care for one resident only. The staff member is to be present with the resident at all times including visual contact during their 1:1 monitoring assignment.The facility failed to ensure that Patient A did not leave the facility Absent Without Leave (AWOL) by not implementing the care plan developed for the safety of Patient A. The care plan intervention included one to one monitoring [(1:1) one staff to one patient ratio]. Patient A was able to leave AWOL from the facility four times, two times while on 1:1 monitoring for safety. The above violation had a direct relationship to the health, safety, and security of Patient A. |
| 920000051 |
LANCASTER HEALTH CARE CENTER |
920010030 |
A |
26-Sep-13 |
8SYX11 |
14049 |
?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. On January 19, 2012, the Department received a complaint allegation from a family member, that (Resident 1) fell when getting up to go to the bathroom on January 15, 2012. This resident sustained multiple injuries that included a broken shoulder, broken elbow, and facial lacerations that required 10 sutures. On January 20, 2012 at 3:19 p.m., an unannounced complaint investigation was conducted. Based on interview and record review, the facility did not take actions to prevent injury to Resident 1, who had history of falls with a recent hip fracture with surgical repair by failing to: 1. Follow the facility policy regarding fall management for Resident 1. 2. Ensure Resident 1 had a mattress alarm in use, in place, and operable as prescribed by the physician. 3. Provide a specific plan of care for fall prevention for Resident 1, who was at risk for falls due to the history of falls with injuries. These failures resulted in Resident 1 falling, sustaining blunt head trauma with a 4.5 centimeter (cm) in length left peri-orbital (area surrounding the socket of the eye) laceration requiring sutures, a left inferior orbital fracture, a non-displaced left sacral (triangular-shaped bone at the bottom of the spine) fracture, left-sided comminuted (bones broken into several pieces) inferior/superior pubic rami (part of the pelvis) fracture, being transferred to a general acute care hospital (GACH), receiving blood transfusions, morphine sulfate (strong narcotic pain medication) intravenously (into the vein), requiring multiple wound care, and undergoing a closed surgery of the left hip and hemi-pelvis (half of the pelvis). On January 20, 2012, according to Resident 1's Admission Record, the resident was an 86 year-old female originally admitted to the facility on August 6, 2011, and last re-admitted to the facility on December 30, 2011. The resident?s diagnoses included aftercare for a traumatic left hip fracture (sustained August 2, 2011 from a fall at home), status-post surgical hip repair, chronic obstructive pulmonary disease (lung disease), and muscle weakness with difficulty walking.A Minimum Data Set (MDS), a standardized assessment and care screening tool, dated August 13, 2011, indicated she had the ability to understand others and make herself understood. Resident 1 required two-person extensive assistance for activities of daily living such as dressing, personal hygiene, transferring, and she was totally dependent with locomotion on the unit. A review of the facility's fall risk review tool, dated August 8, 2011, indicated Resident 1 was assessed as having moderate risk for falls.A review of a care plan and physician?s order, dated September 7, 2011, indicated the resident required an alarming mattress while in bed to prevent injury due to being prone to falls.According to an investigation/incident report, dated September 8, 2011, Resident 1 was heard yelling for help from the floor near the bottom of her bed. The resident was alert and oriented and stated, "I was trying to straighten out my blankets.? The primary physician was notified and the resident was transferred to the general acute care hospital emergency room (GACH-ER) for evaluation and treatment. The facility's final Outcome/Deposition included: using an alarming pad to wheelchair to prevent and to remind resident to not to get out of bed without calling for assistance to prevent recurrence of fall.According to the Emergency Room report, dated September 8, 2011, Resident 1 sustained left parietal (head) scalp laceration 1.5 centimeter in length requiring staples for closure, left elbow, shin, and left shoulder skin tears. Resident 1 was re-admitted to the facility on September 8, 2011.A care plan, dated September 8, 2011, titled, "Actual Incident of Fall," did not indicate the resident was at risk for falls due to previous recurrent falls with injuries. The plan of care interventions included providing an alarming pad (a pad that is placed underneath the resident to monitor movement) while in wheelchair every shift, continue safety devices as ordered, placing the call light within reach and checking frequently, and encouraging her not to get up without assistance.A review of a physician's order, dated January 12, 2012, indicated Resident 1 had an order to have an alarming mattress pad while in bed for fall injury prevention.A review of an Interdisciplinary Team (IDT) Summary of a care plan conference, dated January 13, 2012, indicated the resident had a history of falls with poor safety awareness.A review of the facility?s incident report, dated January 15, 2012, indicated the resident was found on the floor in a face down position (prone) bleeding a lot. The resident had multiple skin tears to the left eyebrow, left shoulder, and left leg. A review of a ?Change of Condition/Alert Documentation Nursing Progress Note,? dated January 15, 2012, indicated the resident was found on the floor with bleeding and steri-strips (adhesive strips used to close small wounds) were applied to the resident?s left cheek, shoulder, and leg. The resident complained of left hip pain. The note indicated the physical therapist was there and assisted with positioning the resident on her back. According to a review of a ?Post-Fall Evaluation Assessment Worksheet,? dated January 15, 2012, and timed at 8:35 a.m., the resident complained of pain post-fall at left hip and left face area. The section for devices, alarms, wheelchair, and bed were checked for Resident 1, but indicated the resident did not have any footwear on during the fall. The Assessment Worksheet indicated Resident 1?s roommate (Resident 2) observed Resident 1?s fall. The roommate stated Resident 1 stood up and then fell to the floor. Under the section to identify the possible cause of incident included: unstable gait, weakness, difficulty in walking, requiring a one-person assist, and poor safety awareness. Under the section to identify what interventions may be effective to prevent recurrent fall or decrease injury associated with a fall the facility?s staff documented; increase observational rounds every two hours; always check placement and functions of safety devices. CNA 1 did not check the function and placement of the mattress alarm. A physician's order, dated January 15, 2012, indicated to transfer the resident to a GACH emergency room (ER) for further evaluation of fall with multiple injuries to left eyebrow, left shoulder, and left leg skin tears. According to the facility's ?Patient transfer form,? dated January 15, 2012, Resident 1 was transferred to the GACH status post fall.A review of the GACH?s ER note, dated January 15, 2012, indicated the resident arrived via ambulance at 9:50 a.m., with a chief complaint of a fall with injuries, skin tears, and pain to the left hip, head, left shoulder and elbow, and face. The left eye was swollen with much ecchymosis (small hemorrhagic spot in the skin or a mucous membrane). According to the ER note, Resident 1 stated, ?I fell out of bed and I hurt all over.? The resident received morphine IV for pain for suturing and overall pain management. The resident had multiple x-rays, computed tomography scan (CT) which uses X-rays to make detailed pictures of structures inside the body and blood work done. A review of the GACH?s Operation note, dated January 16, 2012, indicated the resident underwent a closed non-manipulative treatment to the left hip and hemi-pelvis fracture. A review of the facility?s investigation interview of CNA 1 that was conducted by the facility?s administrator, DON, and DSD, regarding the alarming mattress pad, on January 19, 2012 and timed at 6:15 p.m., CNA 1 stated she just knew the light needs to be blinking and if the resident moves it beeps. She stated she saw the light was on, and when she repositioned Resident 1 she did not hear the alarm go off and she did not check the pad for proper placement, because the resident stated she was in pain?. According to the manufacturer?s guidelines, the alarm should alarm upon movement or when weight released. According to a review of the facility?s policy, dated November 30, 2006, titled, "Bed Safety Guidelines," the purpose was to assure proper implementation and application of approved bed-safety rails and devices.On January 20, 2012 at 3:55 p.m., during an interview, the administrator stated, ?The resident had a bad fall and sustained many injuries and needed to be sent to the hospital immediately.? The administrator stated the resident had a history of falls while in the facility, but continued to fall and sustained serious injuries.On January 20, 2012 at 4:06 p.m., during an interview, a certified nursing assistant (CNA 1) stated, ?I saw her on the floor when I got to the room, she was by the foot of the bed face down (prone) and she did not say much.? CNA 1 stated when the resident was asked what she was trying to do, the resident stated, "I don't know." During an interview with the director of nurses (DON), on January 20, 2012, at 4:20 p.m., she stated, ?The resident fell on a Sunday, (January 15, 2012) and it was not the facility's fault, the resident had a history of dementia (loss of brain function that occurs with certain diseases) and the CNA (CNA 1) was busy with a resident in another room at the time of Resident 1's fall.? When the surveyor, asked if Resident 1 had an order for an alarm and was it in place before the fall, the DON replied, ?Yes, a bed alarm was under the bedding.?A review of a typed letter, dated February 28, 2012, from the resident?s family member, indicated the resident suffered many injuries as a result of the fall. According to the letter, the family members went to the facility on January 15, 2012, after the resident had fallen and was admitted into the GACH, and spoke to Resident 2 (Resident 1?s roommate). The letter indicated Resident 2 informed the family how and where Resident 1 fell and that an alarm did not sound when the resident got out of bed. The letter also indicated the family arrived one time prior to the fall (no date indicated) and found the resident up coming out of the bathroom unsupervised and there was no alarm sounding.On March 15, 2012 at 8 a.m., during a telephone interview, Resident 1?s family member stated the resident was to have a bed alarm because she was a high fall risk and would attempt to get out of bed without assistance.On June 7, 2013 at 3:59 p.m., a telephone interview was conducted with Resident 2. Resident 2 stated she remembered Resident 1?s fall last year. Resident 2 stated she heard the resident get up and stand at the end of the bed and then fell hard to the floor. Resident 2 stated the fall was so hard she thought Resident 1 had passed out. Resident 2 was asked if an alarm sounded and she stated, ?I never heard an alarm sound, not then, or ever in our room.? Resident 2 stated she was unaware of Resident 1 having a bed alarm, because she had never heard an alarm sound in the room. Resident 2 stated she got up out of bed and saw Resident 1 on the floor bleeding and went to the door to yell for help. A review of Resident 2?s clinical records on July 10, 2013, indicated the resident was a 69 year-old female who was admitted to the facility on January 10, 2012, status-post exploratory laparotomy (a 'look-see' operation usually of the peritoneal cavity) surgery with a colostomy placement secondary to a small bowel obstruction. A MDS, dated January 17, 2012, indicated the resident had the ability to understand and be understood. It also indicated the resident was oriented to month, year, and date. The MDS indicated Resident 2?s memory recall was intact and required no cueing. On July 5, 2013 at 9 a.m., during an interview, the administrator stated CNA1 no longer worked in the facility due to disciplinary issues. A review of the CNA?s Disciplinary Action Records, dated January 20, 2012, indicated she was verbally warned regarding not following safety policies and procedures related to the January 15, 2012 incident of Resident 1. The record indicated the CNA failed to check the placement of the mattress pad alarm after the alarm did not sound during repositioning (weight shifting) of the resident. Another Disciplinary Action Record, dated July 3, 2012, indicated the CNA was suspended for four days due to careless/reckless behavior resulting in possible danger to the residents. According to the facility?s policy and procedure, dated November 30, 2006, titled, "Resident Bed Safety Risk Review," if a resident is determined to be at risk for safety, an individualized care plan must be immediately implemented and reviewed with staff to ensure the resident?s safety. However, the facility failed to develop a plan of care for the resident?s risk of falls. Also, under procedure: A Bed-Safety Device Risk Tool was to be completed for each resident to identify the risk factors that may lead to potentially serious injury to the resident. In addition, this tool was not completed.The facility did not take actions to prevent injury to Resident 1, who had history of falls with a recent hip fracture with surgical repair by failing to: 1. Follow the facility policy regarding fall management for Resident 1. 2. Ensure Resident 1 had a mattress alarm in use, in place, and operable as prescribed by the physician. 3. Provide a specific plan of care for fall prevention for Resident 1, who was at risk for falls due to the history of falls with injuries. The above violations presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 970000081 |
LEISURE GLEN POST ACUTE CARE CENTER |
920010260 |
A |
10-Feb-14 |
FP9711 |
14851 |
42CFR ?483.25 (d) Urinary Incontinence F315 Based on the resident's comprehensive assessment, the facility must ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. 42CFR ?483.25(j) HydrationF327 The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. Based on observation, interview, and record review, the facility failed to prevent dehydration and a urinary tract infection (UTI) that progressed to urosepsis [a systemic infection with an accumulation of pus-forming bacteria or their toxins in the blood originating in the urinary tract leading to overwhelming bacteremia (bacteria in the blood) and septic shock (a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure] by failing to:1. Provide adequate fluids to Resident 3 who was assessed at risk for dehydration. 2. Monitor Resident 3?s hydration status by means of an intake and output (I&O) record as indicated in the facility's policy and procedures to ensure the resident had consumed the volume of fluids (1980 cubic centimeters/cc) as indicated in the nutritional assessment.3. Provide incontinent care for Resident 3 using the accepted standard of nursing practice to prevent UTI. According to the admission record, Resident 3 was an 87 year-old female originally admitted to the facility on March 9, 1998, and readmitted on February 7, 2013, with diagnoses that included diabetes mellitus (is a chronic disease in which high levels of glucose (sugar) build up in the bloodstream), and dementia (loss of brain function that occurs with certain diseases; it affects memory, thinking, language, judgment, and behavior).The Minimum Data Set [MDS-a standardized comprehensive assessment of the resident's problems and conditions], dated December 4, 2012, indicated the resident's cognitive patterns were moderately impaired and needed extensive assistance from staff members for toilet use, and personal hygiene. The resident was always incontinent of bowel and bladder. The MDS also indicated the resident was always incontinent of bowel and bladder and had a weight and height of 144 pounds and 62 inches respectively. There was a care plan for incontinence (a care plan is an individualized document developed by the facility that identifies nursing interventions with specific approaches to address assessed patient needs and serves as a guide for nursing care) last updated on December 4, 2012. According to the record, the resident was totally incontinent for bowel and bladder and had functional incontinence. The care plan goal was for the resident to be continent at least during the day and to be kept clean and dry after each incontinence episode. The approaches (interventions) included to keep the resident clean and dry, provide good perineal care for every episode of incontinence, assist resident to the toilet at least before meals and/or after meals.On April 10, 2013 at 10:15 a.m. Certified Nurse Assistant 1 (CNA 1) was observed providing incontinent care to Resident 3. The resident was observed with fecal material in the skin folds around the genitalia.CNA 1 removed the resident's soiled incontinent brief with her gloved hands, and then proceeded to cleanse the resident's perineal region with an up and down stroke motion using a wash cloth soaked with soapy water. CNA 1 did not use the appropriate cleansing technique. She used an up and downward, back and forth motion contaminating the resident's urethral meatus that put the resident at risk for UTI. According to the accepted standard of nursing practice, cleaning the perineal region and genitalia should be done using gentle downward strokes from the front to the back of the perineum to prevent intestinal organisms from contamination of the urethra or the vagina. Avoid the area around the anus and use a clean section of the washcloth for each stroke by folding each used section inward (Lippincott's Visual Encyclopedia of Clinical Skills, 2009, Pages 383-384). On April 10, 2013 at 10:30 a.m., during the incontinent care observation, CNA 1 was interviewed about the care provided and stated that she should have cleansed the resident's genital region using a one stroke top to bottom technique and should have not used the same wash cloth.A review of the resident's clinical record indicated the resident had recurrent urinary tract infections manifested by positive urinalysis, microscopic urine tests, and urine culture and sensitivity tests. For example:A review of the laboratory test results on a specimen taken on March 6, 2012 at 3:15 a.m., indicated Resident 3 had a UTI as follows: 1. The urinalysis test result indicated the urine was cloudy (reference range-clear) and had a moderate amount of blood- (reference range-negative). The microscopic urine test result indicated the presence of WBC (white blood cells) 5-10 (reference range- 0-2), RBC (red blood cells) 2-5 (reference range 0-2), many bacteria (reference range-none), 2. The urine culture and sensitivity test results indicated the presence of Escherichia coli (gram-negative, facultative anaerobic, rod-shaped bacterium that is commonly found in feces and in the lower intestine) 100,000 cfu (colony formation unit). The resident was treated for UTI.In addition to the diagnoses of UTI, Resident 3 was also diagnosed at the acute care hospital on February 3, 2013, with dehydration.According to a review of the clinical records leading to the resident?s transfer to the acute hospital, Resident 3 was 62 inches tall and 144 pounds. Her physician ordered diet was regular, no concentrated sweets, small portions, skim milk only. The last assessment by the registered dietician (RD), a quarterly assessment documented in the Nutrition Progress Note was dated December 5, 2012, did not include assessments of fluids but recommended ?continue with current plan of care?. The last nutrition assessment that included an assessment of fluid needs was dated April 22, 2011. The RD assessed the resident?s fluid needs as 1,980 cubic centimeters (cc). The successive quarterly and annual RD assessments, dated June 4, 2012, September 5, 2012, did not indicate a change in the resident's fluid needs per day. During an interview on April 11, 2013 at 9:35 a.m., the RD stated that since her nutrition needs including fluids had remained the same, the nutrition assessments were only updated. The RD also stated that the facility?s regular diet on average, would provide approximately 2,000 cc per day from food, water and other beverages served, if the resident consumed 100% of the meals. Since Resident 3 was on small portions, she would therefore not consume the average 2000cc per day described by the RD. She would have consumed less than 2,000 cc of fluid per day. Review of ADL records which included amount of food and liquids consumed showed that she consumed between 70 and 100% of her meals. This implied that the amount of fluid consumed from meals is further decreased. The MDS dated December 4, 2012, indicated the resident's cognitive patterns were moderately impaired and needed extensive assistance from staff members for eating. Observation on April 10, 2013, at approximately 9:30 am revealed her continued dependence on staff for fluids. She was not able to reach a cup of water placed next to her less than a foot away on the night stand.A review of the resident's laboratory test results included the following indicators for dehydration: 1. On March 6, 2012, the resident had an elevated level of blood urea nitrogen (BUN) of dated was 29 mg/dL (reference range 5-20 mg/dL) and a creatinine of 0.6 mg/ dl (reference range 0.7-1.5 mg/dL). The BUN/Cr Ratio was 48. A BUN/Cr. ration of more than 20 indicates dehydration (Nursing Care Ready Reference: Resident Assessment Protocol, Pages 53-55).2. On December 4, 2012: BUN was 19 mg/dl and the Cr. was 0.5 mg/dl. The BUN/Cr ratio was 38:1. 3. On February 3, 2013, the resident had an elevated sodium level of 152 mEq/L (reference range 135-145 mEq/L), and an elevated BUN of 32 mg/dL and the Cr was 0.7 mg/ dl. The BUN/Cr ratio was 46:1. A review of the literature indicates a BUN/Cr. ratio ranging from 20:1 to 24:1 is an indicator for impending dehydration and a BUN/Cr. ratio at or above 25:1 is an indicator for dehydration (American Journal of Nursing June 2006 Volume 106 No. 6). Resident 3 had a BUN/Cr ratio ranging from 38:1 to 46:1.A review of the care plan dated December 4, 2012, indicated- potential for dehydration secondary to dementia. The care plan goal was for the resident to be well hydrated as evidenced by but not limited to moist mucous membranes, good skin turgor, etc. for 90 days. The care plan approaches/interventions included: to monitor for signs and symptoms of insufficient fluid intake such as dry skin, dry mucous membranes, cracked lips, poor skin turgor, thirst, fever. Watch for concentrated urine, to monitor laboratory values and to notify the physician, the family and the registered dietitian if above symptoms occur and intake and output (I&O) if necessary. No intake and output record was observed in the record and this was confirmed on April 10, 2013 at 10:40 a.m. during an interview with Licensed Vocational Nurse 3 (LVN 3).On April 10, 2013 at 10:40 a.m., during an interview, LVN 3 also stated the resident only drinks small sips of water when she was offered water. There was no plan of care to give the resident specified amount of fluids at a specified time intervals to meet the daily requirement of 1980 cc per day.A review of the licensed nurse progress note, dated February 3, 2013 at 12 a.m., indicated the resident had a change of condition that included a fever of 101.2 degrees Fahrenheit [øF normal 98.6 øF], blood pressure of 180/110 (normal 120/80), and an elevated fasting blood glucose of 493 milligrams [mg per deciliter (dl) reference range 65- 99 laboratory test mg/dl].On the same date at 10 a.m., the resident's vital signs were: blood pressure (BP) was 200/98, pulse rate was 98 beats per minute (normal 60-100), respiratory rate of 18 per minute (normal 14-18). The resident was responsive to verbal commands and showed weakness in extremities. The physician was notified of the resident's change of condition and orders for laboratory tests were obtained.A review of the laboratory test results, dated February 3, 2013, indicated Resident 3 had a UTI as following: 1. The urinalysis test result on a specimen taken at 3:15 a.m. on February 3, 2013, indicated the color of the urine was orange (reference range- straw-yellow), slightly cloudy (reference range-clear), blood- moderate amount (reference range- negative), protein 100 mg/dL (reference range-negative), glucose 1000 mg/d/L (reference range- negative). The microscopic urine test result indicated the presence of WBC 5-10 (reference range- 0-2), RBC 2-5 (reference range 0-2), many bacteria (reference range-none),2. The urine culture and sensitivity test results indicated the presence of Klebsiella Pneumonia (gram-negative, non-motile, encapsulated organism) 100,000 cfu (colony formation unit), resistance to two out of 15 antibiotics tested.On February 3, 2013 at 8:30 a.m., a physician order was obtained to transfer the resident to the general acute care hospital (GACH) before a treatment was ordered for the UTI. On February 3, 2013 at 10:30 a.m., after a two hour delay, the resident was transferred to the acute care hospital by an ambulance. A review of the clinical record, dated February 3, 2013, obtained from the GACH indicated the resident presented a chief complaint of altered level of consciousness had been having decreasing mental status and worsening weakness.A review of the emergency room (ER) physician's documentation, dated February 3, 2013, indicated the resident was a 87 year old female admitted with a fever of 100.7 øF (reference range 98.6 øF), pulse of 97 beats per minute (reference range 60 to 70), respiration 31 breaths per minute (reference range in adult 12?24), and a blood pressure of 230/110 (reference range 120/80- 139/89). A review of the ER History and Physical examination record, dated February 3, 2013, obtained from the GACH, indicated increased white blood cell count, with renal insufficiency and an elevated blood sugar as well. The laboratory test results indicated hypernatremia- (elevated Sodium in the blood) of 151 mEq/L milliequivalent/liter [one thousandth of 1 equivalent of a specific substance dissolved in 1 liter of solution or plasma]. Hypernatremia is almost always an indicator for excessive fluid depletion/dehydration; it usually occurs with inadequate fluid intake and increased water loss], an elevated BUN of 38 mg/dl, 3+ white blood cells in the urine, elevated white blood cells count greater than 100 red blood cell count. The resident was diagnosed with altered mental status, urinary tract infection, dehydration and urosepsis and admitted to the hospital.According to the physician note dated February 3, 2013, Resident 3 was admitted to the GACH and hospitalized for four days. Resident 3 was treated with an intravenous (IV) fluid and two different antibiotics (Vancomycin 1 gram and Zosyn 3.375 gram). The resident was discharged, to the skilled nursing facility on February 7, 2013.The facility failed to prevent dehydration and a urinary tract infection (UTI) that progressed to urosepsis [a systemic infection with an accumulation of pus-forming bacteria or their toxins in the blood originating in the urinary tract leading to overwhelming bacteremia (bacteria in the blood) and septic shock (a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure] by failing to:1. Provide adequate fluids to Resident 3 who was assessed at risk for dehydration. 2. Monitor Resident 3?s hydration status by means of an intake and output (I&O) record as indicated in the facility's policy and procedures to ensure the resident had consumed the volume of fluids (1980 cubic centimeters/cc) as indicated in the nutritional assessment.3. Provide incontinent care for Resident 3 using the accepted standard of nursing practice to prevent UTI. The above violations jointly, separately, or in any combination presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 970000081 |
LEISURE GLEN POST ACUTE CARE CENTER |
920012245 |
A |
12-May-16 |
SNDR11 |
11196 |
483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.483.25 (h) Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 2/5/16, at 8 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 sustaining a fall at the facility resulting in a fractured (broken) left hip.Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure Resident 1, who was assessed as high risk for falls due to history of falls, mental confusion, physical limitations, unstable balance, medications, diagnoses, and in need of one-person physical assistance for transfer and walking, was provided with supervision, assistance, assistive device, and an environment free of accident hazards as possible to prevent fall and injuries by failing to:1. Re-evaluate Resident 1 for the safe use of a self-release belt to ensure effectiveness and safety of the resident. 2. Ensure Resident 1?s self-release belt was released and the resident was repositioned every two hours as indicated in the plan of care. 3. Evaluate Resident 1?s medication regimen to identify and adjust when possible, medications that may be associated with an increased fall risk as per facility?s policy. As a result, on 1/25/16, at 4:40 p.m., while left unattended sitting in a wheelchair in the hallway, Resident 1 released the self-release seat belt, attempted unassisted transfer and walking and fell on the floor sustaining a fractured left hip. Resident 1 required transfer to a general acute care hospital (GACH) where the day following the fall, 1/26/16, she underwent an open reduction and internal fixation (ORIF) surgery of the left hip under general anesthesia.On 2/5/16, a review of the admission record indicated Resident 1 was admitted to the facility, on 6/23/15, with diagnoses including dementia (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), diabetes mellitus (high blood sugar levels), and epilepsy (a group of neurological diseases characterized by epileptic seizures that can vary from brief and nearly undetectable to long periods of vigorous shaking). The Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 11/ 26/15, indicated Resident 1 was severely impaired in cognitive skills for daily decision making, rarely or never understood others or made herself understood, required extensive to total assistance from staff with activities of daily living (ADLs) including transfers, bed mobility, and dressing. The resident was assessed as unable to walk, had unstable balance requiring one-person assistance with surface to surface transfers (between bed, chair, or wheelchair), and used a wheelchair for mobility. The resident was receiving daily psychoactive medications (alters brain function, resulting in temporary changes in perception, mood, consciousness and behavior) and used daily restraining devices when in wheelchair. According to the Physical Restraint/Device Assessment form dated 9/25/15, Resident 1 used a lap buddy restraint (a cushion over the lap that impede standing) which was changed to a self-release seat belt (not considered to be restraints as long as the individual is capable of releasing the closures themselves), because the lap buddy increased the resident?s restlessness and yelling. The form did not include an assessment of the safe use the self-release seat belt and its effectiveness. There was no documented evidence the use of self-release belt was re-evaluated since 9/25/15 to 1/26/16, over four months.A physician?s order dated 9/29/15 indicated to apply to Resident 1 a self-release seat belt attached to a wheelchair alarm.A plan of care developed on 9/29/15 for the use of the self-release seat belt while in the wheelchair included in the approaches to assess Resident 1's response to restraints, to release and reposition the device every two hours, and to assess at least quarterly for continued use of restraint.A further record review disclosed no documented evidence Resident 1?s self-release seat belt was released and she was repositioned every two hours as per plan of care, to ensure the resident would not attempt to stand up if she was sitting for a prolonged period of time. There was no evidence the resident demonstrated safe use of the self-release seat belt. There was no evidence the effectiveness of the self-release belt was re-evaluated a least quarterly as per plan of care.The plan of care developed for the resident?s high fall risk last revised on 11/26/15, had a goal was to minimize risk for fall and injury. The interventions included providing safe, secure environment, repositioning to good body alignment, providing cueing and supervision as needed, using a low bed, and using a self- release seat belt with alarm when in wheelchair.A review of the Fall Risk Assessment form dated 11/26/15 indicated Resident 1 had a history of falls within the past three months, was confused, and received medications that increased her fall risk. The total score was score of 15, which indicated high risk for fall.A review of the facility's Verification of Investigation report dated 1/25/16 indicated that on 1/25/16, at 4:20 p.m., while the resident was sitting in the hallway by the Nurses Station, Resident 1 fell from the wheelchair after she released her seat belt. The alarm sounded, staff responded, and Resident 1 was found lying on her left side next to the wheelchair complaining of pain to her left hip. The attending physician was notified and ordered x-rays to both hips. The x-ray report obtained on the same day could not rule out a fracture. On 1/26/16, resident was transferred to the emergency room of a GACH where she was diagnosed with a left hip fracture. According to the resident?s medication regimen since 11/2015 to 1/25/16, the resident was receiving five medications that according to the manufacturers may cause drowsiness or dizziness as side effect or adverse reaction.Since 6/23/15 the resident received Keppra (levetiracetam) 500 milligrams (mg) orally every 12 hours for seizures. Keppra may cause drowsiness or dizziness.Since 6/23/15, the resident received Lexapro (escitalopram) 5 mg by mouth daily for depression manifested by crying. Lexapro common side effects include dizziness or drowsiness.Since 6/23/15, the resident received amlodipine 10 mg by mouth daily for hypertension. Amlodipine side effects include dizziness.Since 6/23/15, the resident received Lisinopril 10 mg by mouth daily. Lisinopril common side effects include drowsiness, lightheadedness, and faintness. Since 11/20/15, the resident received Nuedexta (dextromethorphan and quinidine sulfate) 20 mg/10 mg by mouth every 12 hours for pseudobulbar affect (PBA- emotional incontinence refers to a neurological disorder characterized by involuntary crying or uncontrollable episodes of crying and/or laughing, or other emotional displays). Nuedexta adverse reactions include dizziness.According to the facility's policy titled, "Falls and Fall Risk, Managing" revised 12/2007, based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falls. In conjunction with the consultant pharmacist and nursing staff, the attending physician would identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period.Further record review disclosed no documented evidence the interdisciplinary team (pharmacist, nursing and physician) addressed the multiple medications that increased the resident?s risk for fall as indicated in the facility?s policy on Falls.On 2/5/16, at 10:10 a.m., during an interview, the Assistant Director of Nursing (ADON) stated that after reviewing Resident 1?s clinical record, he could not locate documented evidence Resident 1?s use of the self-release seat belt was re-evaluated for effectiveness and safety after it was ordered on 9/29/15.The ADON stated Resident 1 should have been re-assessed for the use of self-release seat belt at least quarterly.On 2/12/16, at 3:40 p.m., during an interview, the Director of nursing (DON) stated she was not able to provide documented evidence Resident 1?s self-release belt was released and the resident was repositioned every two hours. The DON also stated a care plan was not developed for the use of Nuedexta which added fall risk to the resident and was unable to explain the reason the facility?s policy on Managing Fall and Fall Risk was not implemented.The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure Resident 1, who was assessed as high risk for falls due to history of falls, mental confusion, physical limitations, unstable balance, medications, diagnoses, and in need of one-person physical assistance for transfer and walking, was provided with supervision, assistance, assistive device, and an environment free of accident hazards as possible to prevent fall and injuries by failing to:1. Re-evaluate Resident 1 for the safe use of a self-release belt to ensure effectiveness and safety of the resident. 2. Ensure Resident 1?s self-release belt was released and the resident was repositioned every two hours as indicated in the plan of care. 3. Evaluate Resident 1?s medication regimen to identify and adjust when possible, medications that may be associated with an increased fall risk as per facility?s policy. As a result, on 1/25/16, at 4:40 p.m., while left unattended sitting in a wheelchair in the hallway, Resident 1 released the self-release seat belt, attempted unassisted transfer and walking and fell on the floor sustaining a fractured left hip. Resident 1 required transfer to a general acute care hospital (GACH) where the day following the fall, 1/26/16, she underwent an open reduction and internal fixation (ORIF) surgery of the left hip under general anesthesia.The above violation presented either (1) imminent danger that death or serious harm to the resident of the Skilled Nursing Facility would result therefrom, or (2) substantial probability that death or serious physical harm to the resident of the Skilled Nursing Facility would result therefrom. |
| 920000031 |
La Crescenta Healthcare Center |
920012496 |
A |
1-Sep-16 |
2Y3I11 |
13553 |
483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 483.25 (c) Pressure Sores Based on the comprehensive assessment of a resident, the facility must ensure that? (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual?s clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. On 1/14/16, an unannounced visit was made to the facility to investigate a complaint related to Resident 1 developing wounds on her back and her family was not informed about the wounds or given an explanation how the wounds occurred. Based on interview and record review, the facility failed to ensure Resident 1, who was admitted to the facility with no pressure sores and was identified as low risk for developing pressure sores, was provided with the necessary treatment and services for pressure sore prevention, and to promote healing for pressure sores, and to prevent infection including: 1. Failure to conduct ongoing accurate assessments of the resident?s skin to promptly identify the development of pressure sores. 2. Failure to monitor the progress of the pressure sores and response to treatment in order to promote healing and prevent complications including infection. As a result, on 12/9/16 Resident 1 was transferred to a general acute care hospital (GACH) where she was found with multiple pressure sores of undetermined depth on the upper and lower back, the left shoulder, and both heels. Resident 1 was diagnosed with sepsis. Resident 1 was discharged home from the GACH on 12/11/15 under hospice care and expired on 1/2/16. According to the Death Certificate, Resident 1?s immediate cause of death was Alzheimer?s disease. A review of the admission record indicated Resident 1 was admitted to the facility, on 9/2/15, and re-admitted on 10/16/15, with diagnoses included anemia (a condition in which there are not enough healthy red blood cells to carry adequate oxygen to the body's tissues), dementia (loss of memory and other mental abilities severe enough to interfere with daily life) with behavioral disturbances, and age related osteoporosis (bone weakening). Resident 1 had no pressure sores upon admission. According to the initial Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 10/23/15, Resident 1 was alert, able to make some needs known, sometimes she understood staff and sometimes staff understood her. Resident 1 required extensive assistance with activities of daily living (ADLs) such as personal care, dressing, and transfers. A review of the Braden Scale For Predicting Pressure Sore Risk form, dated 9/2/15, 9/21/15, 9/28/15, and 10/19/15, indicated Resident 1 had some sensory impairment which limited her ability to feel pain or discomfort and her skin was occasionally moist requiring an extra linen change once a day. The pressure sore (bedsores, injuries to skin and underlying tissue resulting from prolonged pressure on the skin, most often develop on skin that covers bony areas of the body) risk form indicated Resident 1 had a total score of 18. A total score of 12 or less represented high risk. According to the forms Nursing Weekly Summary dated from 10/24/15 through 11/29/15, the licensed nurses indicated Resident 1 had no skin breakdown to the back area and her skin was intact with no treatment ordered. The Nursing Weekly Summary dated 11/30/15 and 12/7/15 indicated Resident 1 developed a blister on the right upper back. There was no description of the blister such as size, color, and presence of drainage and/or pain. A review of Resident 1's Situation Background Assessment Recommendation (SBAR) form dated 11/30/15 indicated there was a change of condition due to a right upper back, open blister. An order was obtained for antibiotic ointment daily for 21 days and to cover with dry dressing. The Physician?s Progress Record dated 12/1/15 and signed by Attending Physician 1 indicated the resident had no skin lesions. According to the SBAR form dated 12/7/15, Resident 1 had a change of condition due to an abscess (a collection of pus that has built up within the tissue of the body)/cellulitis on the right upper back. The Medicare Daily notes from 10/23/15 to 12/1/15, indicated Resident 1 had a pressure sore, open blister, to the right upper back. There was no documentation describing the pressure sore/open blister. The Medicare Daily notes from 12/2/15 to 12/7/15 indicated Resident 1 had a pressure sore/open blister to the right upper back. There was no documentation describing the pressure sore/open blister, the surrounding skin, or the response to the treatment. On 2/9/16, at 10 a.m., during an interview, Family Member 1 stated she visited Resident 1 every day and was not made aware the resident had many pressure sores. Family Member 1 stated that on 12/7/15, a nurse informed her Resident 1 had a small blister on the right upper back. Family Member 1 stated that on 12/9/15 she discovered the open sores, not blisters, when Resident 1 complained of pain to the back. Family Member 1 stated she asked the assigned certified nursing assistant (CNA 1) to remove Resident 1?s dressings to expose the back and observed multiple open wounds. Family Member 1 stated she then demanded the resident to be transferred to a GACH. On 2/9/16, at 3 p.m., during an interview, CNA 1 stated Resident 1's wounds were there since 11/30/15. CNA 1 stated the wounds were not new and that he did not report to Family Member 1 or to the treatment nurse because he thought they already knew the condition of the wound. A review of the Medicare Daily notes from 12/7/15 to 12/8/15, indicated Resident 1 did not have a pressure sore, but had cellulitis (potentially serious bacterial skin infection) to the right upper back. There was no further documentation describing the affected area including color, odor, drainage, size, presence of pain, etc. A review of the facility?s policy and procedure titled, "Skin Care Management," dated 9/2009, indicated the licensed nurses would document in the progress notes on the Weekly Pressure Ulcer Record the size, stage, location, drainage, odor, and presence of pain. The licensed nurses would document in the Daily Monitoring Pressure Ulcer Record on a daily basis the status of the surrounding skin and presence of possible complications. The director of nursing would maintain a log book and the Quality Assurance Team would develop a tracking/trending basis for required process improvement. On 2/9/16, at 3:10 p.m., during an interview, the director of staff development (DSD) stated he could not provide documentation of description of Resident 1?s sores as indicated in the policy. DSD stated a blister was considered a Stage II pressure sore (partial thickness loss of skin, presenting as a shallow open sore with a red/pink wound bed) and should have been identified and treated as a pressure sore. A review of the Discharge Orders/Resident Transfer form dated 12/9/15 indicated Resident 1 was transferred to a GACH at 9:45 p.m., with two wounds to the right upper back, one wound to the left lateral upper back, and two wounds in the middle upper back. A review of the Emergency Department (ED) Report on 12/9/15, at 10:52 p.m., indicated Resident 1 was transferred from the skilled nursing facility for evaluation of the pressure sores on her upper back. Resident 1's diagnoses included pressure sore, sepsis, and cellulitis. The GACH Initial Physician Pressure Ulcer Progress Notes (photographic record) dated 12/9/15, at 10:36 p.m., and 12/10/15, at 12:26 a.m., signed by two registered nurses (RNs) assessed the following: -Right upper back and left upper back pressure sore, stage UTD (undetermined ?the stage is not clear because the base of the sore is covered by a thick layer of tissue breakdown that may be yellow, gray, green, brown, or black) -Right upper back pressure sore (multiples) 7 centimeters (cm) in length by 3 cm in width, stage UTD; 4 cm in length by 1.9 cm in width (lower), stage UTD. -Left upper back (multiples) 3 cm in length by 2 cm in width, stage UTD; 1 cm in length by l cm in width, stage UTD. -Left shoulder pressure sore, stage UTD -Left heel stage UTD -Right heel 4 cm in length by 4 cm in width, stage UTD. A review of the facility's policy and procedure titled, "Pressure Ulcer -Definition and Stages," dated 2/2007, indicated Stage II was partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough and may also present as an intact or open/ruptured serum filled blister. During interview and record review with DSD on 2/9/16, at 2:20 p.m., he stated a blister was considered a Stage II pressure sore and he could not explain why the treatment nurse did not treat it like a pressure sore. DSD stated he did not have any documentation of the measurements or assessment of the blister to the right upper back. DSD stated he could not locate the information for Resident 1 in the Weekly Pressure Ulcer Log because the resident was not on the list to monitor since the nurses did not identify the blister as a pressure sore. A review of the care plan dated 11/30/15, indicated Resident 1 developed non-pressure/non-surgical wound to the right upper back (site #1) and was at risk for wound infection. The plan of care interventions included assessing the wound for decrease in size and improved wound appearance, staff to follow wound treatment protocol. However, there was no documentation regarding the size or appearance of the wound/blister to the resident?s back. A review of the care plan dated 12/6/15, indicated Resident 1 further developed an abscess to the non-pressure/non-surgical wound to the right upper back (site #1), mid upper back (site # 2), mid upper right back (site #3), and was at risk for wound infection. The plan of care included assessing the wound for decrease in size and improved wound appearance or signs of healing, and staff to follow wound treatment protocol. However, there was no documentation regarding the size or appearance of the wound/blisters to the back. On 2/9/16, at 3:55 p.m., during an interview, DSD stated the protocol for pressure sores was not implemented because the nurses did not identify Resident 1's wounds as pressure sores. On 2/10/16, at 1 p.m., during an interview, Treatment Nurse 1 stated that on 12/7/15 when she provided treatment to Resident 1's right upper back found multiple pressure ulcers on the back with black yellowish eschar (a dry, dark scab or falling away of dead skin), and slough (dead tissue that can be stringy or thick and adherent on the tissue bed). Treatment Nurse 1 stated she immediately notified management for the wound consultant and the director of nursing (DON) to assess the resident?s pressure sores. During an interview with Wound Consultant 1, on 2/17/16, at 2 p.m., he stated on 12/7/16, he came to the facility to assess Resident 1's pressure sores. He with the DON observed multiple pressure sores to the resident's upper and lower back. Wound Consultant 1 stated the areas had black eschar (thick leathery black or brown dead tissue) with some areas with yellowish slough (yellow dead tissue) in need of debridement (the removal of damaged/dead tissue from a wound). Wound Consultant 1 stated Resident 1 did not have blisters and he recommended the use of a debriding ointment (helps healing wound by removing the dead tissue). A review of the facility's policy and procedure titled, "Pressure Ulcer-Definition and Stages," dated 2/2007, indicated Unstageable as full thickness tissue loss with the base of the ulcer covered in slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until the slough and or eschar is removed to expose the base of the wound, the true depth and stage cannot be determined. The facility failed to ensure Resident 1, who was admitted to the facility with no pressure sores and was identified as low risk for developing pressure sores, was provided with the necessary treatment and services for pressure sore prevention, and to promote healing for pressure sores, and to prevent infection including: 1. Failure to conduct ongoing accurate assessments of the resident?s skin to promptly identify the development of pressure sores. 2. Failure to monitor the progress of the pressure sores and response to treatment in order to promote healing and prevent complications including infection. As a result, on 12/9/16 Resident 1 was transferred to a general acute care hospital (GACH) where she was found with multiple pressure sores of undetermined depth on the upper and lower back, the left shoulder, and both heels. Resident 1 was diagnosed with sepsis. Resident 1 was discharged home from the GACH on 12/11/15 under hospice care and expired on 1/2/16. The above violations presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1. |
| 920000051 |
LANCASTER HEALTH CARE CENTER |
920012545 |
A |
27-Jan-17 |
33XF11 |
13025 |
F327
42 CFR ?483.25(j) Hydration.
The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.
The facility failed to ensure Resident 1, who had a history of poor oral intake, and frequent urinary tract infections (UTI-an infection in any part of the urinary system) was provided and consumed adequate fluid intake to prevent dehydration, by failing to:
1. Provide her daily fluid needs of 1200 cubic centimeters (cc) as assessed by the registered dietician (RD) to maintain hydration and prevent dehydration.
2. Evaluate the intake and output (I&O) records as indicated in the resident?s plan of care to ensure the resident?s hydration needs were met as indicated in the nutritional assessment.
As a result, Resident 1 did not receive adequate fluids for a period of fourteen days, from February 21, 2015, to March 7, 2015, to maintain hydration. The resident had a change in condition, and was sent to the general acute care hospital (GACH) where she expired on XXXXXXX 2015.
On March 10, 2015, the Department of Public Health received a complaint (CA00434513) alleging Resident 1 became dehydrated due to lack of fluid intake. An unannounced investigation was initiated on March 24, 2015.
A review of Resident 1?s GACH history and physical examination record, dated December 14, 2014, indicated she had a history of poor oral intake and appetite. Resident 1?s admission record indicated she was a 77 year-old female, admitted from the GACH to the skilled nursing facility (SNF) on XXXXXXX 2015. She had diagnoses that included after care for a fractured hip and hip replacement following a personal fall, anemia (low red blood cell count), paralysis of vocal cords, and lung cancer. She had advanced directives indicating she was a Full Code (wanted all life-saving measures performed in an emergency) except for no life support.
The admission Minimum Data Set (MDS), a comprehensive assessment and care screening tool, dated March 3, 2015, indicated Resident 1's cognition was moderately impaired. Resident 1 required extensive assistance with two or more persons for transfers, and required one person physical assist with toileting and eating/drinking. The MDS indicated Resident 1 was frequently incontinent of urine. The MDS Care Assessment Area (CAA) was triggered as a concern for dehydration, requiring monitoring and the development of a care plan for dehydration.
A review of the Nutritional Assessment Record dated February 20, 2015, completed by the Registered Dietician (RD) indicated Resident 1's estimated daily fluid requirements, based on the resident's weight, was 1200 cc. The RD also documented that the resident made a statement of being thirsty and offered small sips of water.
The RD?s Nutritional Assessment Plan and interview with Resident 1 completed March 3, 2016, indicated the resident was able to make her needs known, even though short of breath. Resident 1 stated she is more thirsty than hungry and has been drinking Ensure at home. She stated she had been steadily losing weight over the past month due to cancer. The assessment indicated Resident 1 was at high risk for further weight loss and decline in nutritional status due to her diagnoses and poor fluid intake.
There was a plan of care for ?Eating/Nutrition? dated February 23, 2015, that indicated at risk for alteration in nutrition (dehydration) for less than body requirements related to inadequate fluid intake by mouth. The care plan interventions included RD evaluation of needs, food/fluid consumption measured/documented/monitored daily, diet as ordered per physician and RD recommendations, and to alert the licensed nursing staff if the resident consumed less than twenty-five percent of fluids daily. The diet was mechanical soft with nectar-thick liquids, high protein three times per day, and whole milk with all meals.
According to Resident 1?s fluid intake record from February 21, 2015, to March 7, 2015, for approximately 14 consecutive days, she did not receive the volume of daily fluids required of 1200 cc to maintain hydration, as recommended by the RD.
A review of the fluid intake record from February 21, 2015, to March 7, 2015, indicated Resident 1's fluid consumption was less than 1200 cc daily, as follows:
1. On February 21, 2015, Resident 1 received a total of 900 cc, which was 300 cc less than the daily fluid requirement of 1200 cc.
2. On February 22, 2015, Resident 1 received a total of 900 cc, which was 300 cc less than the daily fluid requirement of 1200 cc.
3. On February 23, 2015, Resident 1 received a total of 560 cc, which was 640 cc less than the daily fluid requirement of 1200 cc.
4. On February 24, 2015, Resident 1 received a total of 990 cc, which was 210 cc less than the daily fluid requirement of 1200 cc.
5. On February 26, 2015, Resident 1 received a total of 960 cc, which was 240 cc less than the daily fluid requirement of 1200 cc.
6. On February 27, 2015, Resident 1 received a total of 1026 cc, which was 170 cc less than the daily fluid requirement of 1200 cc.
7. On February 28, 2015, Resident 1 received a total of 360 cc for breakfast and no fluid during lunch and dinner. This was 840 cc less than the daily fluid requirement of 1200 cc.
8. On March 1, 2015, Resident 1 received a total of 960 cc, which was 240 cc less than the daily fluid requirement of 1200 cc.
9. On March 2, 2015, Resident 1 received a total of 570 cc, which was 630 cc less than the daily fluid requirement of 1200 cc.
10. On March 3, 2016 Resident 1 received a total of 720 cc total for breakfast and lunch, however, for dinner the resident received no fluids. The resident received 480 cc less than the daily fluid requirement of 1200 cc.
11. On March 4, 2015, Resident 1 received a total of 940 cc, which was 260 cc less than the daily fluid requirement of 1200 cc.
12. On March 5, 2015, Resident 1 received a total of 900 cc, which was 300 cc less than the daily fluid requirement of 1200 cc.
13. On March 6, 2015, Resident 1 received a total of 420 cc total of fluid for breakfast and dinner but no fluid for lunch. The resident received 780 cc less than the daily fluid requirement of 1200 cc.
14. On March 7, 2015, Resident 1 received a total of only 360 cc of fluid. The resident received 840 cc less than the daily fluid requirement of 1200 cc.
Based on the above fluid intake records, from February 21, 2015, to March 7, 2015, Resident 1 had a total fluid intake deficit of 6234 cc. There was no documented evidence that indicated the physician was notified when the resident's fluid intake was less than the daily fluid requirement until March 7, 2015, as required in the policy and procedure titled Hydration/Fluid Management.
On March 5, 2015, the physician ordered (telephone orders) speech therapy treatment for difficulty swallowing and antibiotic treatment for 10 days due to pneumonia. On March 6, 2015, the diet was changed to mechanical soft with nectar thick liquids, no added salt, high protein drink three times per day between meals, extra protein powder to all meals, and whole milk with all meals.
A review of the nurse's notes on the Situation Background Assessment and Recommendation (SBAR) dated March 7, 2015, (no time) indicated the physician was notified of Resident 1?s refusal to eat or drink. The physician ordered intravenous (IV) fluid replacement therapy with normal saline at 80 cc per hour for 72 hours for dehydration. The IV therapy medication record indicated the IV was started at 8 p.m.
A review of the Interdisciplinary Team (IDT) Progress Notes dated March 9, 2015, at 5 p.m. for a ?late entry? for March 9, 2015, at 2 p.m., indicated the family was concerned and notified the registered nurse (RN), who was writing the note, that Resident 1 didn?t eat or drink anything today, and had decreased appetite during the weekend (March 7 and 8, 2015). The IDT notes indicated Resident 1 was started on antibiotic treatment on March 5, 2015, for pneumonia. The IDT notes indicated the RN assessed Resident 1, on March 9, 2015, at 5 p.m., in bed, sleepy, and able to answer yes to her having difficulty breathing. The medication nurse was instructed to check Resident 1?s oxygen (O2) saturation level, take vital signs and call the physician. The O2 level had dropped to 62 percent while receiving 2 liters of oxygen per minute via nasal cannula (tubes in the nose). The resident received a breathing treatment, the O2 level increased to 70 percent, but the physician had not responded, therefore 911 paramedics were called.
A review of the physician's order dated March 9, 2015, indicated instructions to transfer Resident 1 to the GACH due to low oxygen saturation.
A review of the GACH emergency (ER) report dated March 9, 2015, indicated that Resident 1 was diagnosed with severe dehydration, hypernatremia (excessive sodium in blood), hypokalemia (low potassium level in the blood). Resident 1 was treated with one liter of normal saline via IV bolus (administered fast). Resident 1 expired XXXXXXX 2015, while being hospitalized at the GACH.
The GACH ER laboratory test results dated March 9, 2015, indicated Resident 1 had indicators for dehydration as follows:
1. An elevated sodium of 162 milliequivalent /liter [reference range 135- 146 mEq/L].
2. An elevated blood uremia nitrogen (BUN) of 33 milligram (mg)/per deciliter [mg/dl, reference range less than 17 mEq/dl].
3. A Creatinine (Cr) of 0.6 mg/per deciliter [mg/dl, range less than 1.0 mg/dl]. The resident's BUN/Cr ratio was 55.
A BUN/Cr Ratio ranging from 20:1 to 24:1 is an indicator for impending dehydration. A BUN/Cr Ratio of 25:1 or more is an indicator for dehydration.
On May 8, 2015, at approximately 11:30 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) was asked the effect of Resident 1 not consuming the daily volume of fluids necessary to maintain hydration, 1200 cc, as the RD assessed. LVN 1 stated dehydration could not have occurred if the nursing staff had followed the daily fluid intake recommended by the RD.
On May 8, 2015, at about 12 noon, during an interview the Director of Nursing stated Resident 1?s dehydration occurred because of poor fluid intake.
The facility's policy and procedure titled "Hydration/Fluid Management," revision January 5, 2011, indicated the purpose for hydration management is the promotion of adequate fluid balance that prevents complications resulting from abnormal or undesired fluid levels. Under Section 3.0, Fundamental Information, "Residents will be monitored for physical signs of dehydration, (i.e. sunken eyeballs, concentrated urine, poor skin turgor, etc)..." and "Residents will be provided with fluids daily... to meet fluid needs, unless a fluid restriction is ordered by the physician." Then under Section 4.0, Procedures, "Each resident's hydration needs will be determined by the nutritional professional upon admission."..."The care plan interventions related to proper hydration are developed according to the resident's needs." "The physician is to be notified when there is a significant change in the resident's fluid intake or output."
The facility's December 2012 policy and procedure titled "Resident Condition Changes That Required Physician Notification Guidelines" indicated for routine notification, to notify the physician when the resident's diet changes unless interventions are needed immediately. When urgent response is required, indicating, "A situation/condition that would require physician notification and a physician response within 2 to 4 hours. Such conditions include...a change in resident behavior." The section for "Expectations" indicated, "Licensed nurses (staff and management) are expected to recognize resident situations/conditions that require physician notification. The nurse shall complete an assessment of the condition, including level of urgency."
The facility failed to ensure Resident 1, who had a history of poor oral intake, and frequent urinary tract infections (UTI-an infection in any part of the urinary system) was provided and consumed adequate fluid intake to prevent dehydration, by failing to:
1. Provide her daily fluid needs of 1200 cubic centimeters (cc) as assessed by the registered dietician (RD) to maintain hydration and prevent dehydration.
2. Evaluate the intake and output (I&O) records as indicated in the resident?s plan of care to ensure the resident?s hydration needs were met as indicated in the nutritional assessment.
As a result, Resident 1 did not receive adequate fluids for a period of fourteen days, from February 21, 2015, to March 7, 2015, to maintain hydration. The resident had a change in condition, and was sent to the GACH where she expired on XXXXXXX, 2015.
The above violations presented a substantial probability of death or serious physical harm to Resident 1. |
| 920000031 |
La Crescenta Healthcare Center |
920012843 |
A |
4-Jan-17 |
WCF911 |
10470 |
CFR 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. CFR 483. 25 ( e) (2) Based on the comprehensive assessment of a resident, the facility must ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. 483.25 (h) Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 8/4/16, at 8 a.m., an unannounced visit was made to the facility to investigate an entity reported incident related to Resident 1?s injury of unknown origin. Based on interview and record review, the facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, by failing to ensure residents with limited range of motion (ROM - the extent of movement of a joint), receives appropriate treatment and services to prevent further decrease in the ROM, and by failing to ensure each resident receives adequate supervision and assistance devices to prevent accidents, including: 1. Failure to ensure a therapist (occupational, physical, or speech) performed an initial and quarterly rehabilitation therapy screening to Resident 1 who was admitted with limitation of the ROM, as indicated in the facility?s policy and per plan of care. 2. Failure to conduct a contracture screen form on admission and quarterly to determine the degree of contractures and if ROM exercises were or not indicated, as indicated in the facility?s policy and to prevent injuries to Resident 1. 3. Failure to provide supervision of certified nursing assistants (CNAs) while providing care to the resident to ensure the ROM exercises given during care were safe to prevent injuries to Resident 1. As a result, Resident 1 experienced severe pain and on 7/24/16 was diagnosed with an acute fracture (broken bone) of the right supracondylar humerus (elbow - fracture that occurs when an elbow has bent backwards beyond its normal ROM). A review of the clinical record indicated Resident 1 was admitted to the facility on XXXXXXX with diagnoses including cerebral infarction (blockage in the blood vessels supplying blood to the brain), dysphagia (difficulty swallowing), hypertension (high blood pressure), and cerebro-vascular accident (CVA - stroke) with contractures (deformity and stiffness of the joints) to all four extremities. The Resident Data Collection form dated 4/13/16 indicated Resident 1 was admitted to Hospice Care (end of life care), had a gastrostomy tube (GT ? a tube surgically inserted to the stomach through the abdominal wall to provide nutrition and hydration), and had contractures to both hands and both lower extremities. A care plan developed on admission addressing the resident?s self-care deficit, indicated Resident 1 required total assistance due to impaired cognition and physical limitations/disability. The interventions included incorporating ROM exercises during care unless contraindicated, conducting joint mobility assessment quarterly or as needed, observing changes in ROM, and referring to therapy services if needed. According to another plan of care developed on admission addressing the resident?s alteration in comfort, Resident 1 had pain caused by contractures. The care plan goals indicated to alleviate pain with interventions, improve quality of life with interventions, and maintain and enhance the resident's functional ability with interventions. The interventions included assessing pain level, administering pain medication, and encouraging and promoting activity participation. The Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 4/25/16 indicated Resident 1 was unable to communicate needs, was totally dependent with one-person assist for all ADLs, and had impairment to all extremities. The Care Area Assessment Summary form indicated the care area for ADL function/Rehabilitation potential was not triggered and the care planning decision was left blank. A review of a blank Contracture Screen form in Resident 1?s clinical record, indicated a section to screen a resident's elbow, extension to flexion from 0 to 145 degrees (extension describes the action of straightening the elbow, flexion describes the action of bending the elbow), or if the resident had normal ROM . A review of the Situation, Background, Assessment, and Recommendation form (SBAR) dated 7/20/16, indicated Resident 1 had slight edema (swelling) on the right upper arm. The nursing interventions included monitoring and resting the extremity on a pillow. The SBAR form dated 7/24/16 indicated Resident 1 had edema to the right elbow with warmth and tenderness and had facial grimacing. Pain medication was given to the resident. On 7/24/16, Physician 1 ordered x-rays to the right elbow. The result, obtained on the same day, indicated an acute supracondylar humerus fracture (an elbow fracture). A physician?s order dated 7/25/16, indicated Resident 1 was to receive Norco (a narcotic used to treat pain), and immobilization of the right elbow. A review of the pain management flowsheet, dated 7/25/16 to 7/27/16, indicated Resident 1 received Norco six times for moderate to severe pain, score of 6 to 8 out of 10 (pain rating scale from zero to 10, zero indicating no pain and 10 indicating the worst possible pain). According to the orthopedist (a physician specialized in treating problems of the musculoskeletal system) progress note dated 7/27/16 on-operative treatment and the application of an arm splint (to immobilize the affected area) was recommended for Resident 1. A review of the facility's policy and procedure, dated 2/2013 titled, "Rehabilitation Therapy Screens," indicated a physician's order was not required for a therapy screen to establish a skilled need for therapy services. At least one discipline of Physical, Occupational, or Speech Therapy would screen a resident for therapy services upon admission and quarterly thereafter. If an initial evaluation was performed upon admission, an admission screen was not necessary. The facility's policy and procedure dated 2/2013 titled, "Therapy Contracture Assessment Procedure," indicated the rehabilitation staff ensured the appropriate assessment for rehabilitation services intervention through an initial and ongoing assessment. A routine admission, quarterly, or change of condition therapy screen may indicate a joint contracture was present. If a therapy screen identified joint function was limited by contracture, a contracture screen was used to identify the specific deficits in ROM. The contracture screen was performed at least quarterly with ROM measurements taken. The therapist would assess whether to continue existing intervention or update the plan of care. On 8/4/16, at 9 a.m. during an interview, the Director of Nursing (DON) stated on 7/20/16 he assessed Resident 1?s edema to the right elbow and stretched out the right arm gently and there was no facial grimacing. The DON stated the right elbow was placed on a pillow and the edema subsided on 7/23/16. On 8/14/16, at 9:10 a.m., during another interview with the DON and further record review, the DON stated he was unsure who was responsible for completing the joint mobility assessment. The DON was unable to find evidence Resident 1?s joint mobility and contractures status were assessed since admission. The DON could not explain the lack of implementation of the facility?s policy and the plan of care and stated without joint and contracture assessment, the nursing staff was unable to determine whether or not incorporating ROM exercises during care was indicated. During an interview with the Director of Rehabilitation Services, on 8/14/16, at 10:30 a.m., she stated Resident 1 was contracted to both upper extremities and there was no physician?s order for an evaluation (contrary to the policy). The Director of Rehabilitation Services stated even though Resident 1 was on Hospice care, the Contracture Screening form should have been completed to indicate the degree of elbow extension to flexion and to determine Resident 1?s limits to prevent injury. Furthermore, the Director of Rehabilitation Services stated anyone who performed ROM needed to be trained. If an extremity was extended too far, the pull of the tendon and bone can cause a fracture. The facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, by failing to ensure residents with limited ROM, receives appropriate treatment and services to prevent further decrease in the ROM, and by failing to ensure each resident receives adequate supervision and assistance devices to prevent accidents, including: 1. Failure to ensure a therapist (occupational, physical, or speech) performed an initial and quarterly rehabilitation therapy screening to Resident 1 who was admitted with limitation of the ROM, as indicated in the facility?s policy and per plan of care. 2. Failure to conduct a contracture screen form on admission and quarterly to determine the degree of contractures and if ROM exercises were or not indicated, as indicated in the facility?s policy and to prevent injuries to Resident 1. 3. Failure to provide supervision of certified nursing assistants (CNAs) while providing care to the resident to ensure the ROM exercises given during care were safe to prevent injuries to Resident 1. As a result, Resident 1 experienced severe pain and on 7/24/16 was diagnosed with an acute fracture (broken bone) of the right supracondylar humerus (elbow - fracture that occurs when an elbow has bent backwards beyond its normal ROM). The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and was a direct proximate cause of death of Resident 1. |
| 930001558 |
LOS ANGELES COMMUNITY HOSPITAL D/P SNF |
930011647 |
B |
05-Aug-15 |
1WXY11 |
12346 |
CFR 483.13 (a) Restraints The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. The facility failed to ensure Resident 6 had the right to be free from any physical restraints when Resident 6 was observed with bilateral soft wrist restraints, and the resident's clinical record did not indicate an assessment and care planning for restraint use, least restrictive measures prior to use of restraint, and a physician order for the use of restraints as indicated by the facility's policy and procedure.The above violation resulted in: (a) Resident 6 having swollen hands when the soft wrists restraints were not released for 3 to 4 hours; (b) Resident 6 was at risk for psychological harm, loss of dignity, physical harm such as increased risk serious injury like fracture. Findings: During the recertification survey on April 24, 2015, at 9:10 a.m., Resident 6 was observed lying in bed, and soft restraints were applied to both wrists. Resident 6's hands were observed swollen. Resident 6 was also observed with a tracheostomy (opening surgically created through the neck into the trachea), an indwelling catheter (a tube which is inserted into the bladder to drain urine from the bladder into a bag), and was receiving total parental nutrition (TPN- is a form of feeding in which all nutritional needs are met with a solution which is infused into the veins) at 65 cubic centiliters (cc) per hour. During an interview on April 24, 2015, at 9:10 p.m., Registered Nurse (RN) 1 stated Resident 6's family member was requesting to apply restraints on Resident 6's wrists due to Resident 6's attempt to pull out tubes.On April 24, 2015, at 9:15 a.m., during an observation, Resident 6's family member (Family Member 2) was present in the resident's room and was seated on a cot besides Resident 6. During a concurrent interview, Family Member 2 (FM 2) stated she had a concern that there was no physician order for restraints. FM 2 stated Resident 6 was restrained on some days and not restrained on other days. FM 2 stated she wrote a letter and gave it to the charge nurse earlier today about her concern with the use of restraints.A review of the Face Sheet indicated Resident 6 was re-admitted from the acute care unit of the hospital to the sub-acute unit of the hospital on April 18, 2015, with diagnoses that included respiratory failure (a condition in which not enough oxygen passes from your lungs into your blood). The facility document indicated Resident 6's original admission to the sub-acute unit was January 22, 2015.The full Minimum Data Set (MDS- an assessment and care plan tool) dated February 24, 2015, Section P - Restraints, indicated limb restraint used daily. The full MDS dated February 24, 2015, indicated Resident 6 was severely impaired for daily decision making. She was totally dependent on the staff for activities of daily living in bed mobility, walking, dressing, eating, toileting, and bathing. Resident 6 had functional limitation/impairment in range of motion to her bilateral upper and lower extremities.A review of the Assessment and Care notes dated April 18, 2015, at 4:48 p.m., indicated Resident 6 was alert and oriented to time, place and person. The Activity Progress Notes dated April 20, 2015, indicated Resident 6 was able to verbalize her needs.The Assessment and Care notes dated April 23, 2015, at 9:40 p.m., entered by Licensed Vocational Nurse (LVN) 1, indicated Resident 6 was turned and repositioned every two hours for comfort to prevent skin breakdown. LVN 1 documented Resident 6's Neuro Assessment was "WDL" (within defined limits). There was no documented evidence the bilateral soft wrists restraints were applied on the resident's wrists and no documentation of the swelling on Resident 6's hands. There was no other documentation by the licensed nurses until April 24, 2015 at 8:30 a.m.A review of the Assessment and Care notes dated April 24, 2015, at 8:30 a.m., indicated while RN 1 was making rounds, she found Resident 6 with bilateral soft wrist restraints which were applied by Resident 6's family member (Family Member 2). The family member gave RN 1 a letter and ordered RN 1 to call the physician to get an order for restraints. RN 1 asked Resident 6 if she wanted to be restrained and Resident 6 stated she "does not want wrists" restraints. The other family members also do not want Resident 6 to be placed in bilateral soft wrist restraints. The physician was notified. There was no documented evidence RN 1 had removed the bilateral soft wrist restraints upon discovery at 8:30 a.m. and an assessment for Resident 6's swollen hands.During an interview on April 24, 2015, at 11:45 a.m., Resident 6's family member (Family Member 1) stated Resident 6 was alert. Resident 6's family member told Resident 6 the surveyor wanted to know if she wanted to be restrained. Resident 6 opened her mouth and mouthed in Spanish, "No, loca hija" (the English translation means crazy daughter referring to Family Member 2). When asked again if she wanted the wrist restraints, Resident 6 shook her head side to side and said, "No." Resident 6's family member stated the resident's hands became swollen when the restraints were not released for 3 to 4 hours. The surveyor observed Resident 6's hands were still swollen.During a review of Resident 6's electronic record for the re-admission date of April 18, 2015, and an interview with RN 1 on April 25, 2015, at 3:15 p.m., RN 1 stated Resident 6's family member, who visited the resident in the evening and slept in the resident's room, requested the restraints. RN 1 stated she informed Resident 6's physician about the family member's request. RN 1 further stated there was no documentation in the resident's record prior to April 24, 2015, that Resident 6's family member had requested the restraints and the physician was informed. There was no documentation the resident was assessed for pulling out her tubes. There was no documented evidence of an assessment and care planning for restraint use, least restrictive measures prior to use of restraint, and a physician order for the use of restraints. When asked who provided the restraints to Resident 6's family member, RN 1 was unable to answer.During an interview, on April 25, 2015, at 4 p.m., Employee 1 was asked what were the expectations when conducting rounds with the residents. Employee 1 stated the licensed nurses were expected to go into the room to conduct a head to toe assessment. The licensed nurses were to observe for residents' intravenous medications and tube feeding. When asked about the restraints, Employee 1 stated observe the resident for use of restraint and document their findings. On April 25, 2015, at 5:45 p.m., during an observation, Resident 6's family members were visiting Resident 6. During a concurrent interview, when asked about the restraints, Resident 6's family member (Family Member 3) opened the top drawer of Resident 6's night stand and pulled out soft wrist restraints. When asked who provided the bilateral restraints, Family Member 3 stated Resident 6 used soft restraints to prevent pulling out tubes when she was in the intensive care unit of the hospital and also when the resident was initially admitted to the sub acute unit. Family Member 3 further stated that Resident 6's hands became swollen when the soft wrist restraints were applied and not released for 3 to 4 hours. She further stated the restraints were applied by Family Member 2 when no one was in the room to watch the resident. Family Member 3 stated Family Member 2 visited the resident in the evening, stayed during the night in the resident's room, and applied the soft restraints on Resident 6's wrists at night. Family Member 3 stated Family Member 2 removed the soft restraints before the other family member arrived.During an interview on April 26, 2015, at 7:30 a.m., RN 1 stated she removed the bilateral soft restraints from the resident's room.On April 26, 2015, at 8:30 a.m., RN 1, Licensed Vocational Nurse (LVN) 2, verified a pair of bilateral soft wrist restraints were in Resident 6's top night stand drawer. RN 1 stated she did not know where the soft restraints came from as she removed the restraints on April 24, 2015.During a telephone interview on April 28, 2015, at 9:50 a.m., Resident 6's family member (Family Member 1) stated the restraints were only applied by the other family member (Family Member 2) who stayed in the resident's room overnight. Family Member 1 stated Family Member 2 arrived in the evening, between 9 p.m. to 10 p.m. Family Member 1 stated prior to re-admission on April 18, 2015, Resident 6 was in Room 117 (sub acute unit) and had the soft wrist restraints. Family Member 1 stated Resident 6's hands were swollen.During a telephone interview, on April 28, 2015, at 12:07 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 6's family member, who comes into the facility in the evening, sleeps besides Resident 6 and applies the soft restraints on Resident 6's wrists. CNA 1 stated, "Yes, I had seen Resident 6's family member applied the restraints." CNA 1 stated she reported the restraints to her charge nurse. CNA 1 stated she quickly provided care to Resident 6 before 9:30 p.m. because the family member (Family Member 2) arrived to the facility, placed the restraints on Resident 6, closed the door, and she did not want to be disturbed. CNA 1 stated she returned to the resident's room, between 10:30 p.m. -11 p.m., with the licensed vocational nurse to make rounds and observed soft restraints were applied on Resident 6's wrists. During a telephone interview, on April 29, 2015, at 9:30 a.m., RN 3 stated Resident 6's family member stays overnight and applies wrist restraints to the resident. RN 3 stated that the CNA had informed her that Resident 6's family member had applied restraints to the resident. When asked had she assessed Resident 6 for attempting to pull out the tubes, RN 3 stated she was busy and informed the LVN to remove all restraints. RN 3 further stated Resident 6's family member requested the restraints, and she forwarded the information to the day shift staff. When asked what shift does RN 3 work, RN 3 stated, "7 p.m. to 7:30 a.m. shift."A review of the facility's policy and procedures titled, "Non Behavioral Restraints Use," dated January 2013, indicated the facility's leadership staff recognizes restraints have the potential to produce serious consequences such as physical or psychological harm, loss of dignity, violation of patients' rights and death. Non behavioral restraints shall be used only when alternative less restrictive measures were not sufficient to protect resident or others from injury. The policy was to ensure the proper and safe use of restraints when clinically warranted. The objective included to assure regulatory guidelines were followed and maintained for resident safety. The procedures included less restrictive measures used, nursing assessment, a physician order for restraints, restraint application and removal every two hours, and resident/family notification for use of restraints (informed consent). Physical Restraint is defined as a manual method or mechanical device attached to or adjacent to the resident's body that the resident cannot easily remove that restricts freedom of movement or normal access to one's body. According to "Use of physical restraint in nursing homes: clinical-ethical considerations," (www.ncbi.nih.gov), the physical risks associated with the application of physical restraint to older people included physical consequences such as increased risk for mortality caused by strangulation or as a consequence of serious injuries like fracture or head trauma. Therefore, the facility failed to ensure Resident 6 had the right to be free from physical restraint which resulted in Resident 6's swollen hands when the soft wrists restraints were not released for 3 to 4 hours. Resident 6 was at risk for psychological harm, loss of dignity, physical harm such as increased risk injury like fracture. The above violation has a direct or immediate relationship to the patient health, safety or security. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940009325 |
B |
22-May-12 |
9Y2Y11 |
8615 |
F-323 483.25 (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 4/3/12, at 12:45 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1's safety. On 3/14/12, Resident 1 sustained scratches and bruises from an unsupervised altercation with Resident 2 in the activity room.Based on observation, interview and record review, the facility failed to ensure Resident 1 received adequate supervision to prevent injuries by failing to: 1. Supervise residents with physically abusive behaviors and confusion present in the activity room at all times. 2. Develop policies and procedures to ensure the activity room was not left unattended while residents were present. 3. Develop interventions to ensure Resident 2, who was assessed as having behaviors of striking out and pushing others, would not attack other residents.Residents 1 and 2 were left unsupervised in the activity room resulting in an altercation between the two residents that caused Resident 1 multiple scratches and bruises to the face, right ear and chest. The facility is a 290-bed locked psychiatric facility. On the day of the visit, 4/3/12, the total resident census was 286.On 4/3/12, at 2:15 p.m., Resident 2 was observed sitting in a wheelchair self-propelling around the patio. The resident stated he did not remember any altercation or hitting anybody. On 4/3/12, at 3:15 p.m., Resident 1 was observed in the hallway by his room sitting in a wheelchair with no injuries. The resident was hard of hearing and did not respond to questions. On 4/3/12, a review of the clinical record revealed Resident 1 was admitted to the facility on 8/9/10, and re-admitted on 1/1/12, with diagnoses that included Alzheimer's disease (one form of dementia that gradually gets worse over time), congestive heart failure and diabetes mellitus.The quarterly Minimum Data Set (MDS - standardized assessment and care planning tool) dated 2/17/12, indicated Resident 1 had memory problems, was able to communicate, required extensive assistance with transfer, walking and locomotion and used a walker and a wheelchair as mobility devices. Resident 2?s clinical record review revealed an admission to the facility dated 5/16/03, with diagnoses that included schizophrenia (a complex mental disorder that makes it difficult to tell the difference between real and unreal experiences), psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and bipolar affective disorder (a condition in which people go back and forth between periods of a very good or irritable mood and depression).According to the quarterly MDS assessment dated 11/24/11, Resident 2 was able to communicate, had physical behavioral symptoms directed toward others, required limited assistance with walking, locomotion and dressing and used a walker and a wheelchair as mobility devices.A plan of care developed on 3/24/11, for Resident 2's problem of verbally abusive behavior and physically abusive behavior, manifested by striking out and pushing others, did not include in the approaches/interventions to avoid leaving the resident unattended and unsupervised when in close presence of other residents to prevent altercations. Another plan of care developed on 5/24/11, for the Resident 2's problem of yelling and screaming did not include in the approaches/interventions supervision of the resident when other residents were in the vicinity to prevent altercations. A review of the facility's Resident Incident Investigation Report dated 3/14/12, at 10 a.m., revealed a certified nursing assistant (CNA 2) entered the activity room after hearing a commotion and witnessed Resident 2 hitting Resident 1 in the face. Resident 1, when interviewed, stated Resident 2 hit him. The investigation report lacked information related to the development of preventive measures and specific corrective actions. The report was limited to indicate corrective actions taken were to provide frequent checks and safe environment.According to the licensed nursing notes in Resident 1's clinical record dated 3/14/12, timed at 10 a.m., the body assessment revealed scratch marks on the right side of the resident's face. The physician, when notified, ordered at 10:15 a.m., to cleanse with normal saline solution the multiple scratches on the right side of the face, pat dry, apply triple antibiotic ointment and cover with a dry dressing twice a day for 10 days. According to the facility's policy and procedure titled, "Resident-to-Resident Abuse", undated, the facility will evaluate the circumstances/events leading up to the incident, document the findings and any corrective measures taken in the resident's medical/clinical record and develop a care plan that includes interventions to prevent the recurrence of such incident. However, further record review revealed Residents 1 and 2's clinical record did not have documented corrective actions/measures taken to prevent further incidents and the plan of care lacked new interventions to prevent recurrence of such incident.On 4/3/12, from 2:30 p.m. to 2:37 p.m., interviews with CNA 1, Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 1 (LVN 1) revealed a staff member has to be in the activity room while there are residents to supervise them. On 4/3/12, at 3:25 p.m., a telephone interview was conducted with Activity Assistant 2, who was assigned to activities on the morning of the incident on 3/14/12. Activity Assistant 2 explained on the morning of the incident, he left the activity room to walk a group of resident. Activity Assistant 2 further stated he informed the charge nurse (LVN 3) who was supposed to send someone to the activity room to supervise the residents left in there. On 4/3/12, at 2:40 p.m., during an observation, Activity Assistant 1 left the activity room unsupervised and went to the nursing station then proceeded to leave the unit. On 4/3/12, at 2:45 p.m., when brought to the attention of LVN 1, it was observed that eight residents were left unsupervised in the activity room. LVN 1 immediately called a CNA to stay in the activity room to supervise the residents. On 4/4/12, at 10:40 a.m., during an interview, LVN 2 stated Resident 1 had scratches on the face and a small bruise on the lip after the altercation. On 4/4/12, at 10:45 a.m., during an interview, LVN 3 confirmed before the altercation between Residents 1and 2, Activity Assistant 2 went to the nursing station to inform him he would be leaving the activity room. LVN 3 stated while he was walking towards the activity room, he heard CNA 2 yelling, calling him to go inside the activity room. LVN 3 stated Residents 1 and 2 were both sitting in their wheelchairs and the incident had already occurred.On 4/5/12, at 1:30 p.m., during a telephone interview, Family Member 1 stated Resident 1 had bruises behind the right ear and on the chest as a result of the altercation. On 4/5/12, at 1:42 p.m., during a telephone interview, CNA 2 stated he was near the activity room when he heard a resident yell. When he entered the activity room, CNA 2 stated he saw Resident 2 hitting Resident 1 in the face. CNA 2 stated there were about five more residents inside the activity room and there was no staff member present. The facility did not have policy and procedures on supervision of residents while in the activity room and had no written system in place to ensure coverage of the activity room when the activity staff member had to leave the activity room to ensure residents were not left unattended. The facility failed to ensure Resident 1 received adequate supervision to prevent injuries by failing to: 1. Supervise residents with physically abusive behaviors and confusion present in the activity room at all times. 2. Develop policies and procedures to ensure the activity room was not left unattended while residents were present. 3. Develop interventions to ensure Resident 2, who assessed as having behaviors of striking out and pushing others, would not attack other residents.Residents 1 and 2 were left unsupervised in the activity room resulting in an altercation between the two residents that caused Resident 1 multiple scratches and bruises to the face, right ear and chest. The above violation had a direct or immediate relationship to the health, safety or security of Resident 1. |
| 940000050 |
Lighthouse Healthcare Center |
940009446 |
B |
20-Aug-12 |
H52E11 |
9195 |
Title 22 ?72523. Patient Care Policies and Procedures. (a) Written patient are policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.?72527. Patients? Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. On 4/15/11, at 5:20 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1?s discharge without all his needed medications. Based on interview and record review, the facility failed to implement written patient care policies and procedures and failed to ensure Patient 1 had the right for an orderly transfer by failing to: 1. Provide the patient with the needed supply of prescribed medications and medical prescription in order to obtain the medications. 2. Instruct the patient on how and where to obtain his prescribed medications. 3. Arrange for community resources to assist the patient with his medical needs.Patient 1 was discharged on 2/3/11, to a shelter hotel without all his prescribed medications, the medications provided were in limited amount, there were no instructions, arrangements or prescription provided to obtain the medications and no referral to a physician for continuity of care. This resulted in the patient missing his daily dosage of the prescribed medications. On 4/20/11, a review of the closed clinical record revealed Patient 1 was a 50-year old male admitted to the facility on 11/11/10, and readmitted on 11/21/10, with diagnoses including chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure) and HIV/AIDS (human immunodeficiency virus that causes acquired immunodeficiency syndrome a chronic, potentially life-threatening condition).The Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 12/16/10, indicated the patient had no memory problems but required supervision with all activities of daily living (ADLs).The physician?s ordered routine oral medications for the month of 2/2011 were as follows: 1. Enteric coated Aspirin 81 milligrams (mg) daily for cerebro-vascular accident (CVA) prophylaxis. 2. Norvasc 10 mg daily for hypertension. 3. Clonidine 0.3 mg every night for hypertension. 4. Neurontin 300 mg every night for Neuropathy. 5. Pulmicort 90 micrograms (mcg) inhalation, one puff twice a day for COPD. 6. Colace 100 mg twice daily for constipation. 7. Reyataz 300 mg daily for HIV. 8. Norvir 100 mg daily for HIV. 9. Truvada one tablet daily for HIV. 10. Bactrim DS one tablet daily for pneumocystis pneumonia (PCP) prophylaxis (prevention). 11. Diflucan 100 mg daily for oral candidiasis (fungal infection). 12. Azitrhromycin 600 mg two tablets every week on Sundays for mycobacterium avium complex (MAC) infection prophylaxis. 13. Isentress 400 mg one tablet twice a day for AIDS. 14. Ziagen 300 mg one tablet twice a day for AIDS. 15. Valcyte 450 mg one tablet daily for AIDS. 16. Nilstat Oral solution (anti-fungal) 15 cubic centimeters (cc) swish and swallow three times a day for prophylaxis. 17. Naphazoline 0.1percent (%) ophthalmic solution (for eye redness) one drop in each eye twice a day. 18. Claritin one tablet daily for allergies. 19. Spiriva one puff daily for COPD. The patient also had an order for the month of 2/2011 for Dilaudil (narcotic medications) for pain management to be given on as needed basis.According to the nursing notes dated 2/1/11, timed at 8:30 p.m., the patient came back from being out on a pass since 9:30 a.m., collected some of his belongings and left again. A nursing note dated 2/2/11, timed at 2:30 p.m., indicated the attending physician gave a telephone order to discharge the patient to a place of his choice.Another nursing note dated 2/3/11, timed at 10:45 a.m., documented the patient returned to the facility. A nursing noted the same day at 12 p.m., indicated the patient was discharged from the facility to a hotel with transportation from the facility. According to the undated Physician?s Discharge Summary form, the discharge was necessary due to the patient?s health had improved and no longer needed the services provided by the facility. A review of the Post Discharge Plan of Care form dated 2/3/11, documented the medications taken home and the amount sent home. There were a total of eight listed medications given:1. Reyataz 150 mg tablet, 24 tablets given. 2. Ziagen 300 mg, 32 tablets given. 3. Norvasc 10 mg, 13 tablets given. 4. Valcyte 450 mg, one tablet given. 5. Bactrim DS 800/160mg, two tablets given. 6. Azitrhromycin 600 mg, two tablets given. 7. Clonidine 0.3 mg, eight tables given. 8. Truvada 20 tablets given. There was no documentation addressing the rest of medications (11) ordered to be taken routinely. There was no documentation to explain the reason the amount of medications sent home with the patient was in short supply. There was no documented evidence arrangements were made for the patient to obtain his medications when the supply given was exhausted or how to obtain the medications not supplied by the facility.The facility's Nursing Administration policy and procedure on Continuum of Care - Admission, 24 Hour, revised 3/2010, indicated the discharge planning process included considering financial resources, services available in the area where the patient will be discharged and any barriers in the planned discharge. The social worker notifies and sets up services and resources in the community. The registered nurse (RN) is responsible for making sure medications and prescriptions are ordered. The facility's Nursing Administration policy and procedure on Continuum of Care ? Discharge or Transfer, revised 3/2010, indicated the policy was to provide the patient with a safe organized structured transfer and/or discharge. Discharge home included obtaining orders for discharge and for nursing to do the final medication records and instructions.On 4/20/11, at 3:22 p.m., during an interview, RN 1 stated the facility's policy allowed medications to be sent home with the patient but the patient's attending physician would have to approve patients sent out with controlled (narcotic) medications. RN 1 further stated that sometimes the patients were given over-the-counter (OTC ? non-prescription) medications such as aspirin and Colace. RN 1 further indicated there was no reason for the patient not being provided with all his remaining routine medications.On 4/21/11, at 9:30 a.m., when interviewed, the director of nursing stated the facility would provide patients with seven-day supply of OTC medications when patients/family requested to assist the patients during the transition. The director of nursing could not explain the reason the patient was not provided with all the prescribed medications. On 4/21/11, at 9:58 a.m., when interviewed, Licensed Vocational Nurse 1 (LVN 1) confirmed she did not document the reason the patient was not provided with all his medication upon his discharge from the facility. LVN 1 further stated Neurontin and Diflucan were not given to the patient because the facility did not have them since the facility had an on-going problem receiving medications timely from the pharmacy.On 4/29/11, at 8:15 a.m., during a telephone interview, the patient complained he was living in a shelter and had difficulties making arrangements to obtain medications.Based on interview and record review, the facility failed to implement written patient care policies and procedures and failed to ensure Patient 1 had the right for an orderly transfer by failing to: 1. Provide the patient with the needed supply of prescribed medications and medical prescription in order to obtain the medications. 2. Instruct the patient on how and where to obtain his prescribed medications. 3. Arrange for community resources to assist the patient with his medical needs.Patient 1 was discharged on 2/3/11, to a shelter hotel without all his prescribed medications, the medications provided were in limited amount, there were no instructions, arrangements or prescription provided to obtain the medications and there was no referral to a physician for continuity of care. This resulted in the patient missing his daily dosage of the prescribed medications. The above violation had direct or immediate relationship to the health, safety, or security of Patient 1. |
| 940000050 |
Lighthouse Healthcare Center |
940009449 |
B |
20-Aug-12 |
H52E11 |
10217 |
? 72311. Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. ? 72315. Nursing Service-Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. On 4/15/11, at 5:20 p.m., an unannounced visit was made to the facility to investigate an entity reported incident of patient to patient physical abuse. On 4/2/11, at 10:45 p.m., Patient 3 hit Patient 4 in the head with a chair resulting in Patient 4 sustaining a laceration (cut) to the left scalp (parietal) area.Based on observation, interview and record review, the facility failed to implement Patients 3 and 4?s care plans according to the methods indicated and ensure Patient 4 was not subjected to physical abuse of any kind by failing to: 1. Incorporate frequency of monitoring Patients 3 and 4?s target mood/ behavior in order to effectively refocus mood/behavior to something positive, provide choices to help maintain self-control and alter the environment during periods of behavioral problem.2. Separate Patient 4 from others at first sign of aggression for safety in order to prevent escalation of the behavior. 3. Ensure Patients 3 and 4 were not left together unattended due to their aggressive behavior.On 4/2/11, at 10:50 p.m., Patients 3 and 4, who were irritable and had verbal and physical aggressive behavior, were left unattended in the lobby and Patient 3 hit Patient 4 on the head with a chair. Patient 4 sustained a one centimeter (cm) laceration on the left scalp that required evaluation and treatment at an emergency room where he received one suture to repair the laceration.On 4/20/11, a review of Patient 3?s clinical record revealed the patient was a 72 year old male, admitted to the facility on 9/11/08, and readmitted on 3/4/11, with diagnoses that included paranoid schizophrenia (mental disorder with impaired thought process and persecutory delusions), anxiety (feeling of apprehension, fear, or worry), nicotine dependence and diabetes mellitus. The Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 3/25/11, indicated the patient had no memory problems and required supervision with all activities of daily living (ADLs).The physician?s orders upon readmission included the psychotropic (mind altering) medications Depakote EC (anticonvulsant ? mood stabilizer) 50 milligrams (mg) orally three times a day for mood swings and Zyprexa (anti-psychotic) 20 mg orally every night for paranoia that somebody is trying to poison him. A plan of care dated 3/17/11, developed for the patient?s alteration in mood manifested by persistent irritability or anger, sad or worried facial expressions and repetitive physical movements, included in the approaches to attempt to refocus mood to something positive and monitor target mood/behaviors.Another plan of care dated 3/17/11, developed for the patient?s alteration in behavior manifested by verbal threatening, screaming and cursing at others, physically combative (hitting/striking out) and resistive to care, included in the approaches to attempt to refocus behavior to something positive, provide choices to help maintain self-control and alter the environment during periods of behavioral problem.According to a nurse?s note dated 4/2/11, at 9 p.m., Patient 3 was in the patio smoking. At 10:50 p.m., security reported to the nursing staff that Patient 3 took a chair and hit another patient (Patient 4) in the head. The attending physician was made aware and ordered to transfer the patient to an acute hospital and he was transferred at 11:50 p.m. A review of Patient 4?s clinical record revealed the patient was a 44 year old male, admitted to the facility on 8/4/03, and readmitted on 1/26/11, with diagnoses that included schizophrenia, acute psychosis (loss of contact with reality) and paraplegia (impairment of sensory and motor function of the lower extremities). The MDS assessment dated 12/1/10, indicated the patient had some memory deficit and required extensive to total assistance with ADLs.The physician?s orders included the psychotropic medications Seroquel (anti-psychotic) 300 mg orally in the mornings and 400 mg every night for psychosis manifested by striking out, Haldol (anti-psychotic) 5 mg every eight hours orally for psychosis manifested by yelling for no apparent reason, Depakote ER 500 mg orally three times daily for mood swings and Desyrel (anti-depressant) for depression manifested by verbalization of feelings of hopelessness. A plan of care dated 2/4/11, developed for the patient?s potential to provoke altercations, included in the approaches to separate the patient from others at first sign of aggression for safety. A plan of care dated 1/28/11, developed for the patient?s alteration in mood manifested by repetitive calling out and persistent irritability or anger with self/others, included in the approaches to attempt to refocus mood/behavior to something positive, monitor target mood/behavior and provide a calm and quiet environment. Another plan of care dated 1/28/11, developed for the patient?s alteration in behavior manifested by verbal threatening, screaming and cursing at others, physically combative (hitting/striking out) and socially inappropriate/disruptive behavior (noisiness/screaming), included in the approaches to attempt to refocus behavior to something positive, provide choices to help maintain self-control and alter the environment during periods of behavioral problem.According to a nurse?s note dated 4/2/11, timed at10:45 p.m., Patient 4 was hit in the head with a chair resulting in a cut to the scalp.The attending physician was made aware and ordered to transfer the patient to an acute hospital for evaluation and he was transferred on 4/3/11, at 1:30 a.m.According to the facility?s investigation, on 4/2/11, at 10:45 p.m., Patients 3 and 4 were in the lobby when a security guard observed Patient 3 hitting Patient 4 on the head with a chair and trying to throw the chair around. As a result, Patient 4 sustained a one cm laceration to the parietal area of the scalp. Both patients were separated immediately and Patient 3 stated he hit Patient 4 because he (Patient 4) was trying to hit him. Patient 4 stated Patient 3 hit him without warning. Patients 3 and 4 were transferred to different acute care hospitals. There was no nursing staff in the area, only another patient and a security guard.The investigation report did not address the reason the patients, who were known to be irritable and have physical and verbal aggressive behavior towards others, were left unattended while together in the lobby. The reason the patients got into a physical altercation was not determined since there was no nursing staff present that could have intervened and prevent the incident. On 4/21/11, at 5:30 p.m., during an interview, the director of nursing stated Patient 3 had unpredictable mood swings consisting of restlessness, outbursts, not wanting to do anything and/or not wanting to take his medications.The director of nursing further indicated nursing staff had to monitor his behaviors as stated in the plan of care. On 4/22/11, at 9:28 a.m., during another interview, the director of nursing stated nursing, social service and activity staff were responsible for monitoring Patients 3 and 4?s moods and behaviors; however, the director of nursing could not specify the frequency the patients should have been monitored. On 4/22/11, at 9:35 a.m., when interviewed the Director of Staff Development (DSD) stated security guards were not trained to monitor patients and acknowledged the patients? care plan did not specify how the monitoring of the patients would be done to ensure the patients? safety.On 4/22/11, at 12:09 p.m., when interviewed, Patient 4 stated that on the day of the incident (4/2/11), he was going outside when Patient 3 hit him on the top of his head with a wooden chair.The facility?s policy and procedure on Resident Rights - Abuse, Agitated and Combative Resident, revised 3/2010, indicated all patients who demonstrate agitated or combative behaviors have prompt interventions to prevent injury to the patient, other patients, staff or other individuals in the facility. The purpose of the policy was to ensure prompt and appropriate interventions.The facility?s policy and procedure on Resident Rights - Abuse, Resident to Resident, revised 3/2010, indicated the facility?s policy was to protect the patients from harm at all times including protection of physical and verbal abuse from other patients. According to the Discharge Summary from the acute care hospital dated 4/6/11, Patient 4 had a suture to the scalp laceration and a computerized tomography (CT) scan (radiologic study) of the head was unremarkable and the injury did not result in any complications.The facility failed to implement Patients 3 and 4?s care plans according to the methods indicated and ensure Patient 4 was not subjected to physical abuse of any kind by failing to: 1. Incorporate frequency of monitoring Patients 3 and 4?s target mood/ behavior in order to effectively refocus mood/behavior to something positive, provide choices to help maintain self-control and alter the environment during periods of behavioral problem.2. Separate Patient 4 from others at first sign of aggression for safety in order to prevent escalation of the behavior. 3. Ensure Patients 3 and 4 were not left together unattended due to their aggressive behavior.On 4/2/11, at 10:50 p.m., Patient 3 hit Patient 4 on the head with a chair while both were in the lobby without nursing staff present. Patient 4 sustained a one centimeter (cm) laceration on the left scalp that required evaluation and treatment at an emergency room where he received one suture to repair the laceration.The above violation had direct or immediate relationship to the health, safety or security of Patient 4. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940009535 |
B |
02-Oct-12 |
LBL111 |
6024 |
F-323 483.25 (h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 8/31/12, at 8:30 a.m., an unannounced visit was conducted to investigate seven entity reported incidents regarding resident abuse involving a total of 13 residents. One of the incidents reported that on 8/28/12, while in the television (TV) room, Resident 1 hit Resident 2 resulting in Resident 2 which resulted in a nose bleed.Based on observation, interview and record review, the facility failed to ensure Resident 1 received adequate supervision to prevent injury by failing to: 1. Supervise Resident 1, who had physically abusive behavior, confusion and history of striking out, while in the TV room where other residents were present. 2. Implement policies and procedures to ensure residents were not left unsupervised while in the TV room. Residents 1 and 2 were left unsupervised in the TV room resulting in Resident 1 physically attacking Resident 2 causing her a nose bleed. On 9/20/12, at 1:20 p.m., Resident 1 was observed walking around the hallways alert and oriented to person only.The resident was unable to participate in an interview due to confusion.On 9/20/12, at 1:30 p.m., Resident 2 was observed sitting in a wheelchair, restless, calling out and yelling. The resident was unable to participate in an interview. On 8/31/12 and on 9/20/12, a review of the clinical record revealed Resident 1 was admitted to the facility on 10/1/11, and re-admitted on 1/20/12, with diagnoses that included convulsions and psychosis (loss of contact with reality). The Minimum Data Set (MDS - standardized assessment and care planning tool) dated 6/22/12, indicated Resident 1 had memory problems, had difficulty with communication, hallucinations (false or distorted sensory experiences that appear to be real perceptions), delusions (belief in something untrue) and required supervision with transfers, walking and locomotion. A plan of care developed on 3/22/12, for Resident 1's behavioral problems such as verbal and physical abusive behaviors and at risk of peer altercation included in the interventions to identify situations that might have caused behavioral problem and assist the resident in resolving the identified issues. The interventions did not include not leaving the resident unattended and unsupervised when in close presence of other residents to prevent altercations.According to the nursing notes and plan of care, on 4/16/12, Resident 1 hit another resident in the face which caused a bruise. Resident 2?s clinical record review revealed an admission to the facility dated 11/17/11, and a readmission dated 6/21/12, with diagnoses that included schizoaffective disorder (condition in which a person experiences a combination of schizophrenia symptoms -such as hallucinations or delusions- and of mood disorder symptoms, such as mania or depression), psychosis and airway obstruction.According to the MDS assessment dated 6/19/12, Resident 2 had difficulty with communication, was confused, had delusions, verbal behavioral symptoms and required extensive assistance with all activities of daily living (ADLs). Resident 2 used a walker and a wheelchair as mobility devices. According to the facility's investigation report, on 8/28/12, at 3:50 p.m., there were three residents (Residents 1, 2 and 3) in the TV room. A certified nursing assistant (CNA 1) who was with the residents, left the TV room to attend to another resident and at 3:55 p.m., when CNA 1 returned to the TV room, Resident 1 had hit Resident 2 in the face and Resident 2 was bleeding from her nose. Resident 2 was treated with first aids and the bleeding was contained. Resident 2 was given Tylenol for pain rated 8/10 (pain scale rating from zero indicating no pain to 10 indicating worst possible pain). There was no further bleeding, pain or swelling. The incident was witnessed by Resident 3. The investigation report lacked information related to who was responsible to supervise the residents while in the TV room.According to the facility?s policy and procedure for TV Room Supervision, undated, the TV room will be adequately supervised by facility staff (activity or nursing) when there are residents present in the room. Residents will not be left unattended by facility staff. On 9/20/12, at 3:05 p.m., during an interview, CNA 1 stated he was not assigned to the TV room supervision and he was just helping out. CNA 1 explained one of his assigned residents in the hallway requested his assistance and as he was helping the resident, he heard a resident yell in the TV room. CNA 1 returned to the TV room and found Resident 2 bleeding from the nose. Resident 3 told him Resident 1 punched Resident 2 in the face because she was yelling and would not let them hear the TV. A review of the activity schedule indicated there was no activity program scheduled at the time of the incident. According to the Nursing Staffing Assignment and Sign-in Sheet, CNA 2 and CNA 3 (the team leader) were assigned to the TV room. However, the facility?s investigation report did not address and explain why the nursing staff assigned to supervise the TV room did not fulfill their assignment. The facility failed to ensure Resident 1 received adequate supervision to prevent injury by failing to: 1. Supervise Resident 1, who had physically abusive behavior, confusion and history of striking out, while in the TV room where other residents were present. 2. Implement policies and procedures to ensure residents were not left unsupervised while in the TV room. Residents 1 and 2 were left unsupervised in the TV room resulting in Resident 1 physically attacking Resident 2 which resulted in a nose bleed. The above violation had a direct or immediate relationship to the health, safety or security of Resident 2. |
| 940000107 |
LONG BEACH CARE CENTER |
940009696 |
A |
11-Feb-13 |
CL8911 |
9996 |
CFR 483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free from hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 10/4/12 at 7:30 a.m., an unannounced visit was made to the facility to investigate a complaint and an entity reported incident regarding Resident 1's fall and injury. Based on observation, interview and record review, the facility failed to ensure Resident 1, who was assessed as at risk for falls and was dependent of staff for transfer, locomotion and bathing, was provided with a safe transport to prevent accidents and injuries by failing to: 1. Provide Resident 1 with a shower chair large enough so the lap bar could be closed and secured. 2. Ensure the lap bar of the shower chair used with the resident was not defective and could be secured. 3. Ensure the shower chair used with Resident 1 had foot rest to provide support to the lower extremities.On 9/13/12, at 9:45 a.m., Resident 1 was being wheeled by Certified Nursing Assistant 1 (CNA 1) from her room to the shower room using a broken (the lap bar did not lock to stay in place) and non-fitting (the resident's abdomen size did not allow positioning of the lap bar to go across the abdomen and to lock into place) shower chair that lacked foot rest to support the resident's feet. While trying to go through the entrance door of the shower room, the shower chair tilted forward and the resident fell from the chair to the floor on her knees. On the same day, the resident was transferred to a general acute care hospital (GACH) where she was diagnosed with bilateral non-displaced tibial plateau fractures (right and left knee area broken with the bones still aligned) which could not be surgically repaired but required application of knee braces and pain management. On 10/4/12, a review of the clinical record indicated Resident 1 was a 77 years old female admitted 1/3/12, with diagnoses including cerebro-vascular accident (CVA - stroke) with left sided weakness, arthritis, osteoporosis (bones become porous/brittle), diabetes, and end stage renal disease on hemodialysis treatment (procedure for removing metabolic waste products or toxic substances from the bloodstream). The resident was readmitted to the facility on 9/17/12, with a diagnosis of bilateral plateau tibial fractures.The Minimum Data Set (MDS - standardized assessment and care planning tool) signed as completed on 7/1/12, indicated the resident was alert and oriented, non-ambulatory, and required extensive assistance with one-person physical assist with bed mobility and total assistance with transfers, locomotion and bathing. The resident did not have functional limitation of range of motion (ROM- mobility of the joints) on the lower extremities and used a wheelchair as a mobility device. The Monthly Weight Record dated 8/2/12, indicated the resident weighed 234.5 pounds (lbs). The Care Area Assessment (CAA) notes dated 6/30/12, indicated the resident was at risk for falls/injuries due to her compromised mobility, cardiac medication use and incontinence. It also indicated fall precautions would continue to be implemented. The plan of care dated 1/3/12, developed for the resident's risk for falls/injuries included in the approaches to assess environment for wet spots or items below the field of vision and to use the appropriate device as ordered. The plan of care dated 6/30/12, developed for the resident's risk for injuries had a goal for the resident not to have injuries/fall incidents. The approaches included to maintain a safe and hazard free environment. According to the Licensed Personnel Progress Notes dated 9/13/12, timed at 9:45 a.m., the resident was in the shower, slid down from the shower chair and was assisted by the CNA to the floor in a sitting position. The resident was assisted back to bed by three CNAs. At 10:30 a.m., the resident complained of pain on both legs rated 4 over 10 (4/10 - pain rating scale from zero to 10, zero indicating no pain and 10 indicating the worst possible pain). The resident was given Tylenol 650 milligrams (mg). At 11:30 a.m., the attending physician was called and at 1 p.m., the nurse practitioner on call for the physician ordered to monitor the resident. At 4:30 p.m., the resident complained of pain of 4/10 on both lower extremities and Tylenol 650 mg was given. At 5:10 p.m., the physician was called about the resident's continued pain on both lower extremities. At 5:30 p.m., a physician on call, called back and ordered to medicate the resident with Norco 5/325 mg and to take x-rays of both lower extremities. At 6:10 p.m., Resident 1's family member requested for the resident to be transferred to the hospital. The on-call physician was informed and ordered the resident to be transferred to a GACH. The resident was transferred via ambulance at 7:05 p.m. According to the GACH History and Physical dated 9/14/12, the resident sustained left and right knee non-displaced tibial plateau fractures. The plan was to immobilize the residents' knees and give pain medications. The resident returned to the facility on 9/17/12. On 10/4/12 at 10:04 a.m., during an interview, CNA 1 stated on 9/13/12, he transferred the resident from her bed to a big shower chair using a mechanical lift and a shower sling. The resident in the shower chair was pushed (wheeled) to the shower room and while trying to get in thru the shower room entrance door the shower chair tilted forward and the resident fell off the chair. CNA 1 further stated he grabbed the resident and the sling and slowly lowered her to the floor.During the interview, CNA 1 brought the shower chair used during the incident which had a safety lap bar that went across the front area of the chair and no foot rests. The lap bar was noted to be defective, when snapped into the arm rest, the bar did not stay attached in place (if pulled or pushed). The lack of foot rests would provide less support for the resident to remain in sitting position. CNA 1 explained he used this particular shower chair because it was large enough for the resident. CNA 1 stated the resident was not using the lap bar because the resident did not like it being used. When asked if the lap bar could fit over the resident's abdomen area, CNA 1 replied, "No."On 10/4/12 at 10:44 a.m., during an interview, the maintenance supervisor stated he and his assistants inspect the shower chairs. However, he did not know the shower chair (used by the resident) was broken. According to the maintenance supervisor, the facility had 21 shower chairs and only two had safety lap bars to protect the resident from falling out of the chairs and only four had foot rests.According to the Monthly Maintenance Equipment Inspection log from 1/2012 thru 9/2012, shower chairs were inspected and oiled; however, due to the lack of identification of each chair, it was not determined which shower chairs were inspected and oiled. On 10/4/12 at 12:10 p.m., during an interview, Resident 1 stated that while CNA 1 was pushing her in the shower chair into the shower room, she slid down, her legs were folded underneath the chair and she hit both of her knees on the floor. The resident stated she slid down because CNA 1 kept pulling and pushing the shower chair back and forth trying to get in through the shower room entrance. The resident indicated the shower chair had a lap bar that could not be used because her abdomen was too big. The resident also stated it was hard for her to hold on to the chair because her left side was weak due to a stroke and the shower chair without foot rests did not help in keeping her in the sitting position.On 10/4/12 at 3:15 p.m., during an interview, the Director of Staff Development (DSD) stated he was not aware CNA 1 used a shower chair with a broken lap bar. The DSD was also not aware the shower chair was not large enough for the resident and the lap bar could not close. The DSD could not provide evidence the CNAs were trained in using shower chairs for residents who had body weakness. According to the facility's policy and procedure on Managing Falls and Fall Risks, dated 4/2006, based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes, to try to prevent the resident from falling and to try to minimize complications from falling. The facility failed to ensure Resident 1, who was assessed as at risk for falls and was dependent of staff for transfer, locomotion and bathing, was provided with a safe transport to prevent accidents and injuries by failing to: 1. Provide Resident 1 with a shower chair large enough so the lap bar could be closed and secured. 2. Ensure the lap bar of the shower chair used with the resident was not defective and could be secured. 3. Ensure the shower chair used with Resident 1 had foot rest to provide support to the lower extremities.On 9/13/12, at 9:45 a.m., Resident 1 was being wheeled by CNA 1 from her room to the shower room using a broken (the lap bar did not lock to stay in place) and non-fitting (the resident's abdomen size did not allow positioning of the lap bar to go across the abdomen and to lock into place) shower chair that lacked foot rest to support the resident's feet. While trying to go through the entrance door of the shower room, the shower chair tilted forward and the resident fell from the chair to the floor on her knees. On the same day, the resident was transferred to a GACH where she was diagnosed with bilateral non-displaced tibial plateau fractures which could not be surgically repaired but required application of knee braces and pain management. The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940010074 |
B |
06-Aug-13 |
JOLV11 |
8909 |
F-223 CFR 483.13(b) - Abuse The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. On 5/22/13, at 1:50 p.m., an unannounced visit was made to the facility to investigate a report of Resident A's allegation of verbal and physical abuse perpetrated by Certified Nursing Assistant 1 (CNA 1). Based on interview and record review, the facility failed to ensure the resident had the right to be free from verbal and physical abuse by failing to: Ensure that Resident A was not verbally and physically abused by CNA 1, who, while changing Resident A's diaper, pulled the resident?s blanket off, hit him in the head with an open hand and with his diaper. He then called the resident ?stupid bitch," "monkey ass" and "dirty ass." The incident was heard, witnessed and observed by Employee 1, a phlebotomist from an outside Health Provider Contractor who was in Resident A's room to collect blood specimens on 5/16/13, between 4 am and 9 am and on 5/21/13, between 6:30 am and 7 am.On 5/22/13, a review of the clinical record indicated Resident A was a 76 year old male, re-admitted to the facility on 5/08/13, with diagnoses that included Psychosis, Depressive Disorder, Anxiety, Abnormality of Gait and Chronic Airway Obstruction.The readmission Minimum Data Set (MDS - a standardized assessment and care plan tool), dated 5/15/13, indicated that Resident A had long/short-term memory problems, modified independence in cognitive skills for daily decision-making, was usually able to make himself understood, and sometimes able to understand others. The resident was wheelchair bound required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and bathing.On 5/22/13, at 2:35 p.m., during an interview in the presence of the assistant director of nursing (ADON), the resident was unable to respond due to confusion. A review of the facility's initial letter of investigation on the abuse incident dated 5/22/13, indicated that on 5/21/13, Employee 1 reported he heard and witnessed CNA 1 verbally and physically abuse Resident A, when he visited the facility on 5/16/13 and 5/21/13 at approximately 6:00 a.m. The report revealed that Employee 1 had stated that he heard CNA 1 use foul language towards Resident A and observed CNA 1 hit the resident with a diaper. The report also indicated that CNA 2 was assisting CNA 1 in care on both dates and he (CNA 2) denied that any abuse took place.CNA 1 denied the abuse allegation in his written statement dated 5/21/13. CNA 1 claimed the only profane word he used was "Damn." CNA 1 also claimed that CNA 2 was with him and assisted him to provide care for Resident A on 5/16/13 and 5/21/13.In an interview on 5/23/13, at 6:50 a.m., CNA 2 denied being in Resident A?s room and stated he did not assist CNA 1 to provide care for the resident on 5/16/13 and 5/21/13. The review of CNA 2?s declaration statement dated, 5/23/13, indicated that he did not assist CNA 1 to provide care on the alleged dates of the incidents. On 5/23/13, at 8:00 a.m., Resident B stated during an interview in the presence of Employee 5, that he had seen CNA 1 hit Resident A in the buttocks in the past prior to the incidents of 5/16/13 and 5/21/13. Resident B said he told the CNA he doesn?t have to hit the resident and he reported the incident to a nurse, but did not remember the identity of the nurse anymore.A review of Resident B?s medical record indicated that he was a 54 year old male, re-admitted to the facility on 1/29/13, with diagnoses that included Paranoid Schizophrenia, Hypertension and Chronic Airway Obstruction.The readmission Minimum Data Set (MDS - a standardized assessment and care plan tool), dated 4/5/13, indicated that Resident B had long/short-term memory problems, modified independence in cognitive skills for daily decision-making, was usually able to make himself understood, and usually understand others. The resident was wheelchair bound required supervision with the use of toilet, limited assistance with dressing and extensive assistance with personal hygiene and bathing.On 5/26/13, at 3:30 p.m., during an interview, Employee 3 stated the compliance officer from Employee 1's company reported the verbal and physical allegation of abuse witnessed by Employee 1 to the facility and to the police. Employee 3 stated the facility's administrator immediately started an investigation on the incident.During a telephone interview on 6/27/13, at 7:20 a.m., Employee 4 confirmed that Employee 1 was in the facility on 5/16/13 and 5/21/13, because he checked him into the facility (Employee 4 signed-in Employee 1 to collect blood specimen from facility residents) and he proceeded to Resident A?s room to perform his blood collection. On 6/27/13, at 8:00 a.m., during a telephone interview, Employee 1 stated he heard and witnessed CNA 1 abuse Resident A when he was collecting blood specimens in the resident?s room on 5/16/13 and 5/21/13.A review of Employee 1's declaration statements on the abuse incident revealed that on Thursday 5/16/13, between the hours of 4 am ? 9 am, during his morning routine in the facility's west wing, he was in Room 221 collecting blood specimen from a resident (Resident B). While he was obtaining the specimen he observed CNA 1 in the room with Resident A (resident in Bed C). CNA 1 was waking Resident A up by pulling off his blanket and hitting him in the head with an open hand. The CNA then grabbed a diaper (Employee 1 did not specify where) and while the resident was sitting up, the CNA hit Resident A behind the head with the diaper and verbally abuse the resident telling him," get up you stupid bitch, get your monkey ass up so l can f..ken change your dirty ass."On Tuesday 5/21/13, during his morning routine, at the same station, Employee l stated he was obtaining a specimen from a resident (Resident C) and once again the same CNA 1 came in to wake Resident A up in the same manner as he did previously on 5/16/13. He pulled the resident's blanket off and CNA 1 hit Resident A. Employee 1 said he could not see where the CNA was hitting the resident because the curtains were closed. Employee 1 said he heard the CNA verbally abusing the resident telling him, "hey get the f..k up bitch, get up you smelly f..k." The CNA then looked at him and began to tell him how much he hated his job and that the facility didn't even pay him enough for the job he was doing.A review of the care plan relating to behavior problems, dated 5/9/13, indicated Resident A has a diagnoses and history of dementia, psychosis, depression, disorganized thought process and fluctuating cognition. The care plan intervention indicated the direct care nursing staff members must first identify themselves to the resident. Gently handle the resident during activity of daily living (ADL). Call him by preferred name and approach the resident in a calm manner. Give praise to the resident for activity completed. Speak distinctly, rephrase, simplify, or use gestures to enhance communication and cue the resident with ADL needs. According to the summary of investigation letter sent to the Department of Public Health, dated 5/30/13, the facility terminated CNA 1?s employment after completion of their investigation.The facility's undated policy and procedure on Abuse of Residents indicated that the facility will not condone any form of resident abuse. The facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff members, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, visitors, physicians, consultants, and other individuals. The patient has the right to be free from verbal and physical abuse. The policy defined abuse as physical abuse, neglect, fiduciary abuse, abandonment, isolation, abduction, physical harm or pain or mental suffering or the deprivation by facility custodial goods or services, that are necessary to avoid physical harm. The facility failed to ensure Resident A had the right to be free from verbal and physical abuse by failing to: Ensure that Resident A was not verbally and physically abused by CNA 1, who, while changing Resident A's diaper, pulled the resident?s blanket off, hit him in the head with an open hand and with his diaper. He then called the resident ?stupid bitch," "monkey ass" and "dirty ass." The incident was heard, witnessed and observed by Employee 1, a phlebotomist from an outside Health Provider Contractor who was in Resident A's room to collect blood specimens on 5/16/13, between 4 am and 9 am and on 5/21/13, between 6:30 am and 7 am.The above violation had direct or immediate relationship to the health, safety, or security of Resident A. |
| 940000026 |
LA PAZ GEROPSYCHIATRIC CENTER |
940010297 |
B |
23-Dec-13 |
1VMM11 |
19728 |
F441 483.65 INFECTION CONTROL, PREVENT SPREAD, LINENS The facility must establish and maintain an Infection Control Program designed to prove a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it- (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b)Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Based on observation, interview, and record review, the facility failed to:1. Maintain an Infection Control Program to identify or track rashes and prevent the spread of scabies infection (an itchy, highly contagious skin condition caused by an infestation by the itch mite Sarcoptes scabiei). After an undiagnosed case of scabies was not identified or addressed for Resident 1. 2. Successfully treat a reddened pin-point rash with itching since admission for over 40 days.3. Provide surveillance to prevent the spread of scabies to Resident 1's roommate (Resident 2) who also developed a rash with itching on November 7, 2013, and required Elimite treatment.These failures resulted in Resident 1's rash spreading, becoming infected, continued to itch, which prevented the resident from sleeping, and diagnosed with scabies by a dermatologist. Resident 2, Resident 1's roommate also contracting a red pin-point rash to bilateral hands with severe itching.At 1:25 p.m., on November 6, 2013, a resident (Resident 1) approached the team yelling, "The nurses here don't care and they do their paperwork first before helping me." As the team re-entered the facility from the patio area walking towards the nursing station, Resident 1 continued to follow behind in the wheelchair. Upon reaching the nurse's station, where a licensed vocational nurse (LVN 1) and acting director of nursing (DON) were present. Resident 1 stated, "The nurses don't give me my treatment for my back rash until after they finish their paperwork." Resident 1 pointed towards LVN 1 identifying her as the individual. LVN 1 pulled down the face mask and stated, "Treatments are given in the afternoon and the resident only mentioned today she wanted her treatment in the morning."On November 6, 2013 at 1:35 p.m., while at the nursing station the acting DON reviewed the treatment record for Resident 1 and stated, "The resident is receiving an antibiotic treatment by mouth for a skin infection." On November 6, 2013 at 1:45 p.m., Resident 1 was asked permission for the team to visually assess the resident's rash in the resident's room. Resident 1 agreed to the skin observation and wheeled herself to the room accompanied by the acting DON and four surveyors. Resident 1 stood up from the wheelchair with her back to the staff and removed her clothing (T-shirt, bra, and shorts). There were multiple pin-point, reddish in color patches observed in varying stages of healing on the back and buttocks. The resident was then asked to turn around and more multiple sores in various degrees were noted to the arms, breasts (including areolas area around the nipples, stomach, lower legs, and axilla area (under arm). Multiple areas were observed opened with sores to posterior (back) left arm and axilla area Resident 1 stated, "They itch so bad." The acting DON stated she was unaware the rash had spread, she stated, "I thought it was just on the resident's arms." On November 6, 2013, at 2:25 p.m., during a telephone interview with the resident's attending physician (Physician 1) was asked about Resident 1's rash and had he seen the rash and he stated, "I don't know if she is my patient or not. I have so many patients. If I ordered a treatment for the rash then I must have seen it since there is a treatment ordered. I will come tomorrow to see her."On November 6, 2013, at 2:56 p.m., the facility's medical director (Physician 2) was asked to assess the resident's rash. Resident 1 agreed, after much encouraging, to allow the medical director to assess her skin rashes. Upon completion of the assessment and after the resident redressed, Resident 1 stated, "I was diagnosed with a bug under my skin at the other hospital before coming here and they tried hydrocortisone (corticosteroid topical), but it didn't help." A review of a general acute care hospital (GACH) records dated September 6 and 10, 2013, indicated under physical examination the resident had a small papular (small, somewhat pointed elevation of the skin) rash on the dorsal (top of hand) surface of her hand with no burrowing marks. The resident stated, "I scratch all the time and can't sleep at night. I have a lot of bugs in my hair too." The medical director assessed the resident's hair at that time and asked the resident a series of questions, including if she had ever heard of lice or scabies. Resident 1 responded, "I had lice and scabies before many years ago and received treatment." Resident 1 became tearful and began to cry while sitting in the wheelchair. The resident started screaming, "It's a bug. I want to leave this place. My rash is a bug and it itches. I want to go to the ER. I have shown two to three doctors this rash when they came to visit and I still have it." A review of the Los Angeles County Department of Public Health (CDPH), Acute Communicable Disease Control Program on Scabies Prevention and Control Guidelines, indicated it is essential to have a policy to screen newly admitted patients for scabies during the initial assessment (especially if transferred from another healthcare facility) and any suspect patient will immediately be placed on contact isolation until examined for scabies (this guideline was given to the facility during an inservice by the CDPH in 2013). According to the Centers for Disease Control and Prevention, the most common signs and symptoms of scabies are intense itching, especially at night, (a pimple-like itchy rash) (http://www.cdc.gov/parasites/scabies/gen_info/faqs.html#signs ).At 3:15 p.m., on November 6, 2013, pictures were taken of Resident 1's rash after permission was granted by the resident's conservator (a court appointed person or organization to oversee the care and decision of the resident) per the administrator. Pictures were taken and printed by the facility's medical record staff of Resident 1 anterior (front) and posterior (back) view.On November 6, 2013, at 3:40 p.m., LVN 1 was interviewed regarding Physician 1's notification of the resident's change in condition regarding the rash with itching. LVN 1 stated, "The doctor comes on Thursday so I didn't call him when I saw the rash and it was all over her body. Actually it's worst, but I thought because she received Diflucan (used to treat and prevent fungal infections) on Friday and Saturday (November 1 and 2, 2013) it would get better. I put it in the doctor's communication book only. The patient hasn't been on a treatment for the rash since October 30, 2013, and was not on any anti-itching medication. She came to the facility with the rash." LVN 1 continued, "I knew the doctor would have just told me to wait for him to see her on Thursday, November 7, 2013, I probably should have called him."A review on Resident 1's face sheet indicated the resident was a 49 year -old female who was admitted to facility on September 27, 2013, at 12:05 p.m., from a general acute care hospital (GACH). The resident's diagnoses included morbid obesity (50 -100% or 100 pounds above ideal body weight), diabetes type II (sugar built up in the blood), hypertension (high blood pressure), and congestive heart failure (heart has trouble pumping right amount of blood through the body).A review of the Minimum Data Set (MDS), an admission assessment (a standardized assessment and care screening tool) with an assessment reference date of October 7, 2013, indicated the resident was able to express ideas and wants and had clear comprehension of understanding of verbal content. The MDS functional status (activities of daily living), under Section G indicated Resident 1 required set-up help only for dressing, personal hygiene, bathing, and walking.A review of several "Shower Day Skin Inspection" forms, one dated October 12, 2013, indicated small spots drawn on a full body diagram to illustrate the resident had a rash to bilateral arms, abdomen, and legs. On October 19 and 23, 2013, the Shower Day Skin Inspection form indicated the resident had a full body rash. The initial nursing documentation of Resident 1's skin assessment, dated September 29, 2013, two days after admission, in the physician and physician assistant certified communication book (MD/PAC), indicated the resident had red pin point marks to bilateral arms, abdomen, back, and lower legs with itching.A review of the facility's policy and procedure (P/P) revised on December 24, 2012 titled, "Prevention and Control of Scabies indicated that the infested person will complain of pruritus (itching), which intensifies at bedtime under the warmth of the blankets. Skin lesions are generally seen on the hands, wrists, elbows, folds of armpits, and female breasts. According to the P/P in long term care facility, resident's lesions may be more predominate on the areas of the skin having contact with moist sheets, such as the back and buttocks. The P/P also indicated in typical scabies, the rash is generally characterized as red, raised bumps (papules).A review of Physician 1's note dated, November 7, 2013, indicated Resident 1's chief complaint was skin rash with itching. His observation indicated papules on the body with skin lesions and scales. The physician's assessment indicated to rule out scabies and indicated there were no burrows or warts. However, a review of the facility's policy, revised on December 24, 2012, titled "Prevention and control of scabies" under signs and symptoms, indicated pustules, burrows, blisters, or nodules are seldom seen because the skin is often excoriated due to the intensity of itching and scratching.On November 8, 2013 at 8:25 a.m., the acting DON stated, "If there is a change in condition the nurses should notify the physician by the telephone or if the physician was present then they should let the physician know." The acting DON stated, "I only assessed the resident's arm because that's the only place I knew she had a rash." The acting DON also stated Resident 1 was seen on Thursday, November 7, 2013, by the attending physician (Physician 1), after the survey team questioned staff regarding the rash. She stated Physician 1 did not suspect scabies, but requested a dermatology consult to rule out scabies along with creams to be applied and Benadryl (antihistamine used to relieve itching). The acting DON was asked who was the infection control nurse and she stated she was the infection control nurse at this time and that she did conduct random resident skin checks on residents including the roommates of Resident 1, after seeing Resident 1's rash on November 6, 2013. The acting DON stated Resident 1's roommates (Resident 2 and 16) were free of rashes, but she did not document such findings. When asked about staff with rashes she stated," I didn't question the CNAs providing care to Resident 1, because they would have told me without me asking."The acting DON was asked on November 8, 2013, at approximately 9:35 a.m., about the facility's infection control program. She stated they do not track or do surveillance of skin rashes and/or infections. A review of the facility's CMS 2567 (survey report by the Centers of Medicare or Medical services), dated November 2012, indicated they were cited for their failure to implement their policy, titled "Prevention and Control of Scabies" by not tracking and providing surveillance of potential residents and or staff at risk for contracting scabies. The facility's plan of correction (POC) indicated they would provide in-service to licensed nursing staff regarding the revised scabies policy and procedure, dated December 24, 2012. However, when the DSD (director staff development) was asked about the in-service?s conducted, as indicated on the CMS 2567 POC, he was unable to provide them. According to the MD/PAC communication book and the physician's orders, Resident 1 suffered episodes of itching and scratching for 26 days after last dosage of Benadryl was prescribed by the physician on October 12, 2013. A review of Physician 1's telephone order, dated November 6, 2013, indicated Benadryl 25 mg four times a day was ordered PRN (as needed) for itching for 10 days, Epsom salt (a combination of magnesium and sulfates used to reduce inflammation) bath every evening and soak for 15 minutes for three days, 50:50 mixture of Miconazole cream and Hydrocortisone cream 2.5 % twice daily for seven days to the affected areas.Another Physician's 1's progress note, dated November 8, 2013, indicated the resident was admitted with a rash and self irritated it and spread it to other sites. The documentation further indicated multiple modalities were given, topical, oral, and Epsom salt bathes were ordered. A review of the prior physician's orders for the resident rash treatment included: On October 3, 2013, Benadryl 25 mg by mouth (P.O.) and bacitracin ointment were ordered. On October 13, 2013, Keflex 500 mg po (antibiotic), normal saline, and bacitracin ointment(antibiotic ) were ordered. On October 21, 2013, bacitracin ointment was re-ordered. On October 24, 2013, Keflex 500 mg was re-ordered. On November 1. 2013, DeLuca ( an antifungal) 150 mg one tablet for two days. The above modalities provided no relief for Resident 1's rash with itching. On November 8, 2013, at 9:50 a.m., while in Resident 1's room she stated while smiling happily, "Thank you, I feel much better. I'm not itching as much and I did see my doctor yesterday!" Resident 2 (Resident 1's roommate) was present in the room and was observed in bed laying on the right side while scratching.At 10 a.m., on November 8, 2013, during an observation, LVN 2 (treatment nurse) and the acting DON conducted a skin assessment on Resident 1's two roommates (Resident 2 and 16). Resident 2 was observed with itchy reddish pin-point rash to both hands. Resident 2 stated, in front of the acting DON and LVN 2 that she started to itch after being asked the day before if she had a rash or scratching. The acting DON stated she was unaware of Resident 2's rash with itching and did not tell the physician. Resident 16 denied scratching and was observed free of rash, upon assessment with the DON and LVN 2. On November 8, 2013, at 2:55 p.m., CNA 1 stated she had been caring for Resident 1 since her admission in September 2013. CNA 1 stated," I told the charge nurse (LVN 1) about two to three weeks ago that the patient complained of a rash with itching." CNA 1 was asked if she currently had a rash or itching and she denied having a rash.A review of the medical director's administrative note dictated on November 7, 2013, of Resident 1's skin assessment conducted on November 6, 2013, indicated under Subjective: The patient complained of on and off rash and itching symptoms. Her reports symptoms started at prior hospital before she was transferred to facility. Objective: skin examination diffuse maculopapular rash (flat, red area on the skin that is covered with small confluent bumps) on upper extremity, shoulder and arms with no drainage. Mood noted as "angry." Assessment: "Given diagnosing and treating rashes is out of writer's scope of practice" (psychiatrist), we will work with nursing to communicate concerns and observations to primary care physician. The medical director's plan included nursing staff to assess patient's roommates for any concerns for itching or rash and any institutional infection issues (community living).On November 12, 2013, at 8:20 a.m., the acting DON stated, "The facility doesn't have an infection control log." A job description for an infection control nurse was requested and the acting DON was unaware the job description and responsibilities of an infection control nurse.On November 12, 2013, at 8:30 a.m., during an interview and review of a written declaration LVN 1 stated, " I did not document the skin assessment that the rash had spread all over in the resident's chart or call the doctor on November 5, 2013, because I knew he would have told me he will see her on Thursday." Although the MD/PAC log also indicated the resident had complained on November 3, 2013, "Still itching, requesting something for itch."On November 12, 2013, at 9:06 a.m., the acting DON stated the facility's nurses did the scraping for scabies on Friday, November 8, 2013, and the specimen was sent to laboratory. However, according to Centers for Disease Control and Prevention and the California Department of Public Health (CDPH), only an experienced trained physician or nurse should do skin scrapings for scabies mites. The acting DON stated on November 11, 2013, Resident 1 was seen by a dermatologist. The acting DON stated, ?The facility's physician assistant (PA) stated we should apply Elimite (medication used to treat scabies) on the resident while waiting for the skin scraping results." However, the acting DON was not forthcoming, because a review of the dermatologist consult Resident 1 was assessed as having scabies. The facility then treated Residents 1, 2, and 16 with Elimite. The dermatology consult indicated Resident 1 was seen on November 11, 2013, and was diagnosed with scabies. The dermatologist ordered Elimite cream to be applied from the neck to the feet and to leave on overnight and repeat in one week. A follow-up appointment was given for December 2, 2013, at 2:30 p.m. for Resident 1.On November 14, 2013, at 2:20 p.m., during a telephone interview with the supervisor at the CDPH/Communicable Disease, she stated the facility had contacted them about these recent scabies cases. However, the supervisor stated her staff had recently been to the facility and provided in-service training regarding scabies and did not understand why they were not tracking the rash and following the policy that was given to them. The facility failed to: 1. Maintain an Infection Control Program to identify or track rashes and prevent the spread of scabies infection (an itchy, highly contagious skin condition caused by an infestation by the itch mite Sarcoptes scabiei). After an undiagnosed case of scabies was not identified or addressed for Resident 1. 2. Successfully treat a reddened pin-point rash with itching since admission for over 40 days.3. Provide surveillance to prevent the spread of scabies to Resident 1's roommate (Resident 2) who also developed a rash with itching on November 7, 2013, and required Elimite treatment. The above violation either jointly, separately, or in any combination had a direct of immediate relationship to patient health, safety, or security. |
| 940000026 |
LA PAZ GEROPSYCHIATRIC CENTER |
940010357 |
B |
23-Dec-13 |
1VMM11 |
8135 |
F224 483.13(c) Staff Treatment of ResidentsThe facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.Based on observation, interview, and record review the facility failed to: 1. Implement its policy related to abuse and neglect, by not providing the care necessary to prevent neglect.2. Provide care and services to prevent mental anguish and neglect for Resident 1, who had a rash with itching for 26 days without an anti-itch agent ordered and/or given.3. Ensure Resident 1, who had a rash for over 40 days, since her admission was seen by a dermatologist after multiple treatments failed.These failures resulted in the resident not being adequately treated for the rash which caused severe itching with the inability to sleep at night and was later diagnosed with scabies on November 11, 2013, by a dermatologist.At 1:25 p.m., on November 6, 2013, while the survey team was touring the patio area. A resident (Resident 1) complained the nurses were more interested in doing their paperwork then providing her treatment to her rash. The survey team, the acting director of nursing, and the facility's medical director assessed the resident's rash in her room on November 6, 2013 at 2:56 p.m. There were multiple pin-point areas, reddish in color patches noted in varying stages of healing observed on the back, buttocks, and multiple sores in various degrees were noted to the arms, breasts (including areolas [area around the breast]), stomach, lower legs, and axilla (under arm)area. Multiple areas were observed opened with sores to posterior (back) left arm and axilla area. Resident 1 stated, "They itch so bad." The acting DON stated she was unaware the rash had spread, she stated, "I thought it was just on the resident's arms." Upon completion of the resident's skin assessment with the medical director, acting DON, and the surveyors. The resident redressed and stated, "I was diagnosed with a bug under my skin at the other hospital before coming here and they tried hydrocortisone, but it didn't help. I scratch all the time and can't sleep at night. I have a lot of bugs in my hair too and I had lice and scabies before many years ago and received treatment." Resident 1 became tearful and began to cry while sitting in the wheelchair. The resident started screaming, "It's a bug. I want to leave this place. My rash is a bug and it itches. I want to go to the ER. I have shown two to three doctors this rash when they came to visit and I still have it."A review of a general acute care hospital (GACH) records dated September 6 and 10, 2013, indicated under physical examination the resident had a small papular (small, somewhat pointed elevation of the skin) rash on the dorsal (top of hand) surface of her hand with no burrowing marks.On November 6, 2013, at 3:40 p.m., LVN 1 was interviewed regarding Physician 1's notification of the resident's change in condition regarding the rash with itching. LVN 1 stated, "The doctor comes on Thursday so I didn't call him when I saw the rash yesterday and it was all over her body. Actually its worst, but I thought because she received Diflucan (used to treat and prevent fungal infections) on Friday and Saturday (November 1 and 2, 2013) it would get better."A review on Resident 1's face sheet indicated the resident was a 49 year-old female admitted to facility on September 27, 2013, at 12:05 p.m. from a general acute care hospital (GACH). The resident's diagnoses included morbid obesity (50 -100% or 100 pounds above ideal body weight), diabetes type II (sugar built up in the blood), hypertension (high blood pressure), and congestive heart failure (heart has trouble pumping right amount of blood through the body).A review of the Minimum Data Set (MDS), an admission assessment (a standardized assessment and care screening tool) with an assessment reference date of October 7, 2013, indicated the resident was able to express ideas and wants and had clear comprehension of understanding verbal content. The MDS functional status (activities of daily living), under Section G indicated Resident 1 required set-up help only for dressing, personal hygiene, bathing, and walking.An initial nursing documentation of Resident 1's skin assessment, dated September 29, 2013, two days after the resident was admitted, was placed in the physician and physician assistant certified communication book (MD/PAC) indicating the resident had red pin point marks to bilateral arms, abdomen, back, and lower legs with itching. Resident 1's physician ordered a, dermatology consult on November 7, 2013, although he did not suspect scabies, but indicated to "Rule out Scabies." Benadryl by mouth (antihistamine used to treat itching), for the resident's complaint of itching was also ordered, as well as a topical steroid cream.On November 8, 2013, at 9:50 a.m., while in Resident 1's room, she stated while smiling happily, "Thank you! I feel much better. I'm not itching as much and I did see my doctor yesterday!"On November 8, 2013, at 2:55 p.m., CNA 1 stated she had been caring for Resident 1 since her admission in September 2013. She stated resident's shower times are based on room assignments and Resident 1's shower time was on the evening shift (3-11 p.m.). CNA 1 stated, "I told the charge nurse (LVN 1) about two to three weeks ago that the patient complained of a rash with itching."A review of the medical director's administrative note, with a dictated date of November 7, 2013, indicated Resident 1's skin assessment was conducted on November 6, 2013. The note under "Subjective" indicated the patient complained of an on and off rash and itching symptoms. He indicated the resident reported symptoms that started at the prior hospital before she was transferred to the facility. The medical director documented under "Objective" the resident's skin examination there was diffuse maculopapular (flat, red area on the skin that is covered with small confluent bumps) rash on the upper extremity, shoulder and arms with no drainage. The note indicated the resident's mood was "angry." Under Assessment: he documented "Given diagnosing and treating rashes is out of writer's scope of practice (he is a psychiatrist)," we will work with nursing to communicate concerns and observations to primary care physician. The medical director's plan included, nursing staff agreeing to assess patient's roommates for any concerns for itching or rash and any institutional (community living) infection issues.On November 12, 2013, at 9:06 a.m., a review of a dermatology consult indicated Resident 1 was seen on November 11, 2013, and diagnosed with scabies. The dermatologist ordered Elimite cream (agent used to kill bugs under skin) to be applied from the neck to the feet and left on overnight and to repeat in one week. A follow-up appointment was given for December 2, 2013, at 2:30 p.m., for Resident 1. A review of the facility?s policy titled, ?Policy and Procedure on Abuse Reporting?, revised on, April 10, 2013 indicated, any form of mistreatment of residents including, but not limited to abuse, neglect, exploitation, involuntary seclusion, misappropriation of property or any crime is strictly prohibited. It further defines Neglect as a failure to provide the care necessary to avoid physical harm, mental anguish or illness, or deterioration of resident?s physical or mental condition.The facility failed to: 1. Implement its policy related to abuse and neglect, by not providing the care necessary to prevent neglect. 2. Provide care and services to prevent mental anguish and neglect for Resident 1 who had a rash with itching for 26 days without an anti-itch agent ordered and/or given.4. Ensure Resident 1 who had a rash for over 40 days, since admission was seen by a dermatologist after multiple treatments failed. The above violation had a direct or immediate relationship to Resident 1?s health, safety, or security. |
| 940000107 |
LONG BEACH CARE CENTER |
940010466 |
B |
12-Feb-14 |
VPCD11 |
6500 |
HSC: 1418.91 Reports of incidents of alleged abuse or suspected abuse of residents (a) A long ?term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. On 8/12/13 at 11:55 a.m., an unannounced complaint investigation was conducted at the facility regarding an incident of alleged mistreatment and fiduciary abuse of a resident by a facility staff member. Resident A alleged that Employee 1 mistreated and took advantage of him by requesting of up to $500 from him.Based on interview and record review, the facility failed to implement its abuse policies and procedures by failing to: 1. Notify the Department (State survey and certification agency) about an abuse allegation within 24 hours of the allegation of abuse in accordance with the facility?s policy.On 8/12/13 and 8/13/13, during a telephone interview between 9:30 and 10:30 a.m., Resident A stated that Employee 1 mistreated him by taking advantage of him between October 2012 and March 2013, when he was a resident in the facility. The resident stated Employee 1 requested and received monies from him on multiple occasions for gas and food in increments of $20-$40 which added up to approximately $500, because they were in a relationship. The resident stated that Employee 1 gave him her personal cell phone number and they both called each other every day during and after work hours. After the resident was discharged in March 2013, he stated that Employee 1 immediately discontinued their relationship, stopped flirting with him and disconnected her cell phone number. The resident stated he felt robbed, angry and hurt by Employee 1?s action and immediately reported her to the director of nursing (DON) and to the administrator, however nothing was done. The resident stated he reported the incident in order to prevent Employee 1 from mistreating and taking advantage of other innocent residents that were vulnerable like him.A review of Resident A?s medical record indicated that he was initially admitted to the facility on 10/5/12, with diagnoses that included diabetic retinopathy and hemodialysis. The review of a history and physical report indicated that he had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS) dated 1/1/13, indicated he had no memory problem and he maintained independent cognitive skills for daily decision making. On 8/12/13, at 1:20 p.m., during an interview, Employee 1 admitted that she gave Resident A her personal cell phone number but denied receiving money from the resident. She stated she did not recall taking any money from the resident. However, she admitted that they both spoke and texted each other on the phone frequently during work and after work hours. Employee 1 stated that a key facility staff member once caught her talking and texting on the phone during work hours and gave her a three day suspension. She stated that the DON and administrator told her they received an allegation regarding monetary issues from Resident A and that Employee 1 told them that she had nothing to do with it. Employee 1 stated was not sure if the facility did any investigation about the resident?s allegation.A review of Resident A?s written declaration statement, dated 1/9/14, and indicated that Employee 1 asked him for money for gas and other things. The resident indicated he gave $20.00 cash to Employee 1 each time she requested money, which amounted to a total of $500.00. According to the declaration, Resident A stated that Employee 1 gave him her personal cell phone number and he thought they had started a relationship. However, when he was discharged from the facility she disconnected her telephone number and discontinued their relationship. The resident stated he felt Employee 1 betrayed and took advantage of him during his stay at the facility (Long Beach Care Center). In an interview on 8/12/13, at 3:15 p.m., the DON stated that Resident A called her after he was discharged from the facility and alleged that Employee 1 was not a good nurse. The DON stated that she spoke with Employee 1 and she admitted she frequently texted the resident to check how he was doing. In an interview on 8/12/13, at 4:00 p.m., and on 10/9/13, at 3:40 p.m., the administrator also stated that the resident called him after he was discharged and alleged that Employee 1 mistreated and took advantage of him. The administrator stated that the resident also alleged that he and Employee 1 were engaged in calling and texting each other frequently when he was in the facility, however Employee 1 disconnected and discontinued her telephone service after he was discharged. The administrator stated he did not know that the resident?s allegations were reportable and therefore, did not report it to the State Licensing Agency. The DON also stated that she did not report the resident the allegations to the State Licensing Agency. Upon further review of Resident A?s medical record (investigation report, nursing progress notes), the evaluator noted that there was no documented evidence that the administrator or the DON reported the alleged incident to the Department within 24 hours according to the facility?s policy.A review of the facility's policy and procedure titled, ?Reporting Abuse to State Agencies and others Entities/Individuals:? stipulated that a suspected violation or substantiated incident of mistreatment, neglect, or injuries of unknown source, or abuse be reported. The facility administrator or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: the State Licensing/Certification Agency responsible for surveying the facility; the local/State Ombudsman; the resident?s Representative; the Attending Physician and Law enforcement officials. Verbal/written notices to agencies will be made within twenty-four (24) hours of the occurrence of such incident and be submitted via special carrier, fax, e-mail or by telephone. The facility failed to implement its abuse policies and procedures by failing to: 1. Notify the Department (State survey and certification agency) about an abuse allegation within 24 hours of the allegation of abuse in accordance with the facility?s policy.The above violation had a direct and immediate relationship to the health, safety, and/or security of Resident 1. |
| 940000107 |
LONG BEACH CARE CENTER |
940010468 |
B |
12-Feb-14 |
VPCD11 |
6637 |
F226-?483.13The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.On 8/12/13 at 11:55 a.m., an unannounced complaint investigation was conducted at the facility regarding an incident of alleged mistreatment and fiduciary abuse of a resident by a facility staff member. Resident A alleged that Employee 1 mistreated and took advantage of him by requesting monies of up to $500 from him.Based on interview and record review, the facility failed to implement its abuse policies and procedures by failing to:1. Protect the right of the resident from any form of abuse. 2. Investigate the alleged abuse immediately. 3. Notify the Department (State survey and certification agency) regarding the abuse allegation within 24 hours of the allegation of abuse.On 8/12/13 and 8/13/13, during a telephone interview between 9:30 and 10:30 a.m., Resident A stated that Employee 1 mistreated him by taking advantage of him between October 2012 and March 2013, when he was a resident in the facility. The resident stated that Employee 1 requested and received monies from him on multiple occasions for gas and food in increments of $20-$40 which added up to approximately $500 because they were in a relationship. The resident stated that Employee 1 gave him her personal cell phone number and they both called each other every day during and after work hours. After the resident was discharged in March 2013, he stated that Employee 1 immediately discontinued their relationship and stopped flirting with him. Employee 1 disconnected and discontinued her cell phone service. The resident stated he felt robbed, angry and hurt by Employee 1?s action and immediately reported her to the director of nursing (DON) and to the administrator, however nothing was done. The resident stated he reported the incident in order to prevent Employee 1 from mistreating and taking advantage of other innocent residents that were vulnerable like him.A review of Resident A?s medical record indicated he was initially admitted to the facility on 10/5/12, with diagnoses that included diabetic retinopathy and hemodialysis. The review of a history and physical report indicated that he had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS) dated 1/1/13, indicated he had no memory problems and he maintained independent cognitive skills for daily decision making. On 8/12/13, at 1:20 p.m., during an interview, Employee 1 admitted that she gave Resident A her personal cell phone number but denied receiving money from the resident. She stated she did not recall taking any money from the resident. However, she admitted that they both spoke and texted each other on the phone frequently during work and after work hours. Employee 1 stated that a key facility staff member once caught her talking and texting on the phone during work hours and gave her a three day suspension. Employee 1 stated that the DON and administrator told her that they received an allegation regarding monetary issues from Resident A and she told them she had nothing to do with it. Employee 1 stated she was not sure if the facility did a full investigation on the resident?s allegation.A review of Resident A?s written declaration statement, dated 1/9/14, and indicated that Employee 1 asked him for money for gas and other things. The resident indicated he gave $20.00 cash to Employee 1 each time she requested money, which amounted to a total of $500.00. According to the declaration, Resident A stated that Employee 1 gave him her personal cell phone number and he thought they had started a relationship. However, when he was discharged from the facility she disconnected her telephone number and discontinued their relationship. The resident stated he felt Employee 1 betrayed and took advantage of him during his stay at the facility (Long Beach Care Center). In an interview on 8/12/13, at 3:15 p.m., the DON stated that Resident A called her after he was discharged from the facility and alleged that Employee 1 was not a good nurse. The DON stated she spoke with Employee 1 and she admitted she frequently texted the resident to check how he was doing. In an interview on 8/12/13, at 4:00 p.m., and on 10/9/13, at 3:40 p.m., the administrator also stated that the resident called him after he was discharged and alleged that Employee 1 mistreated and took advantage of him. The administrator stated that the resident also alleged that he and Employee 1 were engaged in calling and texting each other frequently when he was in the facility, however Employee 1 disconnected and discontinued her cell phone service after he was discharged. The administrator stated he did not know that the resident?s allegations was reportable, therefore, he did not conduct the investigation of the allegations of abuse and mistreatment. The DON also stated she did not report the resident?s allegations to the State Licensing Agency. A review of the facility?s policy and procedure titled, ?Abuse Investigation:? stipulated that, Should an incident or suspected incident of resident abuse, mistreatment or neglect be reported, the administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The individual in charge of the investigation will consult daily with the administrator concerning the progress/findings of the investigation. The administrator will inform the resident of the results of the investigation and corrective action taken upon completion of the investigation. The administrator will provide a written report of the results of the abuse investigations and appropriate action taken, to the State Survey and Certification Agency as required by state laws within five (5) working days of the reported incident. A review of the facility investigation report on Resident A?s report of mistreatment and fiduciary abuse incident dated 6/3/13, indicated that the facility did failed to implement the above mentioned abuse investigation policy and procedures. The facility failed to implement their abuse policies and procedures by failing to: 1. Protect the right of the resident from any form of abuse. 2. Investigate the alleged abuse immediately. 3. Notify the Department (State survey and certification agency) regarding the abuse allegation within 24 hours of the allegation of abuse.The above violation had a direct and immediate relationship to the health, safety, and/or security of Resident 1. |
| 940000036 |
LYNWOOD HEALTHCARE CENTER |
940011181 |
A |
23-Dec-14 |
KPLG11 |
10501 |
Title 22 72311 (a) (1) (C) Nursing Service- General (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient?s care plan as necessary by the nursing staff and other professional personnel involved in the care The Department received an entity reported incident (ERI), dated September 27, 2013. According to the ERI, on September 22, 2013, a patient had a fall and sustained a fracture right hip. On the same day, Patient A was sent to the general acute care hospital (GACH) for evaluation and treatment. Based on record review and interview, the facility failed to: l. Revise and update Patient A?s plan of care after each fall to prevent further falls. 2. Follow the Interdisciplinary Team?s (IDT) recommendation, after the patient?s third fall, to prevent further falls. 3. Follow its policy and procedure regarding investigating falls and assessing a patient?s change of condition after each fall. These failures resulted in Patient A having seven falls. After the seventh fall, the patient complained of pain at the right hip area, which resulted in the patient being transferred to a general acute care hospital (GACH) and admitted for three days. Patient A received morphine sulfate (strong pain narcotic) 5 mg via intravenous (IV) push for pain relief. On October 4, 2013, at 11 a.m., an unannounced complaint investigation was initially conducted and a follow ?up investigation was conducted on October 27, 2014. A review of the facility?s investigation report, dated September 22, 2013, and timed at 4:55 p.m., indicated Patient A was found on the floor of his room by a staff member. According to the investigation, Patient A told the staff he was trying to go to the bathroom by himself. Patient A was assessed by the licensed nurse and put back to bed. A report titled, ?Timeline,? dated September 24, 2013, indicated on September 23, 2013, at 9:30 a.m., Patient A began complaining of moderate (5/10, 10 being the worst) right hip pain. The patient?s physician was notified and the patient was sent to the GACH for evaluation. A review of Patient A?s facility?s skilled nursing facility (SNF) medical record indicated the patient was a 86 year-old male who was initially admitted to the facility on May 24, 2011. According to the Minimum Data Set (MDS), an assessment and care screening tool, dated August 17, 2013, the patient required extensive assistance with a one-person physical assist when transferring from the bed, the chair, the wheelchair, and when in a standing position. The MDS also identified the patient as requiring extensive assistance when walking in the corridor or on the unit and required a one-person physical assist when using mobility devices, such as the walker or wheelchair. On October 27, 2014, at approximately 10 a.m., the administrator stated Patient A had several falls since his admission so the facility provided the patient with an alarm while in bed and up in the wheelchair. A review of Patient A?s incident reports from previous falls indicated the patient had the first fall on March 15, 2012. A review of a form titled, ?Change in Condition Report,? dated March 15, 2012, indicated the patient was found on the floor and told the staff he fell trying to go to the bathroom. The patient was assessed with no injuries. However, the patient was sent to the GACH secondary to the patient being on Coumadin (blood thinner) Therapy. A review of the GACH?s emergency room (ER) medical records, dated March 15, 2012, indicated the patient was seen in the ER secondary to a fall from a wheelchair. The report indicated the patient had a fall, face first onto the floor. The report also indicated the patient was evaluated and sent back to the facility the same day via an ambulance. A care plan titled, ?Actual Fall? dated March 15, 2012, indicated the goals were to reduce the patient?s risk for falls daily without adverse complications from the fall and the patient will be free of pain or discomfort. The staff?s approach was to implement fall precautions. Patient A had the second fall on May 30, 2012. The Change in Condition Report, dated the same day, indicated the patient was found on his right side in front of his wheelchair beside the patient?s bed. A review of a care plan, dated May 30, 2012, indicated the goal was to reduce the risk for falls daily, the patient will not have adverse complication from a fall, and will not have pain or discomfort. The staff?s approach was to implement fall precautions, monitor for signs of pain or discomfort, encourage patient to ask for assistance, notify physician of any significant changes in condition, conduct a post fall evaluation with 72 hour charting, and use of a pub alarm (wheelchair and bed pad that alarms when patient get up) when in bed and wheelchair. On July 2, 2012, Patient A had a third fall. The status post fall incident report, dated July 3, 2012, indicated the patient fell on July 2, 2012, and at approximately 12:45 pm was found on the floor by his wheelchair. The patient told the staff he fell while trying to get back into bed. The patient stated he felt dizzy and hit his head when he fell. According to a physician?s order, dated July 2, 2012, the patient went out to the GACH for evaluation. A review of the GACH?s medical records, dated July 2, 2012, indicated the patient was seen, evaluated and sent back to the facility the same day without injuries. The fall incident report on July 2, 2012, for the third fall, indicated the interdisciplinary team (IDT) decided the patient should be put back to bed after lunch. A review of the care plan titled, ?Actual Fall? dated July 2, 2012, indicated the goal was to reduce the risk of falls daily and adverse complications from falls. The staff?s approach remained the same as the previous May 30, 2012?s, care plan. The bed alarm entry was added, however, the plan of care did not include the IDT?s recommendation to put Patient A back to bed after lunch to decrease the risk for falls.According to a care plan, dated October 25, 2012, a certified nurse assistant took the patient down (breaking the fall) because the patient was getting up from the wheelchair and appeared to be falling. The care plan for this fall remained the same as the prior care plans. The care plan was titled, ?Actual Fall.? This fall incident was Patient A?s fourth fall. A review of a report titled, ?Interview Record,? indicated on June 21, 2013, after the patient?s family visited and left the facility, the patient had a fifth fall and was found on the floor outside his bathroom. The patient stated he was trying to go to the bathroom and fell. The patient was assessed and put back to bed. A review of the facility?s investigation incident report indicated the patient had family visiting him and when they left the family did not inform the staff. A review of the care plan for the fall risk remained the same without revision or update to prevent further falls. The only addition to the plan was to educate the family to tell the staff when they leave the facility. A review of the patient?s care plans indicated on September 20, 2013, the patient had the sixth fall while trying to go to the bathroom. However, there was no change in condition or incident report available for review. On November 12, 2014 at 11 a.m., the DON stated she did not remember the patient having a fall on September 20, 2013, because the facility would have done an investigation and a change of condition because it was the facility?s policy to do so. She stated she believed the fall was entered into a care plan by mistake. When asked who entered the information on the care plan she stated she did not know. There was no written copy of the policy available for review. According to an incident report, on September 22, 2013, Patient A had the seventh fall while trying to go to the bathroom and fractured his hip. The report titled, ?Timeline? indicated at 5 p.m., the registered nurse supervisor assessed the patient and there were no visible injuries. The patient was medicated for pain for (3/10, 10 being the worst). However, on September 23, 2013, without a time, the patient complained of severe pain and was sent out to the GACH.A review of the GACH?s medical records indicated Patient A was seen in the emergency room on September 23, 2013, at 4:23 p.m. The emergency room summary indicated Patient A sustained a fracture hip and was admitted to the GACH. The GACH discharge summary indicated the orthopedic surgeon (physician specialized in musculoskeletal treatments or surgery) evaluation of the patient was uneventful and there was no surgery planned for the hip fracture. On September 26, 2013, Patient A was sent back to the SNF. On November 12, 2014, at approximately 11:30 a.m., a subsequent interview with the DON was conducted. When asked why the patient was having so many falls, she stated the patient will not ask for help when he gets up from his wheelchair, so that was why the facility secured a wheelchair and bed alarm. When asked if the alarm was loud and could be heard at the nurse?s station, she did not answer. Patient A?s care plan goals from March 15, 2012 to September 22, 2013, were not revised or updated for each fall and the staff?s approaches were basically the same. There were no revisions after the patient fell to prevent further falls and several of the care plans did not include the continued use of the alarm. On July 2, 2012, after the patient?s fall, a care plan meeting with the IDT team recommended the plan of care should include the patient being put back to bed after lunch to decrease the risk of falls. However, the recommendation was not documented on the patient?s written care plan and was not implemented. The facility failed to: l. Revise and update Patient A?s plan of care after each fall to prevent further falls. 2. Follow the Interdisciplinary Team?s recommendation, after the patient?s third fall, to prevent further falls. 3. Follow its policy and procedure regarding investigation falls and assessing a patient?s change of condition after each fall. The above violations jointly, separately or in any combination presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. 1 |
| 940000050 |
Lighthouse Healthcare Center |
940011471 |
B |
13-May-15 |
JR0411 |
5632 |
1418.21. (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements:(1) The information shall be posted in at least the following locations in the facility:(A) An area accessible and visible to members of the public.(B) An area used for employee breaks.(C) An area used by residents for communal functions, such as dining, resident council meetings, or activities.(2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order:(A) The full name of the facility, in a clear and easily readable font of at least 28 point.(B) The full address of the facility in a clear and easily readable font of at least 20 point.(C) The most recent overall star rating given by CMS to that facility, except that a facility shall have seven business days from the date when it receives a different rating from CMS to include the updated rating in the posting. The star rating shall be aligned in the center of the page. The star rating shall be expressed as the number that reflects the number of stars given to the facility by CMS. The number shall be in a clear and easily readable font of at least two inches print.(D) Directly below the star symbols shall be the following text in a clear and easily readable font of at least 28 point:"The above number is out of 5 stars."(E) Directly below the text described in subparagraph (D) shall be the following text in a clear and easily readable font of at least 14 point:"This facility is reviewed annually and has been licensed by the State of California and certified by the federal Centers for Medicare and Medicaid Services (CMS). CMS rates facilities that are certified to accept Medicare or Medicaid. CMS gave the above rating to this facility. A detailed explanation of this rating is maintained at this facility and will be made available upon request. This information can also be accessed online at the Nursing Home Compare Internet Web site at http://www.medicare.gov/NHcompare. Like any information, the Five-Star Quality Rating System has strengths and limits. The criteria upon which the rating is determined may not represent all of the aspects of care that may be important to you. You are encouraged to discuss the rating with facility staff. The Five-Star Quality Rating System was created to help consumers, their families, and caregivers compare nursing homes more easily and help identify areas about which you may want to ask questions. Nursing home ratings are assigned based on ratings given to health inspections, staffing, and quality measures. Some areas are assigned a greater weight than other areas. These ratings are combined to calculate the overall rating posted here."(F) Directly below the text described in subparagraph (E), the following text shall appear in a clear and easily readable font of at least 14 point:"State licensing information on skilled nursing facilities is available on the State Department of Public Health's Internet Web site at: www.cdph.ca.gov, under Programs, Licensing and Certification, Health Facilities Consumer Information System."(3) For the purposes of this section, "a detailed explanation of this rating" shall include, but shall not be limited to, a printout of the information explaining the Five-Star Quality Rating System that is available on the CMS Nursing Home Compare Internet Web site. This information shall be maintained at the facility and shall be made available upon request.(4) The requirements of this section shall be in addition to any other posting or inspection report availability requirements.(b) Violation of this section shall constitute a class B violation, as defined in subdivision (e) of Section 1424 and, notwithstanding Section 1290, shall not constitute a crime. Fines from a violation of this section shall be deposited into the State Health Facilities Citation Penalties Account, created pursuant to Section 1417.2.(c) This section shall be operative on January 1, 2011. Based on observation and interview, the facility failed to post the overall facility star ratings given by the Centers for Medical and Medical Services (CMS) to the facility.On 3/29/14 at 10 a.m., during inspection of the facility's compliance with Federal postings, the facility did not post the star rating information at the front lobby or anywhere in the facility. During an interview with the director of nursing (DON) at that time, she stated she thought the star rating was posted in the framed bulletin board. Upon inspection of the framed bulletin board in the lobby with the DON, she could not find the star rating. At 10:05 a.m., an interview with the business office assistant, and upon searching for the star rating in another framed bulletin board located in the adjacent hallway, she could not find the star rating posted. The business office assistant stated they are going to post all posting information requirement. On 3/30/14 at 8:12 a.m., during a follow up interview with the business office assistant, she stated she did not know that the star rating was supposed to be posted. At 8:45 a.m., on the same day, the DON stated, ?Maybe they forgot. The Administrator was in charge of posting.?The above violation either jointly, separately, or in any combination had a direct or immediate relationship to patient health, safety, or security. |
| 940000050 |
Lighthouse Healthcare Center |
940011570 |
A |
01-Jul-15 |
JKCM11 |
17516 |
?72319. Nursing Service-Restraints and Postural Supports. (d) Restraints of any type shall not be used as punishment, as a substitute for more effective medical and nursing care, or for convenience of staff. ?72375. Pharmaceutical Service-Staff. (c) A pharmacist shall review the drug regimen of each patient at least monthly and prepare appropriate reports. The review of the drug regimen of each patient shall include all drugs currently ordered, information concerning the patient's condition relating to drug therapy, medication administration records, and where appropriate, physician's progress notes, nurse's notes, and laboratory test results. The pharmacists shall be responsible for reporting, in writing, irregularities in the dispensing and administration of drugs and other matters relating to the review of the drug regimen to the administrator and director of the nursing service. The Department received a complaint on January 6, 2014, the complaint alleged a patient (Patient 1) had various complaints regarding care, medications, food, and missing items. On January 21, 2014, a complaint investigation was initiated and a follow-up visit was conducted on July 1, 2014.The facility failed to ensure Patient 1 was free from unnecessary drugs, by: 1. Administering narcotics without a clear indication of its use. 2. Administering narcotics in the presence of potential adverse reaction due to consumption of alcohol and other narcotics. 3. Administering narcotic in duplicate therapy. 4. The pharmacist consultant not identifying irregularities of the staff continuing to administer narcotics without a clear indication of its use.These failures resulted in Patient 1 continuing to receive Norco (Hydrocodone-Acetaminophen/ a combination of acetaminophen and the opioid pain medication hydrocodone bitartrate) 5/325 milligram (mg) one tablet every six hours PRN (whenever necessary) for pain, Lorazepam 2 mg ([Ativan] used to treat anxiety disorders or anxiety associated with depression) one tablet every 4 hours as needed for anxiety, Soma 350 mg TID (three times a day) PRN (used to treat injuries and other painful muscle conditions) for muscle spasm and Ultram (an opioid pain medication which is used to treat moderate to moderately severe pain) 50 mg PRN in the presence of adverse reaction secondary to alcohol and illicit drug use while out on pass (OOP). There was no documented evidence the patient had any medical condition causing pain requiring narcotic pain medications. The staff continued to administer the narcotics to the patient after Patient 1 would return back from OOP. According to Daily MEd, a FDA approved manufacturing labelling site; patients receiving other CNS depressants, including alcohol may exhibit an additive CNS depression (refers to physiological depression of the central nervous system that can result in decreased rate of breathing, decreased heart rate, and loss of consciousness possibly leading to coma or death/specifically the result of inhibited brain activity). A review of Patient 1's Admission Face Sheet indicated the patient was a 37 year-old male who was admitted to the facility on July 26, 2013. According to the Face Sheet, the patient's diagnoses included schizophrenia (mental disorder often characterized by abnormal social behavior and failure to recognize what is real), which the patient refused to take prescribed medications to control, depression, and muscle weakness with a lack of coordination. A review of a form, titled, ?Resident Pain Re-Assessment? dated November 1, 2013, indicated under the pain site, the patient had general body pain, without specifics. A review of a Psychosocial Assessment, written by social service, dated July 29, 2013, three days after admission, indicated the patient uses alcohol and smokes (not specific). There was no documented evidence on the assessment of the patient having any medical condition resulting in pain. A psychiatric evaluation, dated December 24, 2013, indicated the patient uses medical marijuana. A review of the patient?s clinical record did not indicate a physician?s order for medical marijuana. A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated May 2, 2014, indicated Patient 1 was alert, had the ability to understand and be understood. The patient was ambulatory and required only supervision with activities of daily living (ADLs). Under Section D ? Mood indicated the patient show little interest or pleasure in doing things, feels down, depressed or hopeless, had trouble falling or staying asleep and is fidgety and/or restless. The MDS, under Section J-Health Condition, indicated the patient received no scheduled pain medications, but received PRN pain medications. The MDS indicated the staff did not provide any non-medication interventions for pain. Also, under Section J0700, it indicated an assessment of the patient?s pain was not required. A review of the facility?s policy, revised on February 15, 2010, titled, ?Care and Treatment; Pain Management,? indicated a patient with a pain related diagnosis would be assessed for pain on admission. A review of the physician's orders, dated July 26, 2013, upon the patient?s admission, indicated Norco 5/325 mg one tablet every 6 hours for severe pain and Ativan 2 mg every 4 hours PRN for anxiety; Remeron 30 mg every night for depression; Latuda 80 mg (an antipsychotic medication) twice a day to treat schizophrenia and a multiple vitamin every day. On November 29, 2013, the physician ordered Restoril 30 mg PRN at night for sleep. On February 14, 2014, Ultram 50 mg every 6 hours PRN was ordered for moderate pain. On February 22, 2014, Soma 350 mg TID PRN was ordered by the physician for muscle spasm.A review of a care plan, dated July 26, 2013 and revised on July 8, 2014, titled, ?Fall Care Plan? indicated the patient was at risk for falls and injuries related to alcohol abuse and the use of narcotic/opiates. The staff?s interventions included assessing the patient upon return from OOP for signs of intoxication with no further intervention documented such as, holding the narcotics. A review of a physician?s order, dated August 5, 2013, indicated the patient to go OOP for therapeutic purposes only. Another plan of care, dated August 14, 2013 and revised on July 8, 2014 titled, ?Pain/Chronic Plan,? indicated the patient had chronic pain with complaint of generalized body pain with a chronic use of narcotics/opiates. The staff?s interventions included referring the patient for pain management or evaluation of chronic pain in the hospital. There was no documented evidence the patient was seen by a pain management physician for pain evaluation and/or control. According to the facility?s policy, revised on February 15, 2010, titled, ?Care and Treatment; Pain Management,? under Monitoring indicated the Interdisciplinary Care Plan will reflect the location and type of pain, pharmacological, non-pharmacological interventions, with an evaluation and revisions as indicated. However, there was no care plan that indicated the patient?s type of pain and the staff?s use of non-pharmacological interventions.A review of a nurse?s note, dated December 28, 2013, and timed at 11 a.m., indicated Patient 1 told the nurse he always drank alcohol and smoked ?weed? when he went out on pass (OOP). He stated he drank while OOP the day prior (December 27, 2013) at 3 p.m.-4 p.m. The licensed nurses continued to administer the narcotics, without indication of its use, upon his return to the facility, in the presence of potential adverse reaction. According to the narcotic count sheet and the MAR, Patient 1 received two doses (total of 4 mgs) of Ativan, one doses of Norco (total 10/650 mgs) and one dose of Ultram (50 mg) prior to going OOP. One doses of Norco was administered to the patient a half-hour after returning from being OOP (after consuming alcohol). A review of the Medication Administration Records (MARs) and narcotic count sheets from January 2014-June 2014 indicated the patient received the following:January 2014 Norco 78 tablets Ultram 44 tablets Ativan 55 tablets February 2014 Norco 64 tablets Ultram 30 tablets Soma 15 tablets (ordered 2/22/2014) Ativan 65 tablets March 2014 Norco 75 tablets Ultram 40 tablets Soma 39 tablets Ativan 33 tabletsApril 2014 Norco 62 tablets Ultram 25 tablets Soma 36 tablets Ativan 24 tablets May 2014 Norco 89 tablets Ultram 35 tablets Soma 15 tablets (D/C on 5/14/14) Ativan 46 tablets June 2014 Norco 72 tablets Ultram 35 tablets Ativan 19 tablets According the patient?s clinical records, the patient started receiving Norco upon admission without a pain-related diagnosis and, per the facility?s policy, a patient receiving pain medications would be assessed for the location and type of pain being treated, which Patient 1 was not.Patient 1?s clinical records indicated the patient had received Ativan 2 mg PRN since admission (July 2013) for 12 months. According to Daily MEd, Ativan should be prescribed for short periods of time, only 2-4 weeks, and a continuous long-term use of the drug was not recommended. It also indicated the drug should not be used in patients with a primary diagnosis of depressive disorder, such as Patient 1. Daily MEd indicated Ultram should be used with caution while a patient is receiving CNS depressants such as alcohol, opioids, narcotics and/or sedatives hypnotics, which Patient 1 was receiving and the facility?s staff was aware he was drinking alcohol. Daily MEd indicated Ultram increase the risk of CNS and respiratory depression in these patients. Daily MEd also indicated the impairment of cognitive and motor skills, while using Remeron, has shown to be additive with those produced by alcohol. Thus, the patient should be advised to avoid alcohol while taking Remeron. A review of Patient 1?s Medication Regimen Review (MRR) done by the pharmacist consultant, dated January 1-16, 2014, indicated the patient was receiving two PRNs (Norco and plain Tylenol) medications containing Tylenol. The pharmacist recommended adding Tylenol not to exceed (NTE) 3 grams per day. There were no other recommendations or irregularities reported, although the patient was receiving two narcotic pain medications and a muscle relaxant frequently, without any clear indication for its use. The MAR for February 1-26, 2014, indicated the same as January 2014, to add Tylenol NTE 3 grams. The MRR for April 1-18, 2014, indicated the patient continued to refuse all routine medications (MVI, Remeron and Latuda). ?Please follow-up.? The pharmacist offered no further recommendations or reported any irregularities regarding the frequent use of narcotics for pain without any clinical diagnoses. A nurse's note, dated February 3, 2014, and timed at 2:35 p.m., indicated Patient 1 was at the nurse?s station verbalizing out loud about stealing money and people coming to him if they are having problems with any government issues. According to the note, the patient was talking to himself and the nurse gave the patient Norco (pain medication) 5/325 mg. for inability to relax. However, a review of the physician?s order, indicated this medication was prescribed for severe pain and there was no documented evidence the licensed nurse attempted a non-medication intervention prior to medicating the patient with a pain medication for relaxation.Another nurse's note, dated February 13, 2014, and timed at 8:20 p.m., indicated the patient left the facility without permission and returned at 10:30 p.m. The note indicated the patient was drunk with uncoordinated movements, slurred speech, and a staggering gait upon his return. According to the note, Patient 1 was threatening to break out the facility's windows. According to the Medication Administration Record (MAR) and the Narcotic Count Record, Patient 1 received two tablets of 2 mg Ativan and one tablet of Norco that day for pain and anxiety and was allowed to go out on pass, although the physician?s order stipulated OOP for therapeutic purposes only. A care plan titled, ?Behavior Care Plan,? dated April 18, 2014, indicated the patient had an alteration in behavior related to substance abuse/alcoholism. The staff?s intervention included informing the physician of the patient?s intoxicated state due to his use of prescribed narcotics.According to a nurse's note, dated April 18, 2014, and timed at 10:30 p.m., the patient went out on pass and came back ?drunk.? The nurse's note indicated Patient 1 approached the nurses? station with a full bottle of 40% proof alcohol (vodka). He opened the bottle in front of the nurses and drank about half of the bottle straight. The patient attempted to urinate in the hallway and on the medication cart, while walking unsteady. According to the note, the patient was "using all manners of negative and inappropriate cursing language and was re-directed, but was non-compliant.? The narcotic count sheet and the MAR indicated the patient received Norco twice that day.A physician?s telephone order, dated April 18, 2014, indicated to hold the narcotic medications until further orders. However, the narcotic count sheet and the MAR indicated the patient received Soma and Ultram the next day on April 19, 2014.Another nurse's note, dated April 27, 2014, and timed at 10:40 p.m., indicated Patient 1 returned from being OOP with an unsteady gait and hallucinating (a seemingly real perception of something not actually present, typically as a result of a mental disorder or of taking drugs) and attempted to climb on a high table while holding onto the medication cart. According to the MAR and the patient?s narcotic sheet, Patient 1 received two doses of Norco and one dose of Ativan before going OOP. According to the nurse?s note, the patient became a danger to himself and the nurses in the station. The physician was called and the patient's narcotic medication was placed on hold for 24 hours secondary to alcohol intoxication per the physician?s orders. However, according to the MAR and narcotic count sheet, Patient 1 received two doses of Norco and Ativan the next day on April 28, 2014 and three doses of Norco and one dose of Ativan the following day, on April 29, 2014. A nurse's note, dated April 28, 2014, on the 11 p.m.-7 a.m. shift, indicated the police brought Patient 1 back to the facility and the patient appeared intoxicated. According to the nurse?s note, the patient's narcotic order was placed on hold. The patient was hallucinating and the nurse documented the staff would "Continue to closely monitor, give verbal cues and re-direct patient."On June 16, 2014, the patient?s out on pass order was revoked by the physician due to the recurring episodes of alcohol intoxication and behaviors of aggression toward staff and other patients. However, as indicated in the nurse?s notes, Patient 1 continued to go OOP unsupervised, after the physician?s order, as documented in the nurse?s notes from June 17-21, 2014. On July 16, 2014, at 11:20 a.m., Staff E, a certified nurse assistant (CNA), stated she spoke with Patient 1 often and he felt people were against him. Staff E stated the patient would watch the clock and knew exactly when it was time to ask for Ativan and Norco medications. Staff E was asked about the patient's pain and stated, "The patient never appeared to be in pain and the drugs were given on a routine basis, because if he did not receive the Ativan and Norco medications he would act up." Staff E stated Patient 1 did not sleep much and refused to take his routine medications, and would only take Norco, Ativan and other pain medications.At 10:45 a.m., on July 16, 2014, Staff C, a licensed vocational nurse (LVN) stated the patient would return to the facility with his eyes watery and glossy. Staff C stated, the patient would always complain about not getting enough Ativan and Norco and when she would give the medications to the patient, he would chew them up and swallow them without water. During an interview on July 16, 2014, at 11 a.m., Staff D, another LVN, stated the patient once asked her to make an appointment for him to go and get a medical marijuana card and she stated she told him, "No." Staff D stated everyone catered to Patient 1 just to keep him calm. ?I was afraid of him and I would give him anything he wanted because he would make a big fuss about everything.?A review of the facility's policy titled, ?Pain Management,? revised on February 15, 2010, indicated the staff would comprehensively assess a patient for pain. However, there was no documentation the staff was comprehensively assessing the patient?s pain, was continually documenting that the patient had ?generalized body pain.?The facility failed by: 1. Administering narcotics without a clear indication of its use. 2. Administering narcotics in the presence of potential adverse reaction due to the patient?s consumption of alcohol and other narcotics. 3. Administering narcotic in duplicate therapy. 4. The pharmacist consultant not identifying irregularities of the staff continuing to administer narcotics without a clear indication of its use. The above violations either jointly, separately, or in any combination presented an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 940000050 |
Lighthouse Healthcare Center |
940011573 |
A |
01-Jul-15 |
JKCM11 |
16301 |
?72315. Nursing Service-Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. On January 6, 2014, the Department received a complaint alleging a patient (Patient 1) had various complaints regarding care, medications, food, and missing items. On January 21, 2014, a complaint investigation was initiated and a follow-up visit was conducted on July 1, 2014,The facility failed to ensure eight patients (Patients 2, 3, 4, 5, 6, 7, 8 and 9) were free from verbal, mental, and physical abuse from another patient (Patient 1) by not: 1. Following its policy to prevent abuse and thoroughly investigating each incident. 2. Ensuring patients were safe, free from abuse and mental anguish.These failures resulted in Patients 2, 3, 4, 5, 6, 7, 8, 9 and other patients and staff being subjected to Patient 1's verbal and physical abuse for almost 12 months, resulting in patients? mental anguish and being fearful to reside in the facility.On July 1, 2014, at 10 a.m., a complaint investigation was conducted in the facility. During a tour on Station 2, Patient 1 was observed sitting on his bed, wearing dark glasses with headphones on, playing a video game on his computer. The area around the patient's bed was cluttered with boxes, a fax machine, a large screen television, a digital video disc (DVD) player, a locked box, a telephone, and other personal items.A review of Patient 1's Admission Face Sheet indicated the patient was a 37 year-old male who was admitted to the facility on July 26, 2013. According to the Face Sheet, the patient's diagnoses included schizophrenia (mental disorder often characterized by abnormal social behavior and failure to recognize what is real), which he refused to take prescribed medication to control, depression, and muscle weakness with a lack of coordination. A written psychiatric (relating to mental illness or its treatment) evaluation from a general acute care hospital (GACH), dated July 11, 2013, which was received prior to the patient's admission to the skilled nursing facility (SNF) was reviewed. The evaluation identified the patient as being hostile with violent behaviors and threatening toward staff. The psychiatrist evaluation also referenced the patient's mother, indicating the patient stated, "I would like to get rid of my mother. I ?ll get her out of my life." The writer of the evaluation documented, "He would like to kill his mother." A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated May 2, 2014, indicated Patient 1 was alert, had the ability to understand and be understood. The patient was ambulatory and required only supervision with activities of daily living (ADLs). Under Section D ? Mood indicated the patient show little interest or pleasure in doing things, feels down, depressed or hopeless, has trouble falling or staying asleep and was fidgety and/or restless. The MDS, under Section E-Behavior, indicated Patient 1 exhibited verbally abusive and threatening behavior towards others daily.A review of an Abuse Investigation Report involving Patient 2, written by a registered nurse (RN1), dated September 8, 2013, approximately a month and half after Patient 1 was admitted to the facility, described the incident as a "love/hate relationship," indicating Patient 1 wanted to end the relationship with Patient 2. The report indicated RN1 felt the statement made by Patient 2 was not supported. The report concluded Patient 1 was transferred to another station and both patients were to be closely monitored. A follow-up to the initial abuse investigation report, dated September 12, 2013, written by the facility?s director of nurses (DON) indicated a patient (Patient 2) reported Patient 1 hit her in her right eye on September 8, 2013, when she went to his room to get her personal things. According to the report, written by the director of nurses (DON), Patient 1 denied hitting Patient 2.A review of a daily Medicare Note, dated September 9, 2013, and timed on the 11 p.m. -7 a.m. shift, indicated Patient 1 had a physical altercation with another patient (Patient 2) and was placed on 72 hour monitoring.There was a notice of proposed transfer/discharge completed by the facility and given to Patient 1, after the altercation with another patient, only a month-half after being admitted to the facility, dated September 9, 2013, to transfer the patient to another facility for a psych evaluation, but the patient refused three times. The notice indicated the needs of Patient 1 cannot be met by the facility. However, there was no documented evidence in the medical record of the transfer or discharge ever occurring, after the patient refused three times.Another notice of proposed transfer/discharge, 13 days later, dated September 22, 2013, indicated Patient 1 was to be transferred to a mental health hospital, because the patient?s needs could not be met in the facility and the safety and health of the individuals in the facility were being endangered by his presence. Patient 1 refused to be transferred.On July 2, 2014, at 12:45 p.m., during an interview, the DON stated Patient 1 was refusing to be discharged and whenever the patient found out about the impending discharge, he would go out on pass and not come back for hours.A review of nurses' notes, dated from January 2014 to July 2014, indicated the patient had multiple incidents of aggressive behaviors toward staff and peers. The staff's approaches to manage Patient 1's aggressive behaviors were to medicate with pain and anti-anxiety medications per the patient?s request, monitor, and or re-direct the patient's behaviors.A review of a nurse's note, dated January 17, 2014, and timed at 8 a.m., indicated Patient 1 stated, "I should be like the Nazis and blow this whole sh-t up so everybody can stop being so miserable around here! I hate this place.? The staff's intervention for this behavior was to continue to allow the patient to express his feelings and continue to monitor per the note.According to a nurse?s note, dated February 13, 2014, and timed at 8:20 p.m., after making rounds the nurse did not notice Patient 1 had left the facility and did not notify the staff he was leaving nor did he sign out. According to the note, at 10:30 p.m., Patient 1 returned to the facility and Patient 3, who was returning to the facility at the same time stated, he and Patient 1, had a physical altercation outside of the facility. The note indicated Patient 3 had scratches on the left side of his face. The note indicated the staff questioned Patient 1 about the altercation and he stated, "The guy was fine at the time I left him." There were no witnesses who saw the incident. The patients? physicians and police were called. According to the abuse investigative report, Patient 1 was cooperative when the police ?picked him up.?On February 18, 2014, Patient 1 accused Patient 3 of pouring water on his bed. There were no witnesses who saw the incident. At 10:20 p.m., Patient 1 called the police and reported Patient 3 as threatening him and that his life appeared to be in danger. The police responded and came to the facility and spoke to both patients. However, there was no further staff interventions documented to protect Patient 3.A review of a nurse?s note, dated March, 11, 2014, and timed at 3:15 a.m., indicated Patient 1 became aggressive toward staff and tried to hit the staff stating, ?I?m going to get you fired." Patient 1 wanted to use the telephone and the nurse tried to re-direct the patient, but all attempts failed. The charge nurse asked the patient if he still wanted to use the telephone and Patient 1 stated, ?I will use it to blow off your head.? At approximately 3:20 a.m., according to the nurse?s note, the patient was medicated with Ativan 2mg (anti-anxiety).A review of another nurse?s note, dated March 28, 2014, and timed at 9:41 a.m., indicated Patient 1 was yelling and talking loud saying it was the charge nurse's fault he ate a rotten apple the night before. According to the note, the patient continued screaming at the charge nurse and other patients that walked down the hallway. Patient 1 threatened to cause harm to other patients (Patients 5, 6, and 7), while he was escalating. The note indicated Patient 1 continued to threaten Patient 6 as he stood in the hallway. Patient 1 walked into his room yelling about the government and dead people. However, there was no documented evidence the facility's staff intervened or called the police after Patient 1 continued to escalate and threaten Patients 5, 6, and 7.A review of another nurse?s note, dated April 9, 2014, and timed at 8:25 a.m., indicated Patient 1 was observed coming out of another patient?s room yelling and cursing. Patient 1 was in the hallway of Station 2 when he began cursing and yelling at the charge nurse (LVN 1). The note indicated Patient 1 was in the LVN?s face with his fist ?balled up? to strike him. The note indicated the staff would continue to monitor, encourage patient to express his feelings and redirect behavior.Another nurse's note, dated April 17, 2014, and timed at 2:40 p.m., indicated a hard of hearing patient was walking down the hall talking loud.Patient 1 stated, ?You guys better keep her off this station before I shut her up.? The note indicated Patient 1 was medicated with Ativan 2mg and encouraged to ventilate his feelings.Another nurse's note, dated April 18, 2014, and timed at 10 a.m., indicated Patient 1 was yelling and threatening Patient 4 about using his restroom. Patient 4 was escorted away from Patient 1. Patient 1 stated he would hit him if he comes again and stated he was allowed to use any patient's restroom, but no one could use his.According to a nurse's note, dated April 27, 2014, and timed at 10 p.m., Patient 1 returned to the facility intoxicated. The patient had an unsteady gait, was hallucinating (a seemingly real perception of something not actually present, typically as a result of a mental disorder or of taking drugs) and walking the hallways going in and out of other patients? rooms, kicking barrels and moving things out of order. The nurse's note indicated the patient was encouraged to go to sleep to prevent him from falling and to avoid confrontations with other patients.A nurse's note, dated April 28, 2014, on the 11 p.m.-7 a.m. shift, indicated the police brought Patient 1 back to facility and the patient appeared intoxicated. The patient's narcotic order was placed on hold. The patient was hallucinating and the nurse documented the staff would "Continue to closely monitor, give verbal cues and re-direct patient."A care plan, dated July 26, 2013 and revised on July 8, 2014, titled, ?Risk for Altercation due to mental disorder," indicated Patient 1 was exhibiting hostile and threatening behaviors toward staff and other patients stating he would shoot and gun down the staff. The staff?s interventions included one-to-one supervision and monitoring to ensure safety of others. However, the plan of care failed to stipulate how this task would be accomplished.A care plan titled, ?Risk for further Altercations? dated February 14, 2014, indicated Patient 1 had an anti-social personality disorder, irritable moods, angry outbursts, and was abusing alcohol while receiving narcotics for pain. The staff's interventions were vague and unspecific and stipulated for the staff to accommodate the patient's needs and concerns within the facility's regulations.A review of an Interdisciplinary Team (IDT) conference conducted on July 8, 2014, after the facility's administrator and director of nurses (DON) were questioned about several patients being subjected to Patient 1?s mental and physical abuse. The IDT conference included Patient 1. The note indicated the conference was conducted secondary to patients and others safety. The IDT note indicated patients and staff were afraid of Patient 1 due to his aggressive, threatening, with outbursts of anger behaviors, and returning from out on pass to the facility intoxicated and threatening to shoot everyone.A care plan, titled, "Behavior Care plan,? dated July 15, 2014, indicated Patient 1 hits staff and threatens other patients. The staff approaches did not indicate how other patients would be protected from Patient 1's aggressive behaviors.A review of an investigative summary report, dated July 15, 2014, and timed at 7 a.m., indicated at 6:45 a.m., LVN 1 stated he was hit in the chest by Patient 1 when he told the patient to step out of another patient's (Patient 9) room. Patient 1 was heard cursing and threatening Patient 9. When LVN 1 intervened and tried to re-direct the patient, Patient 1 got in LVN 1?s face stating, "What are you going to do? I know how to beat the system. "A review of a written declaration, written by Patient 9 on July 15, 2015, and timed at 3:10 p.m., indicated Patient 1 came into his room to use the restroom at 3 a.m. When he (Patient 9) asked why he was there, Patient 1 responded, "F- - k you! I can use your bathroom and will kick your F- - king A-s.? Patient 9 stated he was afraid that Patient 1 might come back with a fork or other weapon to harm him. Patient 9 stated LVN 1 attempted to remove Patient 1 from his room and Patient 1 struck the LVN on the chest.A nurse?s note, dated July 15, 2014, and timed at 6:30 p.m., indicated the physician was called and ordered to call the PET team (psychiatric emergency team) for Patient 1 to be placed on a 5150 (involuntary psychiatric hold) and transferred out for his physical aggression toward staff and other patients. Another nurse?s note, dated July 15, 2015, and timed at 11:20 p.m., indicated the transportation ambulance and police arrived, but Patient 1 refused to comply with the police?s instructions becoming aggressive toward the police and required physical restraints to be subdued for transfer.On July 16, 2014, at 9:55 a.m., during an interview, Patient 8 stated, ?We were friends (Patients 1 and 8), when I first got here, he tried to get in my face, but I wouldn't back down and other patients here were afraid of him, but I was not." Patient 8 stated he felt Patient 1 had two personalities, and would become upset and hostile about anything if he did not get his way.During an interview, on July 16, 2014, at 11 a.m., LVN 2 stated she felt Patient 1's anger was directed towards her. She stated, "My heart would beat fast when I saw him. He was very threatening toward the male staff and would get in the faces of both staff and other patients and talked about shooting people, which was very scary to me because I do not want to get shot.? LVN 2 stated Patient 1 was very unpredictable, always talking about harming staff and other patients. When LVN 2 was questioned about training on behavior management, she stated there was no formal training provided to deal with a hostile, abusive patient such as Patient 1.A review of a facility's undated policy and procedure, titled, ?Policy on Patient Abuse and Mistreatment,? indicated the facility would establish a system to prevent not only abuse, but also practices that if left unchecked may lead to abuse. According to the policy, under Protection, it stipulated when incidents involving the health, welfare, or safety of patients are reported, the involved patient shall be removed. However, according to the facility?s documentation the facility made two attempts to remove and transfer Patient 1 out the facility for the safety of other patients, but allowed him to refuse transfer both times, thus preventing to protect the patients from being subjected to abuse and mental anguish.The facility failed by not: 1. Following its policy to prevent abuse and thoroughly investigating each incident. 2. Ensuring patients were safe, free of abuse and mental anguish.The above violation presented a substantial probability that death or serious physical or mental harm would result to Patients 2, 3, 4, 5, 6, 7, 8, 9 and other patient in the facility. |
| 940000107 |
LONG BEACH CARE CENTER |
940011579 |
A |
29-Jun-15 |
C6BJ11 |
17134 |
? 72311 (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 assessment shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and timed-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient?s condition. On August 12 and 13, 2012, the Department received an entity reported incident (ERI) from the facility indicating a patient (Patient 1) was found ?unresponsive and compromised.? The Department also received an undated and unsigned letter after the ERI investigation was initiated, alleging the facility had provided the police, family and the Department wrong information of what actually happened in the death of Patient 1 on August 12, 2012. The letter further stated there was a bottle of medication found at the bedside when the incident happened, there was vomitus seen on the patient and there was a suicide note.On August 14, 2012, an unannounced complaint investigation was initiated. The facility?s staff failed to ensure Patient 1 received the necessary care and services, including failures to: 1. Assess and monitor Patient 1 as being a suicidal risk, after the patient had been identified as having a history of suicidal thoughts and after the patient repeatedly complained of depression, anxiety, sadness and irritability requiring medications. 2. Closely monitor Patient 1?s behaviors due to her drug regimen, which included several medications (anti-psychotic, anti-depressants and anti-anxiety) known to have side effects of increased suicide risk, exacerbate moods, and could further compromise the patient?s existing conditions.3. Develop and implement a plan of care for Patient 1?s increased mood changes and in the medications regimen.The above violations resulted in Patient 1 not being initially or continuously assessed for risk of suicide. Patient 1 was admitted with a history of suicidal attempts and was receiving six medications with side effects of increased suicide risk. This created a situation that led to the suicidal death of Patient 1. A review of Patient 1?s medical record indicated the patient was a 63 year-old female, who was initially admitted to the facility on April 16, 2012, from a general acute care hospital (GACH) and re-admitted on June 2, 2012, after another GACH admission.The patient?s diagnoses included chronic obstructive pulmonary disease ([COPD] a lung disease that makes it hard to breath), diabetes mellitus (high blood sugar), hypothyroidism (a condition in which the body lacks sufficient thyroid hormone), depression, bipolar disorder (a mental illness characterized by periods of elevated mood and periods of depression), anxiety and schizophrenia (mental disorder often characterized by abnormal social behavior and failure to recognize what is real). The patient was also described as having psychomotor anxiety behaviors (a series of unintentional and purposeless motions that stem from mental tension and anxiety of an individual).A review of a psychiatric evaluation from a GACH, dated April 10, 2012, faxed prior to the patient being admitted to the facility, indicated the patient had a past history of suicidal thoughts. The patient complained at the time of not being able to sleep. The psychiatrist?s plan of treatment was to monitor the patient's medication?s side effects. According to the psychiatric evaluation, the physician indicated, it appears the medication?s side effects were responsible for the patients?confusion and change in mental status. There was no documented evidence that the facility?s staff considered the above information from the GACH as part of Patient 1's plan of care upon admission. There were no care plans to address the patient?s status as being at risk for suicidal behaviors, or suicidal attempts, or to address side effects of the medications that may cause suicidal thoughts and behaviors. On August 14, 2012, at 2:30 p.m., a telephone interview was conducted with a family member who stated he visited Patient 1 on Thursday afternoon (August 9, 2012). He stated later that night, at approximately 11:30 p.m., he received a call from the patient. The family member stated he was concerned because it was unusual for him to receive a telephone call from the patient that late. After the phone call, he stated he called the patient?s psychotherapist (a person who interacts with patients to initiate change in the patient?s thoughts, feelings, and behavior). The family member stated after receiving a call from him, the psychotherapist called Patient 1 and found the patient?s mood to be very depressed while crying over the telephone. A review of the physician?s medication orders and the Medication Administration Records (MAR) revealed the patient was receiving three anti-depressive medications (Trazodone 150 milligram (mg) every day, Wellbutrin 75 mg twice a day, and Zoloft 200 mg everyday) one anti-anxiety medication (Ativan 2 mg three times a day), one seizure medication (Tegretol 300 mg at night) and one anti-psychotic medication (Seroquel 800 mg every night). According to a Physician Desk Reference (PDR) Nurse?s Drug Handbook, 2015 Edition, all six of the medications ordered and administered to the patient had suicide listed as a side effect and indicated patients receiving such medications, should be monitored for signs/symptoms of clinical worsening and suicidality. As indicated in the PDR, the above medications had serious side effects, which could have further compromised Patient 1?s thought process and /or increased existing depression and suicidal ideations. There was little documented evidence of the nursing staff monitoring the patient's suicidal behaviors and side effects of administering the medications, such as excessive sadness, moodiness, hopelessness, sleep problems and withdrawal. A Minimum Data Set (MDS), a patient assessment and care screening tool, dated April 23, 2012, indicated under Section C - Cognitive Patterns, the patient had no problems in this area. The transfer records from the GACH identified the patient as having existing problems of depression, anxiety and a bipolar disorder. Under Section D ? Mood, which addresses behaviors, depression and attempts to harm self, was left blank, not assessed by the licensed staff, although the patient had depression and history of suicidal attempts. Section E ? Behavior, this section was checked off indicating the patient was having behavior symptoms not directed toward others. However, there was no description of the behavior symptoms recorded, although the patient had existing problems of depression and anxiety.The Care Area Assessment (CAA), dated April 28, 2012, described Patient 1 as alert, verbally responsive and able to make needs known, oriented to a certain extent with periods of forgetfulness. The assessment indicated the patient was admitted to the facility for the purpose of continued clinical monitoring, stabilization of medical condition, skilled physical therapy and occupational treatments, behavior management and seizure precautions. The assessment however, did not include Patient 1?s previous history of suicidal attempts and thoughts, nor did the assessment identify the patient as being at risk for suicide.A review of Patient 1?s care plans, dated April 16, 2012 and June 4, 2012, did not address the patient?s past history of suicidal thoughts and attempts nor did the care plan identify that the medications being administered to the patient could exacerbate suicide ideations.A psychologist?s progress notes for June - July 2012, indicated on June 7, 14, 21, 28 and July 5, 2012, the patient discussed feelings of being very sad, lonely, and depressed. The note for July 12 and 19, 2012, described the patient as feeling anxious and stressed. The note for July 26, 2012, described the patient as being angry, sad and irritated. A psychiatric progress note, dated July 2, 2012, described the patient as being withdrawn and isolated, having repetitive anxiety and unrealistic fears. During this visit, the patient?s antidepressant, Wellbutrin, was increased from 75mg once daily to 75 mg twice a day (double the amount). The Ativan was decreased from two mg three times a day to one and a half mg every 6 hours, not to exceed five mg in 24 hours.The August 2, 2012, a psychiatric progress note indicated the patient complained of having ?anxiety attacks? and continued depression. According to the note, the patient appeared anxious, but more animated than on previous visits. The Wellbutrin was further increased from 75 mg twice a day to 300 mg a day for depression (doubled the amount). The Ativan 1.5 mg every 6 hours was changed back to 2 mg every 8 hours. This change came after the patient complained to the physician (on July 26, 2012), asking why the Ativan order had been decreased. The patient wanted the medication back to the previous dose.The licensed nursing staff documented nine weekly summaries for the months of June, July, and August of 2012, of the nine summaries, seven documented no changes in the patient?s behavior, although the psychiatrist was documenting to the contrary. The nurses? summaries were also inconsistent with the hash mark documentation noted on the MARs, for example:The MAR for June 1-30, 2012, indicated the patient requested and received 64 doses of Ativan. The recorded reasons for the request were ?inability to relax.? On 17 repetitive administrations of Ativan, the nurses documented the medication was not effective. There was no documentation of the physician being notified of the ineffectiveness of the medication, nor was there evidence of attempts made using non-medication interventions. There was no documented evidence the patient was being assessed for suicidal thoughts.A review of Patient 1?s monitoring episodes of anxiety (tallied by hash marks) documented 29 incidences of the patient having psychomotor agitation. There were 34 documented episodes of the patient verbally complaining of feeling down. The monitoring for hours of sleep indicated the patient slept only 1-3 hours each night. The MAR for July 1-31, 2012, indicated the patient had 49 incidents of anxiety behaviors manifested by psychomotor agitation, which required 62 doses of Ativan. The patient however, continued to verbalize "feeling down." Patient 1 was documented to have slept between 4-7 hours each night. There was no documented evidence the patient was being assessed for suicidal thoughts.The MAR for August 1-11, 2012, indicated Patient 1 had 18 episodes of unspecified anxiety and was administered 20 doses of Ativan. Eleven doses of Ativan were given for ?inability to relax.? During this time period, the MAR indicated the patient was sleeping less from the prior month sleeping only 1-3 hours each night, but yet the nurses? summaries indicated there were no changes in the patient?s behavior. There was no documented evidence the patient was being assessed for suicidal thoughts. On the day of the patient?s death, August 12, 2012, the licensed nurses progress note indicated at 4 a.m., a certified nursing assistant (CNA C) assisted the patient to the bathroom. At 4:30 a.m., a licensed vocational nurse (LVN D) offered the patient medication, which she refused and told the nurse to come back later. At 5:30 a.m., LVN D returned to administer the patient?s medications and found the patient unresponsive with no pulse. Oxygen was given, cardiopulmonary resuscitation (CPR) was started and 911 was called. At 5:45 a.m., the paramedics arrived and ?took over. ?At 5:56 a.m., the paramedics pronounced Patient 1?s death. According to the Advanced Life Support (ALS) Assessment, written by the paramedics on August 12, 2012, the patient was found supine (lying on the back) in a hospital bed, pulseless and apneic (cessation of heart beat and breathing) by staff ?at approximately 6:00 a.m.,? last seen alive at 4:00 a.m. The paramedics report indicated rigor mortis (stiffness, a recognizable sign of death; usually starts in humans 2-6 hours after death) was present to the patient?s arms and jaw. According to the paramedic report, there were no lung sounds or apical pulse (heart beat heard over the apex of the heart with a stethoscope) for 60 seconds, no painful stimuli response, and the patient?s pupils were fixed and dilated (brain dead/no brain activity). During a telephone interview, on August 4, 2014, at 10:30 a.m., the director of nurses (DON) was asked about the document from the GACH, which indicated the patient had suicidal thoughts. She was asked what should be done when a patient has suicidal thoughts and what would she do. The DON stated, ?I would have asked the psychiatrist to do a drug reduction and I would have double checked the information provided on transfer from the GACH.? The DON also stated the patient should have been monitored closely. On August 11, 2014, at 11:30 a.m., a telephone interview was conducted with the psychotherapist, who was treating Patient 1 for two months prior to her death. The therapist stated she held the last psychotherapy session with the patient on August 9, 2012. She stated the patient was very upset and depressed about her upcoming birthday the next day (August 10, 2012). The patient cried and became very emotional. The therapist stated she received a telephone call from the patient, at approximately 11:31 p.m., that night (August 10, 2012). The patient was very sad and depressed and needed to reach out. The therapist stated she spoke with Patient 1 and discussed the idea of the patient possibly being taken to the hospital for her own safety and a suicidal assessment. The patient during the conversation with the therapist stated she had no plans on killing herself, she was just sad and needed to ?hear a friendly voice.? The therapist stated after talking to the patient, she called the facility and asked the nurses to keep an extra eye on her. According to the therapist, Patient 1 called her again on the next day (August 11, 2012), crying and was very emotional. The therapist stated she again called the facility and told the staff the patient was in her room crying, and asked them to please check on her, and the staff agreed. The therapist stated she received a call from Patient 1?s family on August 12, 2012, at 12:45 p.m., indicating the patient had committed suicide. On June 30, 2014, an interview was conducted with the administrator and DON regarding an empty bottle of medication being found at the patient?s side. Both stated they were unaware of a bottle of medication found at the patient?s bedside. They stated the patient did not appear to be suicidal; she was nice, but often stayed to herself. A review of the autopsy report, dated August 19, 2012, a coroner?s investigation report, indicated the patient had a history of three to five suicide attempts, with the last attempt being a few years ago. The autopsy indicated the patient was pronounced dead on August 12, 2012, at 5:55 a.m. The cause of death was documented as ?effects of multiple drugs.? The manner of death was documented as ?suicide.?A review of the coroner?s toxicology report, dated November 21, 2012, indicated Patient 1 had lethal levels of Cyclobenzaprine (Flexeril) at 2.1 ug/mg (ug same as mcg[microgram]) and toxic levels of Quetiapine (Seroquel) was 65 ug/ml. in the blood and heart. According to Forensic Science International, levels of Flexeril at .75 ug/ml or above are toxic and anything 0.4 ug/ml is lethal and Seroquel is toxic at 13ug/ml. The facility failed to: 1. Assess and monitor Patient 1?s suicidal risk, after having a history of suicidal thoughts and repeatedly complaining of depression, anxiety, sadness and irritability requiring medications. 2. Closely monitor Patient 1?s behaviors due to her drug regimen, which included several medications (anti-psychotic, anti-depressants and anti-anxiety) known to have side effects of suicide, exacerbate moods and could further compromise the patient?s existing conditions.3. Develop and implement a plan of care for Patient 1?s increased mood changes and increase in medications.The above violation presented an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 940000050 |
Lighthouse Healthcare Center |
940011590 |
B |
02-Jul-15 |
P3VB11 |
7641 |
F226 ?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 Department received an entity reported incident (ERI) on May 2, 2014, alleging CNA 2 was reportedly observed swinging a folded sheet, striking Resident 1 in the face. The facility failed by not: 1. Implementing its abuse policy to thoroughly investigate and report the alleged abuse incident to the administrator promptly. 2. Reporting the alleged abuse incident within 24 hours to the Department of Health and other reporting agencies. 3. Reassigning CNA 2 duties that do not involve residents' care, until the administrator had completed the review of the investigation results.These deficient practices put Resident 1 and other residents under CNA 2?s care at risk for abuse. On 5/14/14 at 7:30 a.m., an unannounced visit was made to investigate the ERI regarding the alleged abuse.A review of the facility's internal investigation, dated 5/3/14, indicated on 4/27/14 at 12:10 a.m., CNA 1 observed CNA 2 hit Resident 1 with a folded sheet during provision of care. The investigation indicated CNA 1 questioned CNA 2 as to what he was doing and he replied, "He does not let me concentrate." CNA 1 told CNA 2 he should not be hitting the resident. However, according to the investigation report, since a licensed vocational nurse (LVN 1) and a registered nurse (RN 1) did not see any signs of injuries to Resident 1, and they felt it was a "he-say/she-say situation," they did not report the incident to the administrator. According to the facility's undated policy titled, "Reporting abuse to the Administrator," facility's staff must promptly report any incident or suspected incident of resident neglect, abuse, mistreatment, or misappropriation of property to the administrator. A review of the "Nursing Staff Assignment and Sign-In Sheet" dated 4/27/14, indicated CNA 2 was not removed from resident care, as stipulated in the facility's policy instead; CNA 2 was reassigned to another resident. A further review of the facility's investigation report indicated CNA 2 informed the administrator he had just finished feeding Resident 1 some snacks, but used a folded pillow case to clean the resident's face and upper body. The report indicated CNA 2 stated he had a lot on his mind, because he was studying to become a LVN (licensed vocational nurse). According to the report, CNA2 was suspended after the incident, pending further investigation. On 5/1/14, CNA 1 informed the administrator she saw CNA 2 swinging a folded sheet hitting Resident 1 in the face. CNA 1 stated she told CNA 2 to stop, but CNA 2 told her "You are going to regret this." According to the report, on 5/2/14, a registered nurse (RN 1) and LVN 1, told the administrator since there were no signs of injuries, and it was a he-say/she-say situation, they did not report the incident to him. According to the investigation report, RN 1 and LVN 1 both were counseled, in-serviced, suspended and were given a final warning for failing to report the allegation to him and or the director of nurses (DON).On 5/14/14 at 9:20 a.m., during an interview, the administrator stated the staff did not remove CNA 2 from patient care after the incident, but instead they just changed his assignment. The administrator stated during his investigation he reported the incident to the Police Department, the Ombudsman, and the Department of Public Health (DPH).At 10:20 a.m., on 5/14/14, during an interview, CNA 2 stated after feeding Resident 1 his snacks, he dusted the food particles off using a sheet. CNA 2 stated CNA 1 came and saw what he was doing and told other staff members about it. CNA 2 stated what he did maybe was not the best standard of care, but he stated he gives good care to the residents. CNA 2 stated he told RN 1 during the shift what he had done, so they switched him to care for another resident instead of Resident 1.During an interview, on 5/14/14, at 10:27 a.m., CNA 1 stated she was walking down the hallway when she witnessed CNA 2 hit Resident 1 in the face using a sheet. CNA 1 stated she told CNA 2 to stop and she noticed the resident's face had become red, but CNA 2 responded the resident's face was always red. CNA 1 stated LVN 1 then reassigned CNA 2 to another resident.At 11:22 a.m., 5/14/14, the administrator stated he was notified about the incident on 4/29/14 (two days after the incident), but it took him until 5/1/14, to report it the Department, because he wanted to interview the staff. According to the Administrator, CNA 1 did not notify the charge nurse, but CNA 3 heard about the incident and notified LVN 1. The administrator stated the facility's staff failed to immediately report the incident to him, remove CNA 2 away from the residents, report it to DPH within 24 hours, and the Ombudsman and the local law enforcement in a timely manner.A review of Resident 1's clinical records indicated the resident was re-admitted to the facility on 1/16/14, with diagnoses that included psychosis (a loss of contact with reality that usually included false beliefs about what is taking place or who one is, and seeing or hearing things that aren't there), paranoid schizophrenia (delusions that a person or some individuals are plotting against them or members of their family), and intellectual disability (characterized by significant limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills). The Minimum Data Set assessment (MDS), an assessment and care screening tool (resident's functional capabilities, helps nursing home staff identify health problems), dated 8/5/13, indicated the resident did not speak or have the ability to understand or be understood. According to the MDS, the resident had problems with short and long-term memory problems as well as vision problems. Resident 1 was incontinent (no control) of bowel and bladder functions and required extensive assistance for all activities of daily living (ADLs) including eating.A care plan, titled, "Non-Compliance," dated 4/4/14, indicated Resident 1 was at risk for complications related to non-compliance as evidenced by refusal of ADL assistance, diagnoses of mental retardation, schizophrenia, psychosis, resistive to care, and behavior of hitting staff. The staff's approach included to avoid threats when giving care.A review of the facility's undated policy titled, "Reporting Abuse to the Administrator,? indicated the facility's staff that had witnessed or believed a resident had been a victim of mistreatment or abuse must immediately report to the administrator. The policy also stipulated the facility's staff that was accused of resident abuse, may be reassigned to duties that do not involve residents' care, or suspended from duty until the administrator had reviewed the investigation results. In addition, the policy indicated the administrator would report the alleged incident to the DPH within 24 hours.The facility failed by not: 1. Implementing its abuse policy to thoroughly investigate and report the abuse incident to the administrator promptly. 2. Reporting the abuse incident within 24 hours to the Department of Health and other reporting agencies. 3. Reassigning CNA 2 duties that do not involve residents' care, until the administrator had completed the review of the investigation results.The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1. |
| 940000036 |
LYNWOOD HEALTHCARE CENTER |
940011696 |
A |
10-Sep-15 |
QGYZ11 |
11836 |
F223 ?483.13 (b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. F465 ?483.70(h) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.The Department received an entity reported incident (ERI) on 9/11/14 alleging on 9/9/14, at approximately 12:15 a.m., an intruder entered the facility from an unlocked door by the rehabilitation department (west-side door) and entered Resident 1's room and sexually assaulted her. The facility failed by not:1. Ensuring the doors were secured locked and alarm functioning. 2. Ensuring the environment was safe. 3. Preventing Resident 1 from being sexually assaulted.These failures resulted in Resident 1 being sexually assaulted by a naked intruder, being fearful with mental anguish, having insomnia (inability to sleep) and crying spells, requiring a transfer to a general acute care hospital (GACH), for further evaluation following the sexual abuse.On 9/11/14 at 12 p.m., upon entry of an unannounced investigation of the ERI, the facility's west-side door was observed opened with the alarm mechanism disassembled and two maintenance staff working on the system. The front door of the facility had a Wander Guard alarm system intact and was functional (an alarm system that sounds a loud warning when a resident with a Wander Guard monitoring device attempts to leave the facility).During the entrance interview, at 12 p.m., the director of nurses (DON) stated the staff did not hear the alarm sound on the night of the incident, 9/9/14, at 12:15 a.m. The DON stated the registered nurse (RN) supervisors are assigned to check the doors at 8 p.m., every night, but was told by the RN supervisor the west-side door was broken.On 9/11/14, at 12:10 p.m., Maintenance Staff 1 (MS 1) was observed working on the west-side door alarm and lock, and when interviewed, he stated the alarm was not working. He stated he did not know how long the alarm had not been working and the door not locking securely.At 12:30 p.m., on 9/11/14, during an interview, the maintenance supervisor stated the entire door (West Door) was going to be replaced because it was not able to be secured and the alarm was not functioning. He stated it was the maintenance department's responsibility to maintain doors and the alarms at the facility and to verify they functioned well. The maintenance supervisor stated the west-side door was never checked by him or other maintenance staff. He stated when the door was locked, if you pulled it hard, the door would open, and the alarm did not work. The maintenance supervisor stated he was not sure how long the door and the alarm had been broken, but stated, "It had been a while."On 9/11/14, at 1:30 p.m., during an interview, a RN supervisor (RN 1) stated she was the 3-11p.m shift supervisor on the day in question and was still in the facility at 12:20 a.m. She stated she was clocking out after her shift when she was approached by a certified nursing assistant (CNA) stating there was a man in the building that was not a resident. RN1 stated the intruder was found in Resident 1's room, naked. She stated two male CNAs were called to help remove the intruder from the resident's room, and the police were called. RN 1 stated the DON, administrator, the medical director and the resident?s family were notified. RN 1 stated she assessed Resident 1 for injuries and the resident told her the intruder pulled her covers down and touched her groin area. RN 1 stated the west-side door did not lock securely and the alarm had not worked for months. She stated she had logged the broken door and alarm in the maintenance log at the nurses? station. However, a review of the facility?s maintenance logs at Nursing Stations' 1 and 2, from January 2014 through 9/11/14, indicated there were no entries addressing the west-side door not locking and the alarm not functioning. On 9/11/14, at 2:05 p.m., during an interview, a licensed vocational nurse (LVN 2) stated the evening (3 pm-11 pm shift) and night shift (11pm-7am) used the west-side door to come in and out. He stated he had not heard the alarm sound in over a month and the door was "tricky" to close.On 9/11/14, at 3 p.m., during an interview, the DON stated she was not aware the west-side door would not lock securely and that the alarm was not working. She stated the maintenance department was responsible for checking all the doors and alarms in the facility to ensure they functioned properly. The DON stated she did not know what the schedule was for checking doors and alarms and could not produce any logs verifying the doors in the facility were being checkedOn 9/11/14, at 3:35 p.m., during an interview, Resident 2, who resides in a room near Resident 1's room, stated a naked man was in her room one night, but stated the intruder did not touch her or hurt her, but she did not want to talk about it. Resident 2 was not sure of the date of the incident, but stated it was a few days prior.A review of Resident 2's face sheet indicated the resident was admitted to the facility on 7/17/12 and re-admitted to the facility on 5/23/14. The resident?s diagnoses included diabetes (a metabolic disease in which the person has high blood glucose [blood sugar]), end stage renal disease (failure of the kidneys to remove toxins from the blood), and anxiety (anxiety disorders, worry and fear are constant and overwhelming, and can be crippling).A review of a Minimum Data Set (MDS), dated 9/3/14, indicated the resident had clear speech and was able to be understood and understands others. The MDS also indicated the resident had good recall, no signs of delirium, and no behavior issues.On 9/18/14, at 6:20 a.m., during an interview, another supervisor, RN 2, stated she had worked at the facility for a month and the west-side door had not locked properly and the alarm had not functioned during that time. She stated evening and night shift staff used the west-side door to enter and exit the building. However, RN 2 stated she had been instructed the door should not be used and locked after 4:30 p.m.At 6:25 a.m., on 9/18/14, LVN 3 stated he was not on duty when the incident occurred, but stated the west-side door had not been secure for: "A long time." He stated the alarm did not work and if you pulled hard on the door from the outside, it would open.On 9/18/14, at 6:45 a.m., during an interview, CNA 1 stated she had worked at the facility for 15 years and stated the west-side door alarm and lock had not worked in a "long time." CNA 1 stated the staff used the door at night and the management of the facility was aware the west-side door?s lock and alarm did not work.On 9/18/14, at 7 a.m., CNA 2 stated she had worked at the facility for nine years. She stated the west-side door had not worked for "a long time and if you pulled hard on the door, it would open even if it was locked.? CNA 2 stated everyone knew the door was broken, but the staff continued to use the door at night although they were aware they were not supposed to.At 8:30 a.m., on 9/18/14, during an interview, Resident 1, who is Spanish speaking only, stated through a translator, that a naked man had come into her room one night. She stated the man stated he was her son and pulled her covers down and touched her (pointing to her groin area). Resident 1 stated she yelled for help and two nurses came in and took the man away. She stated they moved her into another room, so her family would feel she was safe at the facility.A review of Resident 1's medical record indicated the resident was admitted to the facility on 2/4/14 and re-admitted on 8/6/14. The resident's diagnoses included end stage renal disease ([ESRD] failure of the kidneys to remove toxins from the blood) and receiving dialysis treatments (mechanical filtration of the blood) and dementia (a decline in mental ability severe enough to interfere with daily life).A review a MDS, dated 7/14/14, indicated Resident 1 had clear speech and was able to be understood and understands others (in Spanish). The MDS indicated the resident had good recall, no signs of delirium and no behavior issues, but was Spanish speaking. The resident required extensive assistance in bed mobility, transferring from the bed to a wheelchair, ambulation, and for personal hygiene and bathing. A social service note, dated 9/9/14, and timed at 6:31 p.m., after the incident, indicated the resident had no discoloration, swelling or redness and denied any soreness, pain or discomfort to the perineal area. The note indicated Resident 1?s family member came to the facility and met with the DON, RN supervisor, and the social services director. The resident was moved to a room closer to the nurse?s station.Another social service note, dated 9/10/14 and timed at 3:36 p.m., indicated the resident felt secure in the facility, but felt she had betrayed her husband. The resident was observed with crying episodes regarding the incident.According to a ?Resident Transfer Record? dated 9/9/14 and timed at 7 p.m., indicated Resident 1 was sent to a GACH for assessment following the incident, and returned to the facility on 9/10/14. The GACH's discharge instructions indicated there were no signs of physical trauma following the incident.On 9/18/14, at 9:30 a.m., during an interview, the administrator stated he was not aware the facility's west-side door did not lock securely or that the alarm did not function. He stated the staff uses the west-side door and leaves it ajar so they can get back in. The administrator stated the staff was not supposed to use the west-side door at night or on the evening shift.A review of a care plan titled, "Blank care plan" addressing the sexual abuse allegation, dated 9/9/14, indicated the facility had implemented interventions to address the resident's fears following the incident.The review of a document titled, "Application for 72-Hour Detention for Evaluation and Treatment," received by the facility from the Police Department, dated 9/9/14, and timed 1:30 a.m., indicated an unknown male was taken into custody from the facility, after entering the facility and going into various residents? rooms naked. According to Resident 1?s psychological evaluation, dated 9/12/14, recommended by the psychiatrist, (a physician who specializes in the diagnosis and treatment of mental disorders), for the facility to monitor the resident's sleep pattern. According to the psychological evaluation, Resident 1 expressed fear of how her husband would react to the sexual abuse incident.A review of a facility's policy titled, "Safety and Supervision of Residents," written in 2001 and revised in December 2008, indicated that safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting procedures; QA&A reviews of safety incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. The policy indicated that employees shall be trained and in-serviced on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents.The facility failed by not:1. Ensuring the doors were secured locked and alarm functioning. 2. Ensuring the environment was safe. 3. Preventing Resident 1 from being sexually assaulted. The above violations, either jointly, separately, or in any combination presented an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940011768 |
B |
02-Oct-15 |
750111 |
5941 |
? CFR 483.13 ? (1) (i) F226The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. On 5/30/14 at 7 a.m., an unannounced investigation was conducted at the facility regarding an entity self-reported incident of a resident that was allegedly abused and subsequently left the facility without permission. Based on interview and record review, the facility failed to implement its abuse policies and procedures by failing to: 1. Protect the right of the resident from any form abuse.2. Investigate the alleged abuse immediately. 3. Notify the Department of Public Health within 24 hours of the allegation of abuse. A review of Resident 1's clinical records indicated the resident was admitted to the locked facility on 5/8/14, with diagnoses that included schizoaffective disorder (a mental condition that causes both a loss of contact with reality [psychosis] and mood problems [depression or mania]) manifested by hearing voices telling him to shoot himself.The Minimum Data Set assessment (a standardized comprehensive assessment and care screening tool), dated 5/27/14, indicated Resident 1 had short-term and long term memory problems, was usually understood, moderately impaired in daily decision making, inattentive, was having hallucinations (sensing things while awake that appear to be real but instead have been created by the mind), and delusions (having false or unrealistic beliefs or opinions). The Licensed Personnel Progress Notes, dated 5/10/14 at 1:30 p.m., indicated Resident 1 called the police. The note indicated the resident claimed that last night (5/9/14), an apartment manager, accompanied by a nurse, came to his room and physically assaulted him with a hammer. Resident 1 was assessed for any physical injuries and the psychiatrist was notified of the allegations. According to the police, the allegations could not be substantiated. There was no documented evidence that the staff investigated Resident 1's allegations of physical assault. A review of the Social Work Progress Notes, dated 5/13/14 (time unknown), indicated Resident 1 called the police and the social service director (SSD) and told them that someone was out to hurt him. Resident 1 kept telling the SSD that someone was hurting him. According to the notes, the police arrived but could not substantiate the allegations. On 5/15/14, the SSD notes indicated she received more calls from Resident 1 telling her someone was hurting him. The SSD told Resident 1 that no one was hurting him and he was safe. On 5/15/14, the SSD received a call from the Ombudsman?s office stating Resident 1 called that someone hurt him. The SSD told the Ombudsman that Resident 1 was delusional and that no one hurt him.A review of the Change in Condition Notice form and the Licensed Personnel Progress Notes, dated 5/15/14, on the 3pm-11pm shift, indicated Resident 1 was exhibiting behaviors of paranoid delusions (fixed, false belief that one is being harmed or persecuted by a particular person or group of people) manifested by stating someone came to his room and struck his head and shoulders using a hammer. The notes indicated Resident 1 continued to feel anxious and paranoid.On 5/30/14 at 9:08 a.m., during an interview with the assistant director of nursing (ADON) while reviewing the SSD and nursing notes, the SSD in the presence of the evaluator was not able to find any documented evidence indicating that Resident 1 was protected either by investigating the allegation of abuse or by assessing the resident for signs and symptoms of injuries as a result of the alleged abuse, when he told the staff someone was hurting him and/or was going to hurt him. The ADON was asked if Resident 1's allegation of physical abuse was thoroughly investigated, she said no.On 5/30/14 at 10:07 a.m., the assistant administrator and the administrator both stated facility staff did not report Resident 1?s abuse allegations to them. The administrator stated there was no thorough investigation of Resident 1's abuse allegations, even though Resident 1 called the Ombudsman?s office and the police himself. The facility also failed to report the allegation of abuse to the Department of Public Health. A review of the facility's policy and procedures titled, ?Reporting Abuse to Administrator?, revised 1/1/12, indicated the purpose was to protect the residents from abuse, and mistreatment by ensuring that all facility personnel, volunteers, and visitors promptly report any incident or suspected incident of resident abuse or mistreatment of resident to the administrator.The facility's policy titled, ?Reporting Abuse?, revised 9/1/13, indicated upon an allegation of abuse by a facility staff member, the facility staff member will be suspended and removed from the premises. If the allegation was regarding a resident-to-resident altercation, the residents will be separated immediately, pending the investigation. If the reportable event did not result in serious bodily injury, the administrator, or his/her designee will make a telephone report to the local law enforcement agency within twenty-four (24) hours of the observation, knowledge, or suspicion of the physical abuse. In addition, a written report shall be made to the local Ombudsman, the California Department of Public Health, and the local law enforcement agency within twenty-four (24) hours of the observation, knowledge, or suspicion of the physical abuse.The facility failed to implement their abuse policy by failing to:1. Protect the right of the resident from any form of abuse.2. Investigate the alleged abuse immediately. 3. Notify the Department of Public Health within 24 hours of the allegation of abuse. The above violation had a direct or immediate relationship to the health, safety, and/or security of Resident 1. |
| 940000050 |
Lighthouse Healthcare Center |
940011876 |
B |
02-Dec-15 |
BXS811 |
6659 |
F223?483.13(b) - Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The Department received an entity reported incident (ERI) from the facility on 5/18/15, alleging that a resident (Resident 1) was agitated and threw a tray on the floor and a certified nursing assistant grabbed the resident?s arm causing the resident to slide to the floor and sustaining a skin tear to the left forearm. On 5/22/15, at 1:15 p.m., an unannounced ERI investigation was conducted. The facility failed to: 1. Ensure Resident 1 was free from physical abuse from two certified nurse assistants (CNAs 1 and 2). 2. Follow its policy regarding combative and agitated residents. This failure resulted in Resident 1?s fall and subsequent pulling and dragging of the resident on the floor by nursing staff where the resident sustained a left forearm skin abrasion. On 5/22/15, during a record review, Resident 1's Admission Face Sheet indicated the resident was a 67 year-old female, who was admitted to the facility on 11/4/14, and readmitted on 12/19/14. Resident 1?s diagnoses included paranoid schizophrenia (a psychotic disorder), episodic mood disorder, epileptic (a brief episode of signs or symptoms due to abnormal excessive or synchronous neuronal activity in the brain), hypothyroidism, and dementia (a brain condition that causes problems with thinking and memory). A review of a Minimum Data Set (MDS), an assessment and care screening tool, dated 5/18/15, indicated the resident had short-term memory problems and her cognitive skills for daily decision-making was moderately impaired and required supervision.A review of the facility?s ?Abuse Investigation Reporting Form,? dated 5/17/15 and signed off by the administrator on 5/18/15, indicated after interviewing witnesses, Resident 1 was in the dining room and became agitated and threw a tray on the floor. One CNA (CNA1) attempted to remove the resident from the dining room and the resident fell to the floor. Another CNA (CNA2), assisted CNA 1 and they pulled and dragged Resident 1 by both legs on the floor against her will, while the resident screamed and kicked. On the report, under did the ?investigation find that the abuse occurred,? the box ?Yes? was checked. It indicated the two CNAs acted inappropriately towards Resident 1 that resulted in a skin tear to the resident?s left forearm (measuring 1.4 centimeter [cm.] by 1 cm), that required treatment. The report concluded the two CNAs were suspended pending the complete investigation of the incident, and both CNAs were sent home immediately. The facility notified the local police department of the abuse and they made a visit to the facility and took a report. On 5/22/15, at 1:15 p.m., during an interview, the administrator stated that two CNAs were involved in an altercation with Resident 1. The administrator stated residents were in the dining room waiting for lunch and Resident 1 entered the dining room, yelling at staff and asking for her tray. CNA I approached Resident 1 and explained that her tray would be located right away, but Resident 1 became agitated and demanded her tray. The administrator stated the staff tried to calm Resident 1 down, but she became more agitated and knocked the trays off the table to the floor. CNA 2 approached Resident 1 and attempted to physically remove Resident 1 from the dining room, to avoid further disturbance and protect other residents. The administrator stated during the attempt to remove the resident, Resident 1 slid down to the floor and CNA 2 continued to remove Resident 1 from the dining room, by pulling her by her legs. The resident continued to resist by kicking, striking out, and spitting. , both the CNAs continued to remove the resident by dragging and pulling the resident by the feet. As a result of being pulled and dragged, Resident 1 sustained a left forearm skin tear. A review of Resident 1's care plan titled, ?Non-Compliance,? dated 2/18/15, indicated the staff?s approach included to not force the resident to comply against her wishes. Notify the charge nurse of the non-compliance, and/or change the approach.On 5/22/15 at 2:15 p.m., during an interview, Resident 1 could not remember the incident between her and the two CNAs, but stated did not feel safe in facility. Resident 1 was not able to express why she did not feel safe in the facility.On 5/22/15 at 2:30 p.m., during an interview, the director of nurses (DON) stated that Resident 1's psychotropic medication (used to treat psychiatric conditions) had been reduced in response to a gradual dose reduction (GDR) request. The DON stated the GDR in Resident 1's medication could be the underlying cause for the resident's behavior change. A review of the CNA1?s employee file indicated she was hired by the facility on 8/25/08. CNA1 was suspended on 5/17/15 for misconduct and mistreatment toward Resident 1 and terminated after the investigation was completed on 5/22/15. A review of CNA 2?s employee file indicated she was hired by the facility on 1/15/08. According to CNA2?s employee file, she had a history of misconduct. She was suspended for three days on 6/15/09, for allowing one resident to hit another, without intervening, per the facility?s video. On 9/16/09, CNA2 was written-up for inappropriate behavior of a verbal altercation with another staff member on the work floor. On 10/9/10, she was written-up for not charting a resident?s activities of daily living (ADLs), and on 4/18/14, CNA2 was written-up again for a verbal altercation on the floor with another staff member. CNA2 was suspended on 5/17/15, due to her misconduct toward Resident 1 and was terminated after the investigation was completed on 5/22/15.A review of the facility's policy titled, ?Resident Rights, Abuse, Agitated & Combative Resident,? revised on 3/2010, indicated that all residents who demonstrate agitated or combative behaviors would have prompt intervention to prevent injury to the resident, other residents, staff or other individuals in the facility. The policy also stipulated the first staff who witnessed a combative resident would notify the DON, assistant director (ADON) or the registered nurse (RN) supervisor so they could respond to the resident.The facility failed by not: 1. Ensuring Resident 1 was free from physical abuse. 2. Following its policy regarding combative and agitated residents. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940012236 |
B |
11-May-16 |
X4NK11 |
16771 |
?483.12 (a) (7) Orientation for Transfer or Discharge
A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.
Based on interview and record review, the facility failed to:
1. Ensure that proper discharge instructions and arrangements were made for Resident 1 upon discharge.
Resident 1, who had diagnoses of dementia (a progressive loss of brain function affecting memory, thinking, and behavior) with behavioral disturbances with the lack of capacity to make her own decisions as indicated by the physician, was given discharge instructions and then dropped off at home without ensuring there was someone home to receive the resident.
As a result, Resident 1 was found by the family member wandering in the back yard unsupervised and without proper post (after) discharge care and medications.
A review of Resident 1's Face-sheet (record of admission) indicated the resident was admitted to the facility on XXXXXXX 16, with diagnoses that included dementia with behavioral disturbance, paranoid schizophrenia (a mental illness with altered perception of reality with defining feature that consist of suspicious ideas and beliefs), and autistic disorder (a serious developmental disorder that impairs the ability to communicate and interact).
A review of Resident 1's Minimum Data Set (MDS - a resident assessment and care screening tool), dated 1/18/16, indicated the resident was self-understood and understood others, was severely impaired in cognitive (mental) skills, and required limited assistance (resident highly involved in activity with staff providing guided maneuvering of limbs or other non-weight bearing assistance) in transferring and dressing with one person assistance.
A review of Resident 1's Physician and Telephone Orders, dated 1/26/16, indicated, "May discharge home XXXXXXX16; and Home health (a wide range of health care services that can be given in the home for an illness or injury) for patient/medication management." Another order, dated 1/12/16, included, "Zyprexa (a medication used to treat symptoms of paranoid schizophrenia) 2.5 milligrams (mg) one (tablet) at hour of sleep (QHS) and Aricept (a medication used to improve memory, awareness, and the ability to function) 5 mg one (tablet) every (Q) 5 p.m."
On 1/28/16 at 2:35 p.m., during an interview, the director of case management (CM 1) stated that discharge planning was initiated upon admission through scheduling of an interdisciplinary team (IDT, a group of health care professionals from different fields who work in a coordinated fashion toward a common goal for the resident) meeting and work with the family or other agencies to ensure there was coordination for discharge. CM 1 stated if the family member was not agreeable to the plan, the facility would seek alternative measures for discharge based on the resident's needs. CM 1 stated home health was arranged for Resident 1 to visit the same day as discharge. CM 1 stated that arrangements were made with another family member (FM 2) to ensure someone was home to receive Resident 1 at 7:30 a.m. on 1/27/16. CM 1 stated a message was left for FM 1 of Resident 1's discharge. CM 1 stated transportation arrangements were made by Resident 1's healthcare insurance and the case management assistant (CM 2) would follow to ensure Resident 1 got home safely.
During an interview, on 1/28/16 at 3:05 p.m., CM 2 stated he followed the transportation driver however, due to traffic lost sight of the vehicle, but he was not far behind. CM 2 stated that by the time he pulled up to Resident 1's home address, Resident 1 went through the front gate and CM 2 left. CM 2 did not wait until Resident 1 got inside the house.
During an interview and record review, on 1/28/16 at 3:30 p.m., the administrator stated Resident 1's record titled, "Initial History and Physical," dated 1/13/16, as indicated by the physician that Resident 1 did not have the capacity to understand or make her own decisions. The administrator stated that Resident 1 was not a reliable person to sign/consent for herself for discharge.
During a telephone conference call with Resident 1's family member (FM 1), on 1/28/16 at 4:20 p.m., with the assistant administrator (AA), administrator, assistant director of nursing (ADON), and CM 1 in attendance, FM 1 stated since Resident 1 has been at home, the resident had not been eating or taking her medications. FM 1 stated she was not aware home health was to follow up upon discharge. FM 1 stated Resident 1 was unable to care for herself and fearful that the resident would put herself in danger. FM 1 stated she was not the resident's caretaker.
During an interview, on 1/29/16 at 2:40 p.m., the registered nurse (RN 1) stated Resident 1 would have moments of delusions (a belief held with strong conviction despite clear and obvious evidence that it isn't true or false belief) that her daughter was out to get her. RN 1 stated an appropriate discharge would include a proper placement of the resident, where the resident was safe emotionally, spiritually, and socially. RN 1 stated the facility could not send Resident 1 home if there was no one to care for the resident because she could be a danger to self and or others. RN 1 stated Resident 1 needed monitoring and maybe an assisted living (a long-term senior care option that provides personal care support services such as meals, medication management, bathing, dressing and transportation) arrangements would be better for Resident 1 if family was not able to care for her.
During a telephone interview, on 4/27/16 at 11:10 a.m., FM 2 stated various people from the facility called him but there was never any clear plan of what was going to happen with Resident 1. FM 2 stated he was never informed of the date and time of discharge or that he needed to make arrangements to ensure FM 1 was home to receive Resident 1.
During a telephone interview, on 4/27/16 at 11:35 a.m., FM 1 stated she was not informed that Resident 1 was going to be dropped off on 1/27/16. FM 1 stated that Resident 1 did not have keys to get into the home. FM 1 stated she found Resident 1 wandering in the back yard and stated there was half an acre of land in the back that the resident could have been wandering. FM 1 stated the video surveillance camera caught Resident 1 being dropped off by a yellow minivan at 8:27 a.m. and the resident opened the gate and the driver left. FM 1 stated no one walked Resident 1 to the door to ensure she safely got inside the home.
During a telephone interview, on 4/27/16 at 12:10 p.m., the ADON stated if transportation was taking a resident home, the facility was responsible for making sure there was someone home to receive the resident and if there was not, then the resident should return to the facility.
During a telephone interview, on 4/27/16 at 12:20 p.m., the registered nurse director of the home health agency (RN 2) stated based on their medical records, no home health nurse visited on 1/27/16 or 1/28/16. The referral was placed on hold on 1/28/16.
A review of the facility's policy and procedure titled, "Discharge," dated 12/1/13, indicated that the facility should ensure that residents are discharged in full compliance with State and Federal laws. Prior to discharge, social services staff or designee would provide the resident or responsible party with reasonable notice that the resident was going to be discharged. The policy did not indicate procedures to ensure resident's safety upon discharge.
The facility failed to:
1. Ensure that proper discharge instructions and arrangements were made for Resident 1 upon discharge.
The above violation either jointly, separately, or in any combination had a direct or immediate relationship to Resident 1?s health, safety, or security. |
| 940000050 |
Lighthouse Healthcare Center |
940012287 |
A |
26-May-16 |
DWZ111 |
11770 |
F 323 ? ?483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free from accident hazards as is possible: and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The Department received an entity reported incident (ERI), alleging that a resident (Resident 1) left the facility unsupervised (eloped) and went missing on 1/9/15, and as of 1/17/15, had not been located. The facility failed to ensure the residents environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure regarding resident wandering and elopement. 2. Failure to perform resident head counts every shift (three on the day shift; four on the evening shift, and three on the night shift). 3. Failure of the staff to ensure the doors were locked and the alarm was armed. 4. Failure of the facility?s security guards to do every two hour rounds, as stipulated in their job description. These failures resulted in Resident 1 leaving the facility for over five hours before he was noticed missing. This put Resident 1, who did not have the capacity to make decisions and had medical and mental conditions that required medications for control of both, at risk for any and all dangers of being out of the facility unsupervised. According to Resident 1's Face Sheet (record of admission), the resident was a 64 year-old male who was admitted to the facility on XXXXXXX. Resident 1's diagnoses included schizophrenia (a mental disorder characterized by abnormal social behavior and failure to understand reality), hypothyroidism ([underactive thyroid] causing weight gain, fatigue, and depression), acute kidney failure (sudden and often temporary loss of kidney function), and hypertension (high blood pressure). A review of Resident 1's behavior care plan, dated 9/12/14, indicated the resident would strike out at others, was hostile, demonstrated angry outbursts, and would verbally threaten others with cursing and screaming behaviors. Another plan of care, dated 9/17/14, indicated Resident 1 had vision impairment (cataracts [a clouding of the lens in the eye leading to a decrease in vision; and possible blindness] of both eyes per an optometric consultation, dated 9/19/14). A review Resident 1's history and physical examination, dated 10/7/14, indicated that the examining physician determined that the resident did not have the capacity to understand and make decisions. A review of a physician's note titled, "SOAP Notes," dated 10/31/14, indicated Resident 1 was confused. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/17/14, indicated Resident 1 had moderate vision impairment, and was not able to correctly state the current year, month, and/or day and had poor recall. According to Resident 1's re-capped medication orders, for January 2015, the resident had orders for the following antipsychotic medications (are the treatment-of-choice for schizophrenia and similar severe mental disorders): Seroquel 200 milligram (mg) twice a day; Seroquel 400 mg at bedtime each day; Depakote 1000 mg every 12 hours and Fluphenzaine 5 mg, three times per day, since 9/10/14 and Haldol 10 mg, twice a day since 9/11/14. Resident 1 also had a physician?s order and was receiving Levothyroxine 100 mg every day for hypothyroidism and Metoprolol succinate 25 mg every day for hypertension. A review of the Facility's Report of Missing Resident Form, dated 1/10/15, indicated on 1/9/15 at 7:30 p.m., the facility's staff last saw Resident 1 in the front lobby area. The report also indicated the staff did not discover that Resident 1 was missing until 1/10/15, at 1:15 a.m.., over five hours after the resident was last seen. On 1/16/15 at 6:45 p.m., when interviewed, Administrator 1 stated that on 1/9/15 at 7:30 p.m., Resident 1 had eloped from the facility through the emergency exit doors at the end of the northwest corridor (in Station 1). Administrator 1 stated the staff did not discover Resident 1 missing until five hours and forty five minutes later, on 1/10/15, at 1:15 a.m. Administrator 1 stated that Resident 1 was never found. On 1/16/15 at 6:57 p.m., the emergency exit doors at the end of the northwest corridor were observed with a sign that indicated, "Emergency Exit Only and Alarm Will Sound." On 1/16/15 at 7:45 p.m., the facility's security tapes were observed with Administrator 1. The security tapes were observed from the time of 1/9/15 at "7:31:34" (p.m.) to 1/9/15 at 09:13:02 (p.m.), which was a time length of one hour and thirty-two minutes. On the security video, Resident 1 was observed on 1/9/15 at "7:31:34" (p.m.) at the end of the northwest corridor of the facility and that he exited from the facility on 1/9/15 at "7:32:05" (p.m.). According to the video, on 1/9/15 at 8:05 p.m., a certified nurse assistant (CNA 9) and another staff member exited the emergency exit doors at the end of the northwest corridor, and then moments later, both staff were observed re-entering the facility. Further observation of the security video indicated that there was no indication the facility's staff reacted to a possible sounding of an alarm at the exit door. On 1/16/15 at 7:57 p.m., when interviewed, Administrator 1 stated that there was no audio on the camera; however, he stated he would infer that the door alarm did not sound when Resident 1 was seen exiting through the emergency exit doors because there was no response from the facility's staff. On 1/16/15 at 8:51 p.m., when interviewed, CNA 9 stated on 1/9/15 at 8:05 p.m., she and another staff member opened the emergency exit doors so that she could go outside to lock a side gate. CNA 9 indicated that once the door closes, then a person outside of the door would not have been able to re-enter the facility without someone opening the door from the inside. On 1/16/15 at 9:03 p.m., a licensed vocational nurse (LVN 5), a charge nurse from Station 1, stated the facility's licensed nursing staff was supposed to perform a count of all the residents every two hours and record the information in the nursing stations' communication books. LVN 5 stated that it was the responsibility of all the facility's staff to ensure that the emergency exit doors' alarms were on, and that the emergency exit doors at the end of the northwest corridor had an alarm that when activated, it would emit a very loud alarm sound. LVN 5 stated on 1/9/15, during the 3 p.m. to 11 p.m. shift, he was on duty working in Station 1. LVN 5 stated that no one had reported to him that Resident 1 eloped, and that he did not hear or receive a report that the exit door alarm triggered. On 1/16/15 at 9:16 p.m., when interviewed, a registered nurse (RN4) stated the facility's staff were responsible to count all the residents at four different times during the evening shift, which included 3:30 p.m., 5:30 p.m., 8 p.m., and 10:30 p.m. RN 4 stated that Resident 1 had resided in a room in Station 3 up until the time of the resident's elopement, and the staff on Station 3 would have been responsible to include Resident 1 in the evening count. On 1/16/15 at 9:44 p.m., a licensed vocational nurse (LVN 6), Station 3A's charge nurse, stated the staff were supposed to record the results of residents' head count in the station's communication book. During the concurrent interview, Station 3's communication book, which revealed that there was no documentation the staff provided a head count of Station 3's residents on 1/9/15. LVN 6 stated, "This page is supposed to be for 1/9/15, but there is nothing here." At 9:52 p.m., on 1/16/15, when interviewed, LVN 7, Station 3B's charge nurse, stated she was the charge nurse on duty during the evening shift of 1/9/15. LVN 7 stated the staff was supposed to provide a head count of all the residents to ensure they remained present in the facility. LVN 7 stated that there was no documentation that staff ensured Resident 1's presence in the facility or that a head count of all the residents was done, during the evening shift of 1/9/15. A review of an in-service form for all licensed nurses, dated 1/10/15, indicated residents? head counts should be done every shift at specific times. Three times on the 7 a.m.-3 p.m. shift; four times on the 3-11 p.m. shift, and three times on the 11 p.m. -7 a.m. shift. The form indicated the last headcount done should be reported in the 24 hour log book and verbally endorsed and reported to the incoming shift. The facility's undated security guards job duties statement indicated that their duties included monitoring and patrolling the facility's premises to ensure that it was the free of elopement and security risks. The job duty also stipulated that the guards were supposed to patrol the facility's perimeter and interior every two hours and provide accurate documentation. On 1/16/15 at 11 p.m., during an interview with Administrator 1 and director of nursing (DON 2), the administrator stated that the security guards were supposed to conduct observation rounds. DON 2 stated the security guards and the charge nurses were responsible to ensure that the doors alarms were turned on. On 1/16/15 at 11:32 p.m., with Administrator 1 present, the emergency exit doors, at the mid-south side of the facility, near residents' Room 200, were observed and did not trigger an alarm when the exit doors were opened. Also, at 11:38 p.m., the south carport gate to the perimeter fence was observed unlocked. During the concurrent interview and observations, Administrator 1 stated that the alarms on the mid-south exit doors were supposed to alarm when the doors were opened and that the south carport gate was supposed to be locked. On 1/16/15 at 11:50 p.m., a review of the security guard's rounds logs, titled Door alarm inspection or door alarm test/activity log, indicated there was no documentation the security guards conducted observational rounds of the facility's perimeter and interior from 1/4/15 at 4:56 p.m. through 1/10/15 at 10:30 a.m. On 1/16/15 at 11:51 p.m., when interviewed, Administrator 1 stated that the security guards could not give him a good answer why the logs between 1/4/15 and 1/10/15 were missing. A review of the facility's Wandering and Elopement policy and procedure, revised on 1/1/12, indicated the facility's staff should check all doors to ensure that they are closed properly after each entry and exit. The policy also stipulated that the maintenance staff was responsible to check the alarm systems regularly to ensure they were in good working order. The facility failed to ensure the residents environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure regarding resident wandering and elopement. 2. Failure to perform resident head counts every shift (three on the day shift; four on the evening shift, and three on the night shift). 3. Failure of the staff to ensure the doors were locked and the alarm was armed. 4. Failure of the facility?s security guards to do every two hour rounds, as stipulated in their job description. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000026 |
LA PAZ GEROPSYCHIATRIC CENTER |
940012314 |
A |
10-Jun-16 |
47T411 |
14978 |
F223 ?483.13 (b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The Department received an entity reported incident (ERI) on 7/11/15, alleging a resident (Resident 1) went to his room, and while opening his locker, his roommate (Resident 2) came close to him and stated, ?Don?t bug me.? Resident 2 flicked him off and Resident 1 hit Resident 2 on the back of the head and they started fighting. Resident 1 went to the nurses? station and reported the incident. The facility failed to ensure residents had the right to be free from abuse, including but not limited to: 1. Failure to follow its policy regarding abuse and protect both residents from abuse. 2. Failure to ensure Resident 2 was counseled about his unwanted inappropriate sexual behavior. 3. Failures to assess, monitor, and develop a plan of care to address Resident 2?s inappropriate. 4. Failure to address Resident 1?s multiple complaints of Resident 2?s inappropriate sexual behavior. These failures resulted in both Residents 1 and 2 being abused. Resident 2 was not protected from physical abuse from Resident 1. These failures resulted in Resident 1 being sexually assaulted by Resident 2 (Resident 2 stuck his finger in Resident 1's crotch) and Resident 2 being physically assaulted by Resident 1 (Resident 1 reacted by punching Resident 2's head). Resident 1 sustained a right fractured hand (broken bone), requiring a transfer to a general acute care hospital and Resident 2 sustained facial scratches. On 7/13/15, at 10:50 a.m., during a recertification survey, an entity reported incident (ERI) was reported regarding a resident to resident altercation. On 7/13/15, at 1:50 p.m., during an interview, a certified nurse assistant (CNA 1) stated Resident 2 put his hand into Resident 1's crotch area (the bottom of the pelvis, the region of the body where the legs join the torso, and is often considered to include the groin and genitals) and the two residents got in a fight. On 7/13/15, at 2:05 p.m., during an interview, a registered nurse supervisor (RN 1) stated on Saturday, 7/11/15, at approximately 3:05 p.m., Resident 1 came to the nurses? station and complained that his hand hurt. Resident 1 stated he had a fight with his roommate (Resident 2) because Resident 2 put his hand in his crotch. RN 1 stated Resident 1 was transferred out to the hospital for an evaluation due to the complaint of pain in his hand. RN 1 stated Resident 2 had scratches on his right cheek with a small amount of blood. On 7/14/15 at 1 p.m., during an interview, the director of nursing (DON) stated according to Resident 1, Resident 2 was lying on the bed naked, sticking his finger out and asked Resident 1, "Do you want some of it?" Resident 1 stated Resident 2 then stuck his finger in his crotch area, so he (Resident 1) punched Resident 2. The DON stated Resident 1 sustained a hand fracture as a result of hitting Resident 2. A review of the facility's investigation report, dated 7/11/15, indicated on 7/11/15, at 3:15 p.m., Resident 1 approached Nurses Station 2 and complained that his right hand was hurting. Resident 1 stated he broke his hand while fighting with his roommate (Resident 2). Resident 1 stated while he was opening his closet, Resident 2 came close to him and attempted to hug him. Resident 1 stated he told Resident 2,"Don't hug me man,? Resident 2 flicked him off and he punched Resident 2 in the back of the head. According to the facility's investigation report, the facility's staff interviewed Resident 2 and he stated, "I came close to him and stuck my 3rd finger into his crotch area and he (Resident 1) got mad and hit me in the back of my head." Resident 2 walked away from the facility's staff and refused further interview. Resident 1 was transferred to a general acute care hospital (GACH) for a hand x-ray. The facility's physician reported to the nurses, Resident 1 sustained a fracture of the distal right fifth metacarpal bone (the bone below the pinky finger). A review of Resident 1's interview statement taken by the facility's DON, dated 7/13/15, and timed at 7:55 a.m., indicated when Resident 1 walked into his room, Resident 2 was lying on the bed naked, soliciting sex from him. Resident 2 then got up and stuck his middle finger up in his (Resident 1's) crotch. Resident 1 stated he was heterosexual (sexually attracted to people of the opposite sex) and Resident 2 was gay (a homosexual). Resident 1 punched Resident 2 on the head and both residents started fighting. The two residents rolled over each other on the floor. Resident 1 stated he stopped the fight when Resident 2 told him that it was enough. Resident 1 stated he walked out of the room and reported the incident to staff. On 7/14/15, at 7:10 a.m., during an observation, Resident 2 was lying in bed awake and alert, but refused to be interviewed. A review of Resident 2's Admission Face Sheet indicated Resident 2 was a 68 year-old male who was admitted to the facility on XXXXXXX. Resident 2's diagnoses included Alzheimer's dementia (chronic, progressive disease of the brain that effects thought, memory and the ability to function) and schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real). A review of Resident 2's Minimum Data Sheet (MDS), an assessment and care screening tool, dated 4/9/15, indicated Resident 2 was cognitively impaired (trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), but was independent in his activities of daily living (ADLs). A review for Resident 2's annual psychiatric evaluation, dated 7/13/15, and timed at 8:40 a.m., indicated the resident was admitted to a psychiatric hospital on XXXXXXX, due displaying sexually inappropriate behavior at his board and care facility. A review of Resident 2's nursing care plans indicated the resident did not have a plan of care to address his history of displaying unwanted sexually inappropriate behavior. On 7/14/15, at 2:20 p.m., during an observation, Resident 1 was sitting in the facility's activity room with a right hand sling (a device hanging from the neck to hold the hand up). Resident 1's right hand was swollen with greenish colored bruises on the back of the right hand. On 7/14/15, at 2:25 p.m., during an interview, Resident 1 stated about five days prior (two days prior to the incident) he had told the administrator and the social worker that he wanted Resident 2 to move out of his room. Resident 1 stated he told the administrator and social worker that Resident 2 tried to have sex with him. Resident 1 stated Resident 2 would say, "Let's make love," and stated Resident 2 had put his hands on him twice before the incident (Resident 1 could not remember the dates and times when the incidents occurred), but he would see Resident 2 lying in bed naked. Resident 1 stated the facility's staff offered him to move to another room, but he needed a room with a private bathroom (one room with one bathroom, used by two residents) due to his medical condition requiring self-catheterization (insert a tube/catheter into the bladder to drain the urine out of the body) throughout the day. Resident 1 stated other rooms had shared bathrooms (two rooms with one bathroom, used by eight residents). Resident 1 stated a semi-private bathroom would provide a cleaner environment, decreased the risk of his recurrent urinary tract infection. Resident 1 stated, on the day of the incident (7/11/15), he walked into his room, Resident 2 was lying in the bed naked and said, "Do you want some of this?" Resident 1 stated he ignored Resident 2, but Resident 2 stood up, walked from behind him and stuck his finger up in his crotch. Resident 1 stated putting a finger up in his crotch was an assault and he (Resident 1) stated he reacted by putting Resident 2 on the floor and hitting Resident 2's head. A review of Resident 1's Admission Face Sheet indicated the resident was a 59 year-old male who was admitted to the facility on 5/11/15. Resident 1's diagnoses included schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real), hypertrophy of the prostate (enlarged prostate) with urinary obstruction and other lower urinary tract symptoms (urinary tract infection). A review of Resident 1's Minimum Data Sheet (MDS), an assessment and care screening tool, dated 5/21/15, indicated Resident 1's cognition was intact (a person does not have trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). According to the MDS, Resident 1 did not have short or long-term memory problems and was independent in his ADLs. A review for Resident 1's psychiatric notes, dated 6/24/15 at 1:52 p.m., indicated the resident was doing well; no interim of changes or events; continued to go to groups and play his guitar. The psychiatrist documented Resident 1's only complaint was his roommate (Resident 2) was gay. Resident 1 told the psychiatrist (a physician who specializes in psychiatry, in the diagnosis and treatment of mental disorders) [per the note] that Resident 2 "come on to me." Resident 1 stated Resident 2 should be moved and that he deserves to stay in his room. The psychiatrist's note indicated for the facility's staff to work with Resident 1 to resolve the issue. A review of another of Resident 1's psychiatric note, dated 7/1/15, and timed at 3:05 p.m., indicated the resident was doing well, no interim changes or events. It was documented Resident 1's only complaint was that his roommate bothers him and was "gay and crazy." According to the note, Resident 1 told the psychiatrist, ?that he spends most of his time out of the room, going to groups, so he had not got into any fights with his roommate.? A review of Resident 1's nursing care plans, indicated the resident did not have a care plan in place to address the resident's concern regarding his roommate?s constant attempts to solicit sexual behavior from him after Resident 1 complained about Resident 2's inappropriate sexual behaviors. A review of the physician's order, dated 7/11/15, and timed at 3:45 p.m., indicated Resident 1 had a physician's order to obtain an x-ray of the right hand immediately, to administer Ibuprofen (an anti-inflammatory, used for treating pain) 400 milligrams (mg) by mouth every four hours, as needed for pain and to provide an ice pack to the right hand. A review of Resident 1's x-ray results, dated 7/11/15, and timed at 7:30 p.m., indicated Resident 1 sustained a comminuted fracture (break or splinter of the bone into more than two fragments) of the fifth metacarpal diaphysis (intermediate part of the skeletal hand located between the phalanges [are digital bones in the hands and feet] of the fingers and the carpal bones of the wrist). On 7/11/15, at 8:45 p.m., Resident 1 had a physician's order to transfer to a GACH's emergency room for evaluation of fractured hand. A review of the GACH's note, dated 7/11/15, indicated Resident 1 had a metacarpals fracture (boxer's fracture, breaks in the neck of the second and third metacarpal bones) and a hand splint was applied (a device that support injured limbs; to keep bones from moving while they heal). The GACH's note indicated for Resident 1 to immediately follow-up with an orthopedist (a physician who specialized in bones) and the primary care physician in two to three days and to return to the emergency department (ED) if the symptoms worsen. A review of the nurses' note, dated 7/12/15, and timed at 2:36 a.m., indicated Resident 1 returned to the facility from the ED via gurney at 2 a.m., with a diagnosis of Boxer's Fracture with a hand splint applied to the right hand. Resident 1 was temporarily placed in another room. A review of the nurses' note, dated 7/12/15, and timed at 11:02 p.m., indicated Resident 1 requested a room change due to "feeling uncomfortable," in his current room. The resident became upset, yelled at the staff and stated it was unfair that he had to move instead of his roommate, (Resident 2), who initiated the whole incident by trying to touch him in a sexual manner. The nurses' note indicated Resident 1's nurse advised the resident that he could return to his previous room, with Resident 2, if he chooses to do so. Resident 1 declined and stated "not with that faggot." On 7/14/15, at 3:10 p.m., during an interview with the facility's social worker, she stated Resident 1 requested to have Resident 2 moved to another room. The social worker stated Resident 1 verbalized that he thought Resident 2 was gay and wanted to have sex with him (Resident 1). A review of Resident 2's medical record indicated there was no documented evidence Resident 2 was counseled about his inappropriate sexually behavior related to the facility's abuse policy. There was also no documented evidence that the facility asked Resident 2 to make a room change, due to Resident 1's need to have a semi-private bathroom. On 7/14/15, at 3:20 p.m., during an interview, the facility's clinical director stated Resident 1 had talked about room changing, but there was no open bed available for a male resident. The clinical director stated when there was a room available, Resident 1 refused to move, because Resident 1 requested for his roommate to move. The clinical director stated since Resident 1 was the one who requested for the room change, he had to move, not his roommate. A review of the facility's policy, dated 4/10/13, and titled, "Policy and Procedure on Abuse Reporting," defined sexual abuse as "sexual harassment, sexual coercion and sexual assault are examples." The policy also indicated that each resident had the right to be free from abuse (including physical and sexual abuse). The policy stipulated Residents must not be subjected to abuse by anyone, including but not limited to, other residents. The facility failed to ensure residents had the right to be free from abuse, including but not limited to: 1. Failure to follow its policy regarding abuse and protect both residents from abuse. 2. Failure to ensure Resident 2 was counseled about his unwanted inappropriate sexual behavior. 3. Failures to assess, monitor, and develop a plan of care to address Resident 2?s inappropriate. 4. Failure to address Resident 1?s multiple complaints of Resident 2?s inappropriate sexual behavior. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940012411 |
B |
18-Jul-16 |
5LG411 |
5288 |
483.13(c)(2)
The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
On 10/1/15, at 4:25 p.m., an unannounced visit was conducted at the facility to investigate an entity reported incident (ERI) alleging Resident 1 had an injury of unknown origin.
Based on interview and record review, the facility failed to:
1. Report an injury of unknown origin immediately (as soon as possible but not to exceed 24 hours after discovery of the incident) or within 24 hours of the observation, knowledge, or suspicion of the physical abuse to the Department (Licensing and Certification Program).
The family member (FM 1) made an allegation that Resident 1 was hit by someone and left a mark on resident's left side of the face on 9/22/15. The facility did not report the allegation to the Department until 10/4/15, 12 days after the allegation was made.
During an interview on 10/1/15 at 4:25 p.m., the director of nursing (DON) stated that Resident 1 had discoloration noted to the left side of her cheek and the origin of the discoloration was unknown and neither can anyone indicate how Resident 1 acquired it. The DON stated that the incident was not reported to the Department of Public Health.
During an interview on 10/1/15, at 4:35 p.m., the assistant DON (ADON) stated the incident occurred on 9/22/15 during the 3-11 p.m. shift. ADON stated certified nursing assistant 1 (CNA 1) reported the discoloration of resident's face to the charge nurse, but failed to report the incident to the Department of Public Health.
A review of Resident 1's Face Sheet (record of admission) indicated the resident was initially admitted to the facility on XXXXXXX11 and was re-admitted on XXXXXXX14 with diagnoses that included hypertension (high blood pressure), and unspecified convulsions (abnormal, involuntary contraction of the muscles most typically seen with certain seizure disorders).
The quarterly Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/18/15, indicated that Resident 1 was sometimes able to make his needs known and understand others. Resident 1 was severely impaired in cognitive skills (never/rarely made decisions), and totally dependent with one person physical-assist from the staff in transferring, toileting, and personal hygiene.
During an interview on 5/12/16, at 3:15 p.m., CNA 1 stated he remembered that Resident 1 was with family when he conducted his rounds on 9/22/15 at the start of his shift from 3 p.m.-11 p.m. CNA 1 stated the family and resident did not need anything at that time. CNA 1 stated he returned later at dinner time to feed the resident and he noted the bruising on the resident's face which he verbally reported to the team leader. CNA 1 assumed the team leader then told the charge nurse. CNA 1 stated it was swollen like someone had hit Resident 1.
FM 1 stated during a telephone interview on 5/18/16, at 1:30 p.m., that she went to visit Resident 1 and noticed a bruise to the left chin area like someone had punched him. FM 1 stated whenever she visited Resident 1, she would see other residents coming into the resident's room and going to other resident?s rooms as well. FM 1 stated she did not like the free flow of resident in and out of rooms because Resident 1 could not move and protect himself from other residents who were mentally/impaired/challenged in cognitive skills. FM 1 stated the facility did not report or do anything about the incident.
A review of 11/6/15, facility's policy and procedure titled, "Abuse-Prevention Program," indicated an injury of unknown source was defined as an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury, the location of the injury (for example, the injury is located in an area not generally vulnerable to trauma).
A review of 11/18/15, facility's policy and procedure titled, "Abuse-Reporting & Investigations," indicated the facility would report all allegations of abuse as required by law and regulations to the appropriate agencies. The facility promptly and thoroughly investigates reports of abuse, mistreatment, neglect, or injuries of an unknown source when appropriate. The administrator or designee would notify law enforcement, long term care Ombudsman, and California Department of Public Health (CDPH) Licensing and Certification by telephone immediately or as soon as practicable, an in writing (SOC 341) within 24 hours including weekends of all other allegations of abuse.
The facility failed to:
1. Report an injury of unknown origin immediately or within 24 hours of the observation, knowledge, or suspicion of the physical abuse to the Department.
The above violation had a direct or immediate relationship to the health, safety, and/or security of Resident 1. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940012500 |
A |
19-Aug-16 |
MBD511 |
15743 |
?483.13(c)(1)(i) Staff Treatment of Residents
(1) The facility must ?
(i) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility?s identification of residents? whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis.
?483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
?483.75(i) Medical Director
(1) The facility must designate a physician to serve as medical director.
(2) The medical director is responsible for ?
(i) Implementation of resident care policies; and
(ii) The coordination of medical care in the facility.
On 7/28/14, at 3:15 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 1, who was in bed when Resident 2 hit her on the face with her shoe.
Based on interview, and record review, the facility failed to adequately provide care and services to prevent physical harm, including but not limited to:
1. Failure to protect Resident 1 from Resident 2 who was known to have escalating audio-hallucinatory (A perception in the absence of external stimulus that has qualities of real perception) behaviors.
2. Failure to identify other appropriate non-pharmacological (that includes transfer to psychiatric unit) and/or pharmacological interventions when Resident 2 refused to take two antipsychotic medications Risperdal by mouth, and Haldol Lactate injection PRN (as needed) on 6/13/14, at 5 p.m. and 6/14/14, at 9 a.m. These medications were prescribed for the treatment of Schizophrenia (mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation).
3. Failure to follow the physician?s order to administer Haldol Lactate injection when Resident 2 refused Risperdal on 6/13/14, at 5 p.m., and to administer Haldol Lactate 2.5 milligrams (mg) for twice a day PRN intramuscularly (IM, medication given through injection into deep muscle) ordered on 6/14/14 for anxiety behavior manifested by restlessness when Resident 2 had episodes of restlessness on 6/15/14 and 6/16/14, at 11 p.m. to 7 a.m., shift and on 6/17/14, on the 7 a.m. to 3 p.m., shift.
4. Failure to monitor, evaluate and analyze if the facility is equipped to care for Resident 2 who had escalating audio-hallucinatory behavior after the routine Risperdal was discontinued on 6/14/14, and refusing the Haldol injection as indicated in the facility's policy and procedure.
5. Failure to notify Resident 2?s psychiatrist of Resident 2?s escalating behavior after the Risperdal was discontinued, and refusal of Haldol injection.
6. Failure to notify Resident 2's primary care physician, who is also the facility?s medical director of Resident 2?s escalating behavior after the Risperdal was discontinued by the psychiatrist, and refusal of routine and as needed medication to provide further clinical guidance, and to ensure the resident was receiving adequate care.
As a result, Resident 2 attacked Resident 1 with her shoe while Resident 1 was sleeping. On 7/27/14, at 3:15 a.m., certified nursing assistant (CNA 1) found Resident 2 hitting Resident 1 on the face and hands with her shoe.
Resident 1 sustained the following injuries:
a. A bruise and swelling of the left forehead.
b. A bruise and swelling of the left eye.
c. A swelling of the left side of the face.
d. A bruise and swelling of the upper and lower lip
e. Swelling of the left hand.
f. Discoloration of the right ear.
Resident 1 was transferred to a general acute care hospital (GACH) for evaluation. The GACH Emergency Report (ER) dated 7/27/14 indicated Resident 1 had significant amount of soft tissue swelling of the left face. Both arms and hands were with ecchymosis (discoloration of the skin resulting from bleeding underneath the skin). The ER final impression indicated acute (new) contusions (bruise caused by blunt trauma to muscle).
A review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility on XXXXXXX14, with diagnoses that included urinary tract infection (infection of the kidneys, bladder and urethra), generalized muscle weakness, hypertension (increased blood pressure), and dementia (decline in mental ability).
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/18/14, indicated Resident 1 was disoriented to year, month, and day. The MDS indicated that Resident 1 had short and long term memory problems, and had no physical and verbal behavioral symptoms (hitting, kicking, and scratching) toward others.
A review of Resident 1's Licensed Personnel Progress Notes, dated 7/27/14, at 3:15 a.m., indicated certified nursing assistant (CNA) 1, heard someone crying in Resident 2's room. The document indicated CNA 1 found Resident 2 hitting Resident 1 on the face and hands with her shoe. The document indicated Resident 1 sustained a bruise on the left forehead, swelling of the left eye, both arms and left hand and right ear discoloration. The document indicated the physician was notified and Resident 1 was transferred to GACH for evaluation.
A review of the GACH Emergency Department Report Record, dated 7/27/14, at 7:15 a.m., indicated that Resident 1 was admitted with facial and arm bruising. Resident 1 had " ...significant amount of soft tissue swelling of the left face with ecchymosis" (discoloration of the skin resulting from bleeding underneath the skin). Resident 1 had ecchymosis to both arms and hands. The ER final impression indicated acute contusions.
A review of the facility's Licensed Personnel Progress Notes, dated 7/27/14, at 9:55 a.m., indicated that Resident 1 returned to the facility after evaluation from the GACH. The notes indicated Resident 1's left side of the forehead; left cheek and left chin were swollen with purple and red discoloration. Resident 1's left eye was swollen and partially closed with purple and red discoloration. Resident 1's nasal area was red and the right nostril was with small amount of bleeding. The upper and lower lips were swollen with dark purple discoloration. Resident 1's left shoulder was swollen with purple and red discoloration extending to the upper arm. The left and right posterior (back) hands, fingers, and wrists were swollen with dark purple discoloration. The right lower eyelid was swollen and the right upper eyelid with redness. The right outer ear was with purple red discoloration. Resident 1's left upper back was with purple and blue discoloration.
A review of Resident 2's Admission Record, indicated Resident 2 was admitted to the facility on XXXXXXX14, with diagnoses that included schizophrenia, metabolic encephalopathy (disorder of the brain), and hyperlipidemia (high cholesterol in the blood).
Resident 2's MDS, dated 6/19/14, indicated Resident 2 was disoriented to year, month, and day. The MDS indicated that Resident 2 had behavior of delusions (misconceptions or beliefs that are firmly held contrary to reality), and had difficulty focusing, and a continuous disorganized thinking behavior was present.
A review of Physician's Orders, dated 6/10/14, at 4:30 p.m., indicated Resident 2 had an order for Risperdal 3 milligrams (mg), two times a day to be given by mouth for schizophrenia manifested by auditory hallucination. On the same date an order for Haldol Lactate 5 mg two times a day PRN to be given IM if Resident 2 refused the Risperdal. The physician's order also indicated for Resident 2 to have a psychiatrist consult for schizophrenia.
The Licensed Personnel Progress Notes dated 6/10/14, at 5:05 p.m., indicated the psychiatrist was notified and to continue the Risperdal routinely and Haldol PRN.
A review of Resident 2's Medication Administration Record (MAR), for the month of 6/2014, indicated Resident 2 received Risperdal 3 mg at 9 a.m., and 5 p.m., on 6/10/14, 6/11/14 and 6/12/14. On 6/13/14, Resident 2 received Risperdal 3 mg at 9 a.m., and refused the 5 p.m., dose. On 6/14/14, Resident 2 refused the 9 a.m., dose of Risperdal. There was no indication that Haldol Lactate {(antipsychotic medication- 5 mg; for up to two times a day as needed (PRN)}, was given intramuscularly when Resident 2 refused the Risperdal on 6/13/14, at 5 p.m.
A review of the Licensed Personnel Progress Notes, dated 6/14/14, at 2 p.m., indicated Resident 2 refused the Risperdal by mouth and Haldol IM. At 2:20 p.m., the Licensed Personnel Progress Notes indicated the psychiatrist was notified by telephone and an order was received to continue to encourage Resident 2 to take her medications. At 6 p.m., the documentation indicated the psychiatrist was notified by telephone that Resident 2 refused the afternoon medications. The psychiatrist however, discontinued the Risperdal 3 mg and decreased the Haldol Lactate from 5 mg to 2.5 mg, IM, as needed two times a day for anxiety behavior manifested by restlessness. There was no documentation that Resident 2 was seen by the psychiatrist.
A review of the behavior hash mark monitoring on the MAR for the month of 6/2014, for anxiety manifested by restlessness, indicated on 6/15/14 and 6/16/14, on the 11 p.m. to 7 a.m., shift and on 6/17/14, on the 7 a.m. to 3 p.m., shift Resident 1 had three episodes of restlessness. There was no documented evidence that Haldol Lactate 2.5 mg IM was given to the resident and/or an attempt was made to administer this medication to the resident.
Further review of the MAR record for month of 6/2014 indicated that Resident 2 also refused all her 9 a.m., medications on 6/14/14, 6/15/14, 6/18/14, 6/20/14, and 6/22/14, and all her 5 p.m., medications on 6/14/14 and 6/20/14. There was no documented evidence that the physician was notified of Resident 2?s incidents of medication refusal.
A review of the Licensed Personnel Progress Notes, dated 7/27/14, at 1 a.m., and 2:20 a.m., indicated Resident 1 was sleeping. At 3:15 a.m., the Licensed Personnel Progress Notes indicated a CNA heard a resident crying. The CNA found Resident 2 hitting Resident 1 on the face and hands with her rubber shoe. The Licensed Personnel Progress Notes indicated Resident 2 was unable to explain why she hit Resident 1. The Licensed Personnel Progress Notes indicated at 4 a.m., the psychiatrist was notified and Resident 2 was transferred to a GACH for evaluation.
On 7/28/14, during an interview, Resident 2 stated she hit Resident 1 because Resident 1 was bothering her and keeping her up at night for the past four (4) months. However, Resident 2 was admitted on XXXXXXX14 less than 4 months before the incident on 7/27/14.
On 8/11/14, at 3:20 p.m., during an interview with CNA 2, she stated that there were two incidents when Resident 2 was in the facility's dining room and there were no other residents in the dining room. CNA 2 stated she observed and heard Resident 2 "...yelling stop, stop." CNA 2 stated she had thought that Resident 2 was seeing things. There was no documentation that this observation was reported to licensed nurses and the resident behavior was monitored.
On 8/11/14, at 4:10 p.m., during a telephone interview, the psychiatrist stated that Resident 2 had paranoia (a mental illness that causes extreme feelings that others are trying to harm you), and her mood was unpredictable. He stated that he did not see Resident 2 until the incident of hitting Resident 1.
On 8/11/14, at 4:50 p.m., during a telephone interview, Resident 2's primary care physician, also the medical director of the facility stated that "When Resident 2 refused taking her psychotropic medication it can exacerbate her condition, when it might have been well controlled before." The primary care physician stated when the medication was stopped on 6/14/14, it put the resident back into acute psychotic symptoms (An abnormal condition of the mind described as involving a "loss of contact with reality").
On 6/20/16, at 11 a.m., during an interview with registered nurse supervisor (RNS), she stated Resident 2 would write symbols on her headboard, her behavior was unpredictable and she hit anybody after the Risperdal was discontinued. RNS was unable to provide documented evidence that Resident 2's audio-hallucinatory behavior was monitored after the Risperdal was discontinued. There was no documentation that the resident's primary care physician and/or psychiatrist were notified of the resident escalating behavior.
A review of the facility's policy and procedures dated 8/01/2010, and titled "Medication Monitoring and Management" indicated that, in order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, attending physician/prescriber, and the consultant pharmacist must perform ongoing monitoring for appropriate, effective, and safe medication use. The resident is evaluated before initiating, withdrawing, or withholding medication(s), or using no-pharmacologic approaches.
The facility failed to provide care and services to prevent physical harm, including but not limited to:
1. Failure to protect Resident 1 from Resident 2 who was known with escalating audio-hallucinatory behavior.
2. Failure to identify other appropriate non-pharmacological and/or pharmacological interventions when Resident 2 refused to take two antipsychotic medications Risperdal by mouth, and Haldol Lactate injection PRN on 6/13/14, at 5 p.m. and 6/14/14, at 9 a.m. . These medications were prescribed for the treatment of schizophrenia.
3. Failure to follow the physician?s order to administer Haldol Lactate injection when Resident 2 refused Risperdal on 6/13/14, at 5 p.m., and to administer Haldol Lactate 2.5 milligrams (mg) for twice a day PRN IM ordered on 6/14/14 for anxiety behavior manifested by restlessness when Resident 2 had episodes of restlessness on 6/15/14 and 6/16/14, at 11 p.m. to 7 a.m., shift and on 6/17/14, on the 7 a.m. to 3 p.m., shift.
4. Failure to monitor, evaluate and analyze if the facility is equipped to care for Resident 2 who had escalating audio-hallucinatory behavior after the routine Risperdal was discontinued on 6/14/14, and refusing the Haldol injection as indicated in the facility's policy and procedure.
5. Failure to notify Resident 2?s psychiatrist of Resident 2?s escalating behavior after the Risperdal was discontinued, and refusal of Haldol injection.
6. Failure to notify Resident 2's primary care physician, who is also the facility?s medical director of Resident 2?s escalating behavior after the Risperdal was discontinued by the psychiatrist, and refusal of routine and as needed medication to provide further clinical guidance, and to ensure the resident was receiving adequate care.
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000026 |
LA PAZ GEROPSYCHIATRIC CENTER |
940012543 |
B |
26-Aug-16 |
J3S611 |
9562 |
Staff treatment of Residents ?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 Department received an entity reported incident (ERI) on 9/9/15, alleging a resident (Resident 1) grabbed his roommate (Resident 2) wrists, and when Resident 1 released Resident 2?s wrists, Resident 2 suddenly hit Resident 1 on the right side of his face. Resident 2 sustained redness and complained of mild pain to his face. Based on interview and record review, the facility failed to ensure that residents were free from physical and mental abuse from a resident who was known with aggressive behavior by failing to: 1. Ensure that Resident 2 was immediately removed from Resident 1?s room, after the physical altercation incident with Resident 1. Resident 1 and Resident 2 were roommates and as a result, Resident 1 became afraid and felt unsafe in the presence of Resident 2. 2. Ensure that Resident 2 was monitored closely after the first physical altercation with Resident 1 and as a result, Resident 2 physically assaulted another roommate, Resident 3. Resident 3 sustained a scratch and redness on his left hand. 3. Develop an abuse policy and procedure that addressed specific interventions for protecting a resident (victim) after a resident to resident altercation. On 9/21/15, at 2:20 p.m., during an interview with Resident 1, he stated that his roommate assaulted him. He stated that he is legally blind, and that he had been telling everybody that he was afraid of Resident 2. Resident 1 further stated that while he was lying down in bed, Resident 2 came over and started punching him. A week after, that they were involved in another altercation outside of the bathroom. Resident 1 stated that he told the doctor, medication nurse, and the social service designee, but nobody did anything about it. Resident 1 stated that he did not feel safe with Resident 2 in his room, and was not interested in going to another room. Resident 1 stated he wanted Resident 2 to go to another room. A review of Resident 1's Admission Record (Face Sheet) indicated, that he was admitted to facility on 9/6/12 with diagnoses that included depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and insomnia (inability to sleep). The Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/7/15 indicated Resident 1 had adequate hearing, clear speech, makes self-understood, and had the ability to understand others. Resident 1's cognitive skills for daily decision-making were severely impaired. The MDS indicated the resident's vision was severely impaired (had no vision or sees only light, colors or shapes, eyes do not appear to follow objects). A review of Resident 2's Admission Record indicated the resident was admitted to the facility on 8/21/14 with diagnoses that included schizoaffective disorder (A mental condition that causes both a loss of contact with reality and mood problems (depression or mania), senile dementia (A loss of mental ability severe enough to interfere with normal activities of daily living), and depressive disorder. The MDS dated 7/13/15 indicated that Resident 2 had clear speech; makes self-understood and had the ability to understand others. The resident's cognitive skills for daily decision-making were severely impaired. The MDS indicated the resident had signs and symptoms of delirium (A state of mental confusion that develops quickly and usually fluctuates in intensity). A care plan was developed on 7/6/15 to address issues of periods of confusions and concerns that Resident 2 gets easily irritated. The interventions included to explore what triggers irritability, his aggressive behaviors, and possibly eliminate triggers in order to be able to prevent the resident from acting aggressively towards others. A review of Resident 1's Nursing Progress Notes dated 9/9/15, at 7:56 a.m., indicated Resident 1?s physician called back and ordered to place Resident 1 on safety precautions and to apply an ice pack to affected right side of the face. There was no documented evidence that Resident 2 was removed from the room and/or separated from Resident living /immediate area. The Social Service Progress Notes dated 9/9/15, at 2:35 p.m., indicated that Resident 1 was suddenly hit by his roommate. The progress notes indicated that though Resident 1 did not suffer any injury, the incident frightened him. The progress notes indicated the resident was placed on safety precautions to monitor and prevent further assault. There was no documented evidence that Resident 2 was removed from the room or Resident1?s immediate vicinity after the incident. The facility's Investigation Report event dated 9/9/15, at 6:35 a.m., indicated Resident 1 was lying in his bed when his room-mate, Resident 2 suddenly grabbed his wrist and attempted to hit him. Resident 1 yelled and the staff entered the room and found Resident 2 releasing Resident 1's arms. The Investigation Report further indicated that as Resident 2 released Resident 1's wrist he hit Resident 1 on the right side of his face. The Investigation Report indicated Resident 1 was assessed for pain and injury. The Investigation Report indicated Resident 1 denied pain and had no injury but stated the incident frightened him. The section of the Investigation Report titled: ?Actions Taken,? dated 9/9/15, at 6:35 a.m., indicated that Resident 1 was placed on safety precaution level 2 (every 15 minutes monitoring), and Resident 2 will continue on assaultive precautions level 2 (every 15 minutes). Another facility's Investigation Report event dated 9/9/15, at 7:30 a.m., indicated as staff was walking pass the room of Resident 1 and 2, Resident 2 was observed holding down another roommate (Resident 3) with his left hand as he attempted to hit Resident 3 with his right fist. The Investigation Report indicated that the staff immediately called "Code Green," (Immediate attention/Danger) and entered the room. As staff entered the room, Resident 2 released Resident 3?s fist and backed away. The Investigation Report Conclusion and Summation dated 9/9/15, at 7:30 a.m., indicated the facility concluded that the event was unavoidable as Resident 2 had diagnoses of schizophrenia and dementia. The investigation Report further indicated that the Interdisciplinary Team discussed changing Resident 2 room but decided a room change would not decrease Resident 2 assaultive behavior since there were no distinguishing factors to indicate which of the residents Resident 2 would likely assault . The section of the Investigation Report titled: ?Action Taken,? dated 9/9/15, at 7:30 a.m., indicated action taken included Resident 3 was placed on safety precaution level 2 and Resident 3 remained on 1:1 supervision. During a telephone interview and review of Resident 2's medical record with assistant director of nurses (ADON) on 8/19/16, at 11:35 a.m., ADON stated Resident 1, Resident 2 and Resident 3 were housed with two other residents in the same room. The ADON stated usually the resident (abuser) will be moved to ?Zen Room,? temporarily after the first incident of resident to resident altercation. ADON stated there was no documentation that Resident 2 was moved to another room until 9/21/16. A review of the 8/2/2011, facility's revised policy and procedures titled ?Abuse Reporting,? indicated each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents must not be subject to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members guardians, friends, or other individuals. The policy and procedures indicated that while the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to the resident. If an employee of the facility has been accused of resident abuse, he/she will be immediately removed from the contact with the resident. The Administrator/Designee will take all measures to protect the resident from further potential abuse. The facility?s policy and procedures did not address how the facility will protect the resident (victim) from a resident (perpetrator) after resident to resident altercation. The facility failed to ensure residents were free from physical and mental harm from a resident who was known with aggressive behavior for two of three sampled residents (Resident 1 and Resident 2) by failing to: 1. Ensure that Resident 2 was immediately removed from Resident 1?s room, after the physical altercation incident with Resident 1. Resident 1 and Resident 2 were roommates and as a result, Resident 1 became afraid and felt unsafe in the presence of Resident 2. 2. Ensure that Resident 2 was monitored closely after the first physical altercation with Resident 1 and as a result, Resident 2 physically assaulted another roommate Resident 3. Resident 3 sustained a scratch and redness on his left hand. 3. Develop abuse policy and procedure that addressed specific intervention for protecting a resident (victim) after a resident to resident altercation. The above violation had a direct relationship to the health, safety and security of Resident 1, Resident 2 and Resident 3. |
| 940000101 |
Long Beach Post Acute |
940012624 |
B |
11-Oct-16 |
HPGL11 |
3633 |
?483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). On 1/15/16, at 3:15 p.m., an unannounced visit was conducted at the facility to investigate an allegation of resident's missing money. Based on observation, interview and record review, the facility failed to notify the Department of Public Health (State survey and Certification agency) of alleged financial abuse immediately, or within 24 hours. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 7/28/14 with diagnoses that included cerebrovascular accident (stroke) with hemiplegia (total or partial paralysis of one side of the body). The History and Physical dated 10/1/15 indicated Resident 1 was aphasic (loss of ability to speak) but was able to communicate by writing and speak a few words. A review of the Minimum Data Set (a resident assessment and care screening tool), dated 1/22/16 indicated the resident was assessed as modified independent (some difficulty in new situations only) in his cognitive skills for daily decision-making. On 3/15/16, at 3:15 p.m., Resident 1 was observed in his wheelchair. The resident was aphasic, oriented to staff members and able to respond to questions by writing. During an interview the resident stated he had $80.00 dollars in his wallet that night before going to sleep. The resident stated that when he woke up in the morning his $80.00 was stolen and he did not know who took it. Resident 1 stated he reported the incident to certified nursing assistant 1 (CNA 1) and the social service director. A review of the facility's Investigation Interview dated 12/29/15 indicated that CNA 1 was assigned to Resident 1 on 12/28/15. The documentation indicated CNA 1 noticed that three of the resident's bedside drawers were locked, which was unusual because the resident never locked his drawers before. Then, CNA 1 called the maintenance staff to find the key to the resident's bedside drawer. When the drawer was open; Resident 1 grabbed his wallet and found out that $60 dollars were missing. The documentation indicated CNA 1 reported the incident to the social service director (SSD). A review of the facility's Loss Investigation Report dated 12/29/15 indicated that the reported date of loss was 12/29/15 and there was no witness before the loss. The report indicated that on 12/30/15, after the facility's conclusion of the investigation the administrator refunded $60.00 to Resident 1. There was no documented evidence that the alleged theft and loss was reported to the Department of Public Health or State Ombudsman office. On 3/15/16, at 4:05 p.m., during an interview with SSD, she stated that she and CNA 1 conducted a search everywhere and did not find the money. SSD stated that she did not report the incident to the Department of Public Health. On 6/13/16, at 1 p.m., the administrator stated that he did not know that the resident's allegation was reportable, and did not report the incident to the Department of Public Health or Ombudsman Office. The facility failed to notify the Department of Public Health of alleged financial abuse immediately, or within 24 hours. The above violation had a direct or immediate relationship to the health, safety, and/or security of Resident 1. |
| 970000021 |
La Brea Rehabilitation Center |
940012657 |
A |
3-Nov-16 |
IZ6Z11 |
10993 |
F 315 ?483.25(d) Urinary Incontinence (1) A resident who enters the facility without an indwelling catheter is not catherized unless the resident?s clinical condition demonstrates that catherization was necessary. The facility failed to ensure that a resident who did not have a medical justification for an indwelling catheter (a tube inserted into the bladder via the urethra [a tube that transports urine from the bladder to the outside of the body]) was not catheterized, including but not limited to: 1. Failure to ensure Resident 5 was not catheterized unless clinically necessary. 2. Failure for Resident 5 to receive the necessary care and services to prevent urinary tract infections (UTI) a disease caused by microorganisms that invade the tissue of the kidneys, bladder, or urethra. 3. Failure to implement Resident 5?s plan of care, which indicated the staff would monitor for any signs and symptoms of infection, document and report. 4. Failure to monitor and/or put a plan in place to prevent Resident 5 from pulling the indwelling urinary catheter out. This deficient practice resulted in Resident 5 pulling the indwelling urinary catheter out several times causing trauma to the urethra by repeatedly pulling the catheter out, and having multiple UTIs, which put Resident 5 at risk for urosepsis (sepsis is a life-threatening bacterial infection of the blood; urosepsis is sepsis that complicates a urinary tract infection), which could possibly lead to death. Resident 5, who was a 94 year-old male, had a urinary catheter placed per the family's request, had history of repeated urinary tract infections and pulling the urinary catheter out and sustaining penile ulcers (a sore on the skin or a mucous membrane of the penis). On 8/8/16 at 8:10 a.m., during the facility's recertification tour, accompanied by a registered nurse (RN 8), Resident 5 was observed lying in bed with an indwelling catheter draining blood-tinged urine with sediment (presence of cells, casts, bacteria, crystals, etc.) in the tubing. RN 8 stated a urinalysis (a test performed on urine to assess for bacteria etc.) and C/S ([culture & sensitivity] performed to determine the presence of pathogenic bacteria for suspected urinary tract infection) were obtained on 8/7/16, to rule out a urinary tract infection. A review of Resident 5's Admission Face Sheet indicated Resident 5 was initially admitted to the facility on 1/18/16, and most recently readmitted on 7/5/16. Resident 5's diagnoses included sepsis, (refers to a bacterial infection in the bloodstream or body tissues), urinary tract infection ([UTI] an infection involving any part of the urinary system), peripheral vascular disease ([PVD], narrowing of blood vessels that restricts blood flow), and dementia (significant loss of intellectual abilities, such as memory capacity, that is severe enough to interfere with social or occupational functioning). A review of Resident 5's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/25/16, indicated Resident 5's memory was impaired as evident by a brief interview of mental status (BIMS) score of 3 (score of 8-15 means inter-viewable). According to the MDS, Resident 5 did not have recall and was non-English speaking and spoke Russian. Resident 5 was non-ambulatory (unable to walk) and required an extensive one-person assist with activities of daily living (ADLs), such as dressing, eating, toilet use, and personal hygiene (shaving, brushing teeth, and combing hair) and total assistance with bathing. Several MDS, dated 1/25/16 (admission MDS), 7/12/16, and 7/19/16, under Section H0300 (urinary continence) indicated Resident 5's indwelling catheter had been in place since January 2016, without a medical justification. A review of an electronic nurses' note, dated 2/14/16 on the 7-3 p.m. shift, indicated Resident 5 pulled out the indwelling catheter. The noted indicated Resident 5's family member visited and insisted the catheter be re-inserted. Urinary catheter was re-inserted. A review of an electronic nurses? note, dated 2/29/16, not timed, indicated Resident 5 was positive for VRE (Vancomycin-resistant Enterococcus are bacterial Enterococcus that are resistant to the antibiotic vancomycin) in the urine and was started on Linezolid (an antibiotic used for the treatment of serious infections) 600 milligram every 12 hours for seven days (until 3/7/16). A review of an electronic nurses 'note, dated 3/11/16, and timed at 5 p.m., indicated Resident 5 had a positive UA of > 100, 00 colonies of Escherichia coli. Resident 5 was started on Cipro ([Ciprofloxacin] an antibiotic) 500 mg twice a day for 7 days for the UTI. A review of an electronic nurses? note, dated 4/19/16, and timed at 4:33 p.m., indicated Resident 5 was observed pulling on the urinary catheter. Another electronic note, the same day timed at 10:57 a.m., indicated there was ulceration (a sore on the skin or a mucous membrane) on the tip of Resident 5's penis ?due to the Foley catheter." The note indicated the family was at the bedside and was informed that Resident 5 did not have an indication for the use of an indwelling urinary catheter. A review of an electronic nurses' note, dated 4/20/16 (late entry), with a time of 10:36 a.m., indicated Resident 5's physician was called for permission to remove the indwelling urinary catheter due to Resident 5's constant pulling on it resulting in a penile ulceration. The note indicated physician stated, " To call the resident's (Resident 5) family member and asked them.? A review of a Licensed Nurses Weekly Summary, dated 6/27/16, indicated Resident 5 continued to have an indwelling urinary catheter and was currently being treated with antibiotics for a UTI. A review of a care plan, dated 7/6/16, and revised on 8/5/16 titled, ?Resident has a Foley Catheter per Family's Request," indicated the resident would be free of catheter-related trauma and UTIs. The staff?s approaches included monitoring, record, and report signs of UTI, which included pain, burning, blood-tinged urine, cloudiness, elevated temperature, change in behavior and eating habits. A review of Resident 5's nurse's note, dated 8/7/16, and timed at 7-3 p.m. shift, indicated hematuria (blood in urine) was noted in Resident 5's indwelling urinary catheter. A review of a SBAR (situation, background, assessment and recommendation), dated 8/7/16, and timed at 12 p.m., indicated Resident 5 had hematuria (the presence of red blood cells [erythrocytes] in the urine) in the indwelling urinary catheter. The physician was notified with orders for Resident 5 to have a U/A and C/S. On 8/10/16 at 2 p.m., during a telephone interview, Resident 5's family member stated, ?We want him (Resident 5) to have a Foley catheter because the staff would let him stay wet, which would cause problems for his skin." Resident 5's family member stated the facility?s nurses were not knowledgeable or well-trained. He stated one time they came to visit Resident 5 and he was found with blood everywhere after Resident 5 had pulled the indwelling catheter out and there was not a nurse in site. Resident 5's family member stated last week they had to tell the facility's staff about the blood in his (Resident 5) catheter and they asked for a UA and C/S to be performed. A review of Resident 5's UA laboratory results, collected on 8/7/16 and completed on 8/8/16, indicated the urine was straw-amber in color and cloudy many bacteria, > (greater than) 30 red blood cells (normal reference range [NRR] is 0-2) and >50 while blood cells (NRR is 0-5). The C/S, completed on 8/10/16, indicated there was >100,000 colonies of Proteus mirabilis. According to an online article, dated June 2012, titled "Proteus mirabilis urinary tract infection and bacteremia, " indicated Proteus mirabilis (a species of anaerobic, motile, rod-shaped bacteria found in putrid meat, abscesses, and fecal material and a common disease causing microorganism responsible for complicated UTIs that sometimes causes bacteremia (bacteria in the blood). http://www.ncbi.nlm.nih.gov/pubmed/22572004 A review of Resident 5's physician's order, dated 8/11/16, and timed at 8:39 a.m., indicated to start Resident 5 on Augmentin (an antibiotic, used for treatment of bacterial infections) tablet 500/125 [Amoxicillin-Pot Clavulanate] milligrams (mg) one tablet by mouth two times a day for UTI for 7 days (until 8/17/16). The physician discontinued Bactrim DS that Resident 5 was receiving started on 8/7/16 for the right foot wound. A review of Resident 5's care plan, dated 8/11/16, and titled, ?Alteration in health Maintenance - Requires antibiotic for the treatment of UTI, ?indicated Resident 5 continued to have repeated UTI. On 8/15/16 at 3:26 p.m., during an interview, the director of nursing (DON) stated if a resident's family member request for a resident to have an indwelling urinary catheter and the physician approves the family's request, then we would honor it. The DON stated Resident 5's family was close to Resident 5's physician. The DON stated she does not like for residents to have urinary catheter, unless it was necessary, because it results in UTIs and sometimes urosepsis (a life-threatening bacterial infection of the blood; urosepsis is sepsis that complicates a urinary tract infection). According to an online article, dated 8/18/15, titled "Catheter-Related Urinary Tract Infection, by Medscape Reference, indicated catheter-related urinary tract infection (UTI) occurs because urethral catheters inoculate organisms into the bladder and promote colonization by providing a surface for bacterial adhesion and causing mucosal irritation. The article stipulated the presence of a urinary catheter is the most important risk factor for bacteriuria (the presence of bacteria in the urine). Other bacteriuria factors included residents catheterized for longer duration, diarrhea, renal insufficiency, and errors in catheter care (http://emedicine.medscape.com/article/2040035-overview). The facility failed to ensure that a resident who did not have a medical justification for an indwelling catheter was not catheterized, including but not limited to: 1. Failure to ensure Resident 5 was not catheterized unless clinically necessary. 2. Failure for Resident 5 to receive the necessary care and services to prevent urinary tract infections. 3. Failure to implement Resident 5?s plan of care, which indicated the staff would monitor for any signs and symptoms of infection, document and report. 4. Failure to monitor and/or put a plan in place to prevent Resident 5 from pulling the indwelling urinary catheter out. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 970000021 |
La Brea Rehabilitation Center |
940012658 |
A |
3-Nov-16 |
IZ6Z11 |
9014 |
F309 ?483.25 Provide Care/Services for Highest Well-Being Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and to ensure that a resident?s physician?s orders were followed regarding wearing a brace for his neck fracture including but not limited to: 1. Failure to follow the physician?s orders for Resident 1, who had a neck fracture, and was supposed to wear his neck, chest, and back brace. 2. Failure of the facility?s social service and rehabilitation Department to follow-up on Resident 1?s broken brace. These failures resulted in Resident 1 having a diminished quality of life, resulting in Resident 1 staying in bed all day, and requiring an increase in narcotic pain medications. Resident 1, who was a 53 year-old male, had a cervical spine (neck) fracture (broken bone), had a physician's order for a neck/chest/back brace to be in place at all times, except during hygiene care, the brace had been broken for two months and the facility failed to replace it. This failure resulted in Resident 1 being without a neck/chest/back brace for two months while complaining of dizziness, increased pain requiring large amounts of pain medications, and difficulty to perform ADLs, which resulted in Resident 1 staying in the bed. During the facility's recertification initial tour on 8/8/16 at 8:10 a.m., accompanied by a licensed vocational nurse (LVN 7), LVN 7 stated Resident 1 mostly stayed in bed, because his neck brace had been broken for over a month. While at Resident 1's bedside, Resident 1 stated the neck brace had been broken for two months. Resident 1 stated he had notified the social worker and there had not been a replacement of the brace as of yet. Resident 1 stated he becomes dizzy upon getting up out of bed and had difficulty in transferring from the bed to the chair and performing ADLs (activities of daily living) without the neck brace. While still at Resident 1's bedside, LVN 7 pointed to Resident 1's broken neck brace on the floor. The full neck and back brace was observed broken in multiple places with the areas taped in an attempt to secure the areas. At 10:50 a.m., on 8/8/16, during a subsequent interview, Resident 1 stated the brace had been broken for a while and that he cannot get up without the brace. Resident 1 stated he had notified the social worker, the nursing staff, the rehab staff and the physician. Resident 1 stated his physician told him he would get another brace, but the rehab staff told him his insurance would not pay for it. On 8/8/16 at 2:15 p.m., LVN 7 stated she had notified the director of nursing (DON) regarding Resident 1's broken brace. LVN 7 stated the DON had referred it to the rehabilitation (rehab) department. LVN 7 further stated Resident 1 cannot maintain his posture without the brace, so she took the brace to the rehab department and they said they cannot repair it. LVN 7 stated Resident 1's pain had increased since the brace had been broken. On 8/10/16 at 8:40 a.m., during an interview, the two social service designees (SSD 1 and 2) stated that they had recently heard about Resident 1's broken brace. They both stated they were informed about Resident 1's broken neck brace on 8/8/16. SSDs 1 and 2 stated Resident 1 had an appointment to be seen by the neuro surgeon (medical professional who specializes in surgery on the brain and peripheral nervous system), but they were unable to locate the note in the Resident 1's record. The SSDs stated Resident 1 also had an orthotic (a specialty concerned with the design, manufacture and application of orthoses [an externally applied device used to modify a body part]) appointment two weeks ago, but they were unable to locate that documentation in the resident's record. Both SSD 1 and 2 acknowledged that it was the rehab's responsibility to replace Resident 1's broken neck brace timely. At 9:10 a.m., on 8/10/16, during an interview, the facility's director of rehab services (DOR) stated on 7/14/16, the DON asked her to look at Resident 1's neck brace. She stated she did an evaluation on 7/15/16 and identified the need for a further referral. The DOR stated the orthotic person came to the facility on 7/18/16, and provided paperwork to be signed by Resident 1's physician. The DOR stated she had not seen the paper work and stated she did not follow-up on the issue and should had. The DOR acknowledged that she was aware of Resident 1's complaints of pain and immobility to function well without the use of the neck brace and stated it was the facility's responsibility to replace Resident 1's broken neck brace. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on 7/13/15. Resident 1's diagnoses included a neck fracture (a break in one or more of the 7 cervical bones [They protect the spinal cord, support the neck, and allow for movement]), muscle wasting and atrophy (gradually decline in effectiveness or vigor due to underuse or neglect), back pain and insomnia (a sleep disorder that is characterized by difficulty falling and/or staying asleep). A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 6/30/16, indicated Resident 1 was alert and oriented with a BIMS score of 15 (8-15 means inter-viewable). According to the MDS, Resident 1 required a one-person physical assist in all ADLs (activities of daily living) except, eating and personal hygiene. The MDS, under Section JO400: Pain Frequency indicated Resident 1 had frequent pain that required pain medication. A review of a Nurse's Weekly Summary, dated 8/6/16, indicated Resident 1 required assistance with transferring, ambulation, bathing, and dressing. The summary indicated Resident 1 had complaints of pain and dizziness. A Review of Resident 1's physician orders, dated 5/14/16, indicated Resident 1 had an order for pain medications such as: 1. Dilaudid (a potent controlled narcotic) 4 mg one tab every four hours as needed for severe pain. 2. Ibuprofen (nonsteroidal anti-inflammatory drug (NSAID) works by reducing hormones that cause inflammation and pain in the body) 800 mg one tab every 12 hourly as needed for moderate pain. A review of Resident 1's Medication Administration Records (MARs) and Pain Assessment Medication Sheet for the months of 6/2016, 7/2016, and 8/2016, indicated Resident 1 received Dilaudid 4 mg 42 times in 6/2016, 57 times in 7/2016, and 34 times for 8/2016 (from 8/1-8/15/16). Ibuprofen 800 mg, one tablet was given to Resident 1 only once in the month of July 2016 (7/17/16) and none in August 2016. A review of a physician's order, dated 7/1/16, indicated Resident 1 to have a neck brace, extending to the chest and back area, applied every day at all times and to remove only to do hygiene. A review of Resident 1's care plans indicated there was no plan of care for Resident 1's use of the neck brace or any assistive devices. There were also no Interdisciplinary Team Meeting (IDT) notes documented regarding Resident 1's broken neck brace with plans for replacement. A review of an online article by Medscape Reference, dated 1/25/16, titled "General Principles of Fracture Care Treatment & Management," indicated the initial management of fractures consist of realignment of the broken bone and immobilizing it in a splint. The article stipulated splinting was critical in providing symptomatic relief for the patient, as well as in preventing potential neurologic and vascular injury. The ultimate goal of the fracture management was to ensure that once the fracture healed, it would return to its maximal possible function (http://emedicine.medscape.com/article/1270717-treatment). The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and to ensure that a resident?s physician?s orders were followed regarding wearing a brace for his neck fracture including but not limited to: 1. Failure to follow the physician?s orders for Resident 1, who had a neck fracture, and was supposed to wear his neck, chest, and back brace. 2. Failure of the facility?s social service and rehabilitation Department to follow-up on Resident 1?s broken brace. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 970000021 |
La Brea Rehabilitation Center |
940012659 |
A |
3-Nov-16 |
IZ6Z11 |
9959 |
F309 ?483.25 Provide Care/Services for Highest Well-Being Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and to ensure that a resident received an adequate assessment and pain medications prior to an extensive wound care treatment including but not limited to: 1. Failure to follow its undated policy and procedure, titled, ?Pain Monitoring during Care and Treatment,? for Resident 5 who had wounds. 2. Failure to adequately assess and medicate Resident 5, who exhibited pain during a wound care observation. 3. Failure to implement Resident 5?s plan of care, which intervention included to provide pain medication to Resident 5 prior to the resident?s planned activities, which included wound care. A review of Resident 5's Admission Face Sheet indicated Resident 5, who was a 94 year-old male, was initially admitted to the facility on 1/18/16, and most recently readmitted on 7/5/16. Resident 5's diagnoses included sepsis, (a bacterial infection in the bloodstream or body tissues), urinary tract infection ([UTI] an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney), peripheral vascular disease ([PVD], narrowing of blood vessels that restricts blood flow), and dementia (significant loss of intellectual abilities, such as memory capacity, that is severe enough to interfere with social or occupational functioning). A review of Resident 5's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/25/16, indicated Resident 5's memory was impaired as evident by a brief interview of mental status (BIMS) score of 3 (score of 8-15 means inter-viewable). According to the MDS, Resident 5 did not have recall and was non-English speaking and spoke Russian. Resident 5 was non-ambulatory (unable to walk) and required an extensive one-person assistance with activities of daily living (ADLs), such as dressing, eating, toilet use, and personal hygiene (shaving, brushing teeth, and combing hair). A review of Resident 5's care plan, initiated on 7/5/16, and titled, "Potential for alteration in comfort/pain related to multiple gangrene; PVD, " indicated the staff's intervention included to provide pain medication to Resident 5 prior to planned activities, e.g. PT (physical therapy), OT (occupational therapy), and wound care. A review of Resident 5's physician's order for wound care, dated 8/5/16, and timed at 6:35 p.m., indicated to cleanse the right distal leg arterial wound with normal saline (NS), pat dry, paint with betadine (an antiseptic), cover with a dry dressing (DD) every day shift for 14 days. Another physician's order, dated 8/7/16, and timed at 2:04 p.m., indicated to cleanse right distal leg arterial wound right foot gangrene with Dakin's, 0.25% solution (a dilute solution containing sodium hypochlorite and boric acid, used as an antiseptic in the treatment of wounds), pat dry, cover with DD and wrap with a Kerlix roll (gauze) every day for 14 days. On 8/8/16 at 2:20 p.m., during Resident 5's wound care observation, the assistant director of nursing ([ADON] a licensed vocational nurse) was observed removing the dressing gauze saturated with dry yellowish-red stains from Resident 5's right foot with a foul smell permeating the room. Resident 5 was observed with facial grimaces when the dressing was being removed from the right leg. Resident 5 was repetitively saying in Russian, " Dai Pokoi (leave me alone), Dai Pokoi (leave me alone),? while kicking his feet and thrashing in the bed. Resident 5's right shin wound dressing was observed stuck in the pinkish in color wound bed that had yellowish slough (dead tissue in, or cast out from, living tissue) and was difficult to remove. The ADON pulled the dried dressing out of the wound bed and Resident 5 yelled out. The ADON, who was English speaking, was unable to communicate with Resident 5 to evaluate Resident 5's pain level. Resident 5, who had been receiving wound care for months, was not adequately assessed for pain and provided with pain medication prior to wound care as stipulated in Resident 5's plan of care (POC). Resident 5, who had a large right black gangrenous (necrosis or death of soft tissue due to obstructed circulation) foot measuring 18 centimeter (cm) x 11 cm. and depth UTD (unable to determine) and a right shin (the front of the leg below the knee) wound measuring 8 cm. x 2 cm. in depth, was not administered pain medication prior to wound care and was observed yelling, grimacing in pain, and thrashing around in bed. At 2:36 p.m., on 8/8/16, LVN 6, the medication nurse for Resident 5, stated she did not administer any pain medication to Resident 5 before the wound care treatment on 8/8/16 or any day prior to wound care. At 2:38 p.m., on 8/8/16, LVN 8, who speaks both English and Russian was called to Resident 5's room The ADON did not ask LVN 8 to translate to assess Resident 5's pain level. During the wound care, there was a multilingual pain scale posted on Resident 5's room wall with facial grimace with translations in English, Spanish, Tagalog, Chinese, Korean, Persian (Farsi), Vietnamese, and Japanese, with the exclusion of Resident 5's Russian language. On 8/9/16 at 7:40 a.m., LVN 8 was asked did she ask Resident 5 in Russian if he was in pain during the wound care treatment the day before (8/8/16). LVN 8 stated Resident 5 had dementia and was confused and did not respond directly to the question if he was in pain, but kept saying to get out and leave him alone. On 8/9/16 at 8:22 a.m., during an interview, a registered nurse (RN 4) stated Resident 5's right leg and foot wounds were being treated by the wound care physician. RN 4 stated the resident's family were aware of the gangrenous foot and did not want Resident 5 to have it amputated. RN 4 stated the facility?s plan was to stabilize the gangrenous foot. On 8/9/16 at 1:40 p.m., during a second wound care observation, RN 4 was observed preparing supplies for Resident 5's wound care. RN 4 who was English speaking proceeded with Resident 5's wound care at approximately 2 p.m. without assessing or evaluating Resident 5's pain. During the removal of Resident 5's wound's dressings, Resident 5 was observed grimacing and kicking his feet and thrashing in bed during the wound care. LVN 2, who was also at the bedside, stated Resident 5 was given two tablets of 325 milligram (mg) of Tylenol before lunch for Resident 5's newly forehead scratch pain approximately two hours before the right leg wound care. A review of Resident 5's Medication Administration Record (MAR) for the month of August 2016, indicated there was no pain medication ordered for Resident 5 for wound care as was indicated in Resident 5's plan of care, not even the Tylenol LVN 2 indicated he had given to Resident 5 before lunch. An hour later, on 8/9/16, at approximately 3 p.m., Resident 5's MAR indicated Tylenol tablet 325 mg, two tablets by mouth for pain was given that day at 12 p.m. On 8/9/16, at 2:46 p.m., the director of nurses (DON) stated, ?We do not pre-medicate our residents for wound care." The DON stated the nurses should assess the resident's pain and medicate as required before starting wound care treatment. The DON was informed about ADON not assessing Resident 5's pain and not providing medication for the resident's pain. The DON stated the ADON was new and her first day was on 8/8/16 (the day before). On 8/15/16, at 3:15 p.m., during an interview, the DON stated, while reviewing Resident 5's record, Resident 5 should have had a wet-to-dry dressing to the right shin wound because the wound dressing will stick to the wound, since it was deep, and once removed it would cause pain. A review of the facility's undated policy titled, ?Policy and Procedure on Pain Monitoring During Care and Treatment, " indicated residents shall be monitored for any manifestation of pain such as: facial grimaces, crying, tearfulness, moaning, screaming or yelling, withdrawal from touch, and that pain and/or manifestation of pain associated with the following activities should be monitored: wound/pressure ulcer treatment, if a resident is manifesting pain during performance of ADL, ask the charge nurse to assess the resident. The charge nurse should review the physician's order for any order of pain medication and call the physician if there was no order for pain medication. The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and to ensure that a resident received an adequate assessment and pain medications prior to an extensive wound care treatment including but not limited to: 1. Failure to follow its undated policy and procedure, titled, ?Pain Monitoring during Care and Treatment,? for Resident 5 who had wounds. 2. Failure to adequately assess and medicate Resident 5, who exhibited pain during a wound care observation. 3. Failure to implement Resident 5?s plan of care, which intervention included to provide pain medication to Resident 5 prior to the resident?s planned activities, which included wound care. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000050 |
Lighthouse Healthcare Center |
940012694 |
B |
31-Oct-16 |
9ICQ11 |
4671 |
F-323
?483.25(h) Accidents.
The facility must ensure that ?
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
Based on interview and record review, the facility failed to provide supervision and monitoring for Resident 1. As a result, Resident 1 was able to leave and eloped from the facility without being noticed.
On 3/8/16 at 1 p.m., an unannounced visit and follow up visit was conducted on 10/4/16 at the facility to investigate an entity reported incident (ERI) regarding Resident 1's elopement from the facility on 3/6/16.
A review of the admission record (face sheet) indicated Resident 1 was admitted to the facility on 2/23/16 with diagnoses that included schizophrenia (abnormal social behavior and failure to recognize what is real), hemiplegia (weakness of the entire side if the body). According to the Resident 1's face sheet Resident 1 was conserved (someone selected to make decisions for a person that is unable to).
A review of a Minimum Data Set (MDS), a standardized assessment and care-screening tool dated 3/6/16, indicated that the resident had memory problems and had modified independence in making daily decision.
During an interview on 3/8/16 at 1:30 p.m., the administrator (ADM) stated that Resident 1 wanted to leave and go back to where he knew people at the general acute care hospital (GACH) however, the SNF facility failed to develop a plan of care to address the resident?s behavior of trying to leave the facility.
During an interview on 3/8/16 at 3 p.m., the registered nurse (RN 1) stated that the resident kept on going to the lobby to watch the security guard and then, he would wheel himself around to loop back to the lobby to watch the door way and security guards.
During an interview on 10/4/1616 at 9:30 a.m., the security guard (SG 1) stated that Resident 1 attempted a couple of times before 3/6/16 to leave the facility. Resident 1 would always hover at the door. SG 1 stated he notified the staff regarding Resident 1 wanting to leave.
In another interview, on 10/5/16 at 9:10 a.m., RN 1 she stated that she notified the conservator after Resident 1 eloped. The conservator stated the resident frequently eloped when he was at the GACH. The SNF facility failed to develop a plan of care to address the resident?s behavior of trying to leave the facility.
During an interview, on 10/5/16 at 4 p.m., SG 2 stated Resident 1 wanted to leave the facility and looked unhappy and did not talk. SG 2 stated she was doing her rounds and asked certified nurse (CNA 1) to watch the front door. SG 2 stated CNA 1 probably thought Resident 1 had an out on pass privileges and let him leave the facility.
The record review of a statement by CNA 1, on 3/8/16, indicated that SG 2 asked her to watch the front door, but did not specify for how long. When CNA 1 had to take another resident back in the facility she left the front door unsupervised.
The review of the history and physical for Resident 1 dated 2/29/16 indicated that the resident did not have the capacity to understand and make decisions.
A review of Resident 1's Elopement Risk Evaluation, dated 2/23/16 indicated resident scored 12, low risk for elopement. The SNF facility did not reassess the resident or develop a plan of care to address the resident?s elopement risk when staff SG-2 became aware of the resident?s elopement tendencies.
A review of a GACH record titled, Emergency Documentation, dated 3/8/16 around 12:30 p.m. resident attempted to elope from the emergency department. The conservator called the GACH and notified the staff the resident has a history of eloping at multiple skilled nursing facilities (SNF).
The facility policy and procedure titled, "Resident Elopement," with no date, indicated that it was the policy of this facility to identify residents at risk for elopement and to prevent any possible injury as a result of elopement.
The facility's job description of the security guard indicated the security officer was to assure the safety of staff, residents, and visitor. All officers are responsible for monitoring and patrolling the premises to ensure that the facility was free of environmental, elopement, security and altercation risks.
The facility failed to provide supervision and monitoring for one of one sampled resident (Resident 1). And as a result, Resident 1 was able to leave and eloped from the facility without being noticed.
The above violation had an immediate relationship to Resident 1?s health, safety, or security. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940012732 |
A |
18-Nov-16 |
C2L511 |
18664 |
F224
?483.13(c) Staff Treatment of Residents
Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility?s identification of residents? whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis.
F309
?483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
F 323 ?
?483.25 (h) Accidents
The facility must ensure that ?
(1) The resident environment remains as free from accident hazards as is possible: and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On 9/1/16, at 1:32 p.m., an unannounced visit was made to the facility to investigate an allegation that Resident 1 was admitted to the general acute care hospital (GACH) on XXXXXXX 16 with multiple rib fractures. The allegation indicated that Resident 1 had a right sided pneumothorax (abnormal collection of air or gas in the cavity between the lungs and the chest wall causing collapse of the lungs) with placement of chest tube, bruising on right side of the face and temporal area (side of the head behind the eyes).
The facility failed to ensure Resident 1 who had a history of grand mal seizure (a tonic [the person initially stiffens and loses consciousness, causing them to fall to the ground], and clonic phase [following the tonic phase, the clonic phase will start as the muscles begin to spasm and jerk, and loss of alertness]), episodes of placing herself on the floor, assessed as a high risk for falls, had history of falls and had fallen was free from neglect, received necessary care and services, and was provided with adequate supervision to prevent physical harm, including but not limited to:
1. Assess and identify if Resident 1 episodes of placing herself on the floor was a behavior or a type of seizure.
2. Implement the seizure precaution plan of care by monitoring Resident 1's behavioral patterns and providing a safe environment as indicated in the seizure disorder plan of care.
3. Provide 1:1 monitoring as indicated in the SBAR (Situation, Background, Assessment, and Recommendation) a technique that can be used to facilitate prompt and appropriate communication," dated 8/29/16, at 7:30 a.m.
4. Assess Resident 1?s neurological status from 7:30 p.m. to 11 p.m., when the resident sustained a forehead laceration after a fall on 8/29/16, at 7 p.m., to identify early changes in level of consciousness as indicated in the facility?s policy and procedures.
5. Conduct a continuous thorough body assessment when Resident 1 was identified with discoloration on the right upper back and left elbow on 8/29/16, at 6:45 a.m.
6. Transfer Resident 1 immediately to a higher level of care to receive the necessary care, when Resident 1 reported to staff that she thought that she broke her ribs after a fall on 8/29/16, at 7 p.m.
7. Investigate the circumstances of Resident 1's unwitnessed fall and sustaining multiple injuries, and provide this written report to State Agency representative (Evaluator) as indicated in the "Abuse Reporting and Investigation? facility?s policy and procedures.
8. Follow the facility's policy and procedures on fall management program to identify the risk factors and root cause of resident behavior and for licensed nurses and/or interdisciplinary team to develop a plan of care according to the identified cause.
9. Maintain functional cameras in the hallways to capture actual condition of the Resident 1 prior to the fall incident that can be used to identify cause and develop plan of care according to the facility's Fall Management policy and procedures.
As a result of these deficient practices, Resident 1 was found on the hallway floor on XXXXXXX16, at 7:15 p.m., with a cut on the forehead and was not transferred to the general acute care hospital (GACH) until 11:23 p.m., (four hours and eight minutes after a fall). The GACH identified Resident 1 with a large right-sided pneumothorax (abnormal collection of air or gas in the cavity between the lungs and the chest wall, causing collapse of the lung), which required a right tube thoracotomy (surgical artificial opening through the chest wall, usually for the drainage of fluid) a small abrasion and soft tissue swelling in the right temporal region, blunt torso (upper) trauma, and right 7th, 8th and 12th posterior (back) rib fractures.
On 9/1/16, at 1:32 p.m., during an observation at the GACH, Resident 1 was observed with bruises (skin discoloration) purplish in color to the right eye socket, and eye brow. The resident?s right side of the forehead had a healing cut which was yellowish/purplish in color. Resident 1 was observed with a chest tube attached to her right side upper body, connected to a drainage container.
During a concurrent interview, Resident 1 stated ?I fell in my room, I don?t remember how but they (staff) kept jamming ice to my head over and over.? The resident stated a certified nursing assistant (CNA) manhandled and tied her to a wheelchair. The resident continued to cry and repeatedly stating ?I don?t want to go back to the facility.?
A review of Skilled Nursing Facility (SNF), Resident 1's Admission Record indicated she was admitted to the facility on XXXXXXX16 and readmitted on XXXXXXX16 with diagnoses that included generalized muscle weakness, psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), and seizure disorder (uncontrolled jerking movement of the body and momentary loss of awareness).
A review of Resident 1's History and Physical (H&P) dated 6/6/16, indicated the resident did not have the capacity to understand and make decisions.
A review of the Minimum Data Set (MDS, an assessment and care screening tool), dated 7/13/16, indicated Resident 1 had no memory problems, usually makes self-understood and had the ability to understand others. The MDS indicated the resident was not steady, but able to stabilize self without staff assistance, and required supervision setup help only for bed mobility, transfer, walk in room and corridor.
The care plan dated 8/26/16, titled "Fall Risk Prevention and Management, indicated at risk for falls due to lack of awareness, cognitive deficit, impulsive behaviors, forgets to call/wait for assistance and engages in independent transfer/ambulation despite explanation of risks. The care plan indicated actual falls on 8/29/16. The interventions included provide an environment that supports minimized hazards over which the facility has control and to remind the resident to use call light.
A review of the facility's document titled SBAR dated 8/29/16, at 6:45 a.m., indicated Resident 1 was in bed, yelling, screaming for no apparent reason. When staff tried to talk to her, the resident continued to scream, started kicking and tried to bite staff. The note indicated that the resident was on 1:1 monitoring and that another associated behavior with this change was that the resident was placing herself on the floor. The documentation indicated there was discoloration noted at resident's right upper back and left elbow.
A review of the SBAR dated 8/29/16, at 7:15 p.m., indicated Resident 1 was found on the floor, along the hallway by certified nursing assistant 1 (CNA 1). The notes indicated the following vital signs:
- Blood pressure of 136/80 milliliter mercury (mm Hg) (normal range 120/80 mm Hg0, pulse rate 86 beat per minute (bpm) (normal range 70 to 100 bpm),
- Respiratory rate 20 breaths per minute (normal rate 12-20 breaths per minute),
- Body temperature 98.6 degrees Fahrenheit (øF) (normal temperature 91.8-100.8 øF),
- Oxygen saturation (oxygen in the blood) was 99 percent (%) (Normal range from 95 to 100 %).
The SBAR Progress notes indicated the physician was notified and ordered to transfer Resident 1 to the emergency department (GACH) for evaluation. The notes indicated that the resident was waiting to be picked up. The documentation did not specify who was going to pick up the resident and did not address the resident's actual injuries.
A review of Resident 1's Paramedics Report dated 8/29/16 indicated that the paramedics were dispatched at 11 p.m., and arrived in the facility at 11:07 p.m. The documentation indicated a 911 (emergency number) responded to a complaint of head trauma from an unwitnessed ground level fall around 7:00 p.m., this evening with hematoma (localized swelling that is filled with blood caused by a break in the wall of a blood vessel) to back of the head. The Paramedics Report indicated the resident had a second fall unwitnessed approximately 30 minutes later resulting in a hematoma above the right eye with right rib pain. The report indicated that the resident told the staff that her ribs were broken around 7:00 p.m. and the facility did not call 911 for four (4) hours.
A review of the GACH Trauma History and Physical Report dated 8/30/16 indicated Resident 1 had a large right-sided pneumothorax, for which a right tube thoracostomy was placed. The documentation indicated the resident had a small abrasion and soft tissue swelling in the right temporal region. The list of injuries indicated the following:
1. Status post fall
2. Blunt torso trauma
3. Right-sided pneumothorax
4. Right 7th, 8th and 12th posterior rib fractures.
On 9/1/16, at 5:05 p.m., during an interview with the director of nurses (DON) he stated that Resident 1 was not assessed for neurological status because there were no head injuries on 8/29/16 after a fall.
On 9/1/16, at 5:30 p.m., during an interview, licensed vocational nurse 1 (LVN 1) stated around 7 p.m., on 8/29/16, she was passing medication and was called by CNA 1 to assess Resident 1. LVN 1 stated she cleaned the laceration on the resident's right side of the forehead, and notified the primary care physician. LVN 1 stated that the resident's laceration was not too big. LVN 1 stated that a regular ambulance (an ambulance that provides transportation for residents who do not require cardiac [heart] monitoring) was called to transfer the resident to the GACH. However, when the resident got into the gurney, the resident went into a deep sleep, and the ambulance declined to transport the resident, and the 911 was called.
On 9/2/16, at 8:16 a.m., upon request of the investigation report regarding Resident 1?s incident of fall and/or placing herself on the floor on 8/29/16, the DON declined to provide the investigation stated that it was protected by their quality assurance committee.
On 9/2/16, at 8:02 a.m., during a telephone interview with CNA 1 regarding Resident1?s fall incident, she stated that she assisted LVN 1 to get the resident up from the floor. CNA 1 further stated ice packs were applied to Resident 1's bumps to the forehead.
On 9/2/16, at 10:50 a.m., the assistant administrator was asked for the video footage of Resident 1's fall incident in the hallway on 8/29/16. The assistant administrator stated that the video footage was only for 24 hours, and the cameras for the particular hallway were not working.
On 9/6/16, at 2:00 p.m., during an interview, the fire department chief (FDC) stated upon picking-up Resident 1 from the facility, the resident had an injury of her right eye. The FDC stated there was bloody gauze around the resident's head, and "We did not remove the gauze, so it would not aggravate it."
On 9/7/16, at 9:34 a.m., during a telephone interview with the primary care physician, he stated Resident 1 sustained several falls on 8/29/16. The primary care physician stated that he gave an order after the last fall to transfer Resident 1 to a GACH due to the laceration to the forehead.
During an interview and review of Resident 1's medical record on 9/26/16, at 1:49 p.m., the registered nurse supervisor (RNS 1) stated that on 8/29/16, she worked the morning shift (7 a.m., to 3 p.m. shift) Resident 1 was transferred to the East unit for close monitoring of placing herself on the floor behaviors. RNS 1 was asked what type of close monitoring was provided to Resident 1, RNS 1 stated 1:1 monitoring, however, RNS 1 was unable to provide the specific caregiver's name assigned to Resident 1 for 1:1 monitoring. RNS 1 was unable to provide documentation and explain the reason for Resident 1's placing herself on the floor. The cause was not assessed and the behavior was not communicated to the staff to prevent occurrences.
On 9/26/16, at 3:26 p.m., during an interview, RNS 2 stated she was called in at 7:00 p.m., on 8/29/16 by LVN 1 to assess Resident 1 who sustained a fall. RNS 2 stated she assessed Resident 1, but failed to document the assessment. RNS 2 was unable to provide the documentation of the resident's neurological assessment after a fall from 7 p.m., to 11 p.m., on 8/29/16.
On 10/3/16, at 11:19 a.m., during an interview, RNS 1 stated Resident 1?s episodes of dropping herself on the floor were not assessed to determine if they were seizures or a type of behavior. RNS 1 stated Resident 1's neurological assessment should have been done on 8/29/16 after Resident 1 sustained a head injury from a fall. RNS 1 stated the resident had to be monitored every 15 minutes for the first hour, 30 minutes for one hour and then every four hours for a total of 72 hours by standard of practice.
A review of the facility's undated policy and procedures titled "Change of Condition Notification," indicated the licensed nurse will assess the change of condition and determine what nursing interventions are appropriate before notifying the attending physician. The licensed nurse must observe and assess the overall condition utilizing a physical assessment and chart review.
A review of the 1/1/12, facility?s policy and procedures titled ?Neurological Assessment,? indicated:? following an unwitnessed fall, nursing staff shall perform neurological checks every four hours for the first 24 hours, then every eight hours, until attending physician states it is no longer necessary or in 72 hours if resident?s condition is stable and showing no signs and symptoms of neurological injury.?
According to the 4/1/15, facility's revised policy and procedure tilted "Abuse Reporting and Investigation - Operational Manual Abuse and Neglect," the purpose indicated to protect the health, safety, and welfare of the facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, or injuries of an unknown source are promptly and thoroughly investigated. The policy indicated the administrator will provide a written report of the results of all abuse investigations and appropriate action taken to Licensing and Certification and others that may be required by state or local laws, within (5) working days of the reported allegation.
A review of the 3/1/2016, facility's revised policy and procedures titled "Fall Management Program," indicated to provide a safe environment that minimizes complications associated with falls. The policy indicated the licensed nurse and/or interdisciplinary team will develop a plan of care according to the identified risk factors and root cause, and will evaluate the resident's response to the plan of care during weekly summary evaluation and update resident's plan of care as necessary.
The facility failed ensure Resident 1 who had history of grand mal seizure, had episodes of placing herself on the floor, assessed as a high risk for falls, had history of falls and had fallen was free from neglect, received necessary care and services, and was provided with adequate supervision to prevent physical harm, including but not limited to:
1. Assess and identify if Resident 1 episodes of placing herself on the floor was a behavior or a type of seizure.
2. Implement the seizure precaution plan of care by monitoring Resident 1's behavioral patterns and providing a safe environment as indicated in the seizure disorder plan of care.
3. Provide 1:1 monitoring as indicated in the SBAR (Situation, Background, Assessment, and Recommendation) a technique that can be used to facilitate prompt and appropriate communication," dated 8/29/16, at 7:30 a.m.
4. Assess Resident 1?s neurological status from 7:30 p.m. to 11 p.m., when the resident sustained a forehead laceration after a fall on 8/29/16, at 7 p.m., to identify early changes in level of consciousness as indicated in the facility?s policy and procedures.
5. Conduct a continuous thorough body assessment when Resident 1 was identified with discoloration on the right upper back and left elbow on 8/29/16, at 6:45 a.m.
6. Transfer Resident 1 immediately to a higher level of care to receive the necessary care, when Resident 1 reported to staff that she thought that she broke her ribs after a fall on 8/29/16, at 7 p.m.
7. Investigate the circumstances of Resident 1's unwitnessed fall and sustaining multiple injuries, and provide this written report to State Agency representative (Evaluator) as indicated in the "Abuse Reporting and Investigation? facility?s policy and procedures.
8. Follow the facility's policy and procedures on fall management program to identify the risk factors and root cause of resident behavior and for licensed nurses and/or interdisciplinary team to develop a plan of care according to the identified cause.
9. Maintain functional cameras in the hallways to capture actual condition of the Resident 1 prior to the fall incident that can be used to identify cause and develop plan of care according to the facility's Fall Management policy and procedures.
As a result of these deficient practices, Resident 1 was found on the hallway floor on 8/29/16, at 7:15 p.m., with a cut on the forehead and was not transferred to the GACH until 11:23 p.m., (four hours and eight minutes after a fall). The GACH identified Resident 1 with a large right-sided pneumothorax, which required a right tube thoracotomy, a small abrasion and soft tissue swelling in the right temporal region, blunt torso trauma, and right 7th, 8th and 12th posterior rib fractures.
These violations presented a substantial probability of death or serious physical harm to Resident 1. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940012743 |
A |
6-Jan-17 |
750111 |
14344 |
?483.25(h) Accidents The facility must ensure that ? (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 5/30/14, at 7 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 1 who left the facility without permission (AWOL). Based on observation, interviews, and record reviews, the facility failed to ensure Resident 1 who was admitted to a locked unit (A facility locked for purposes of security), assessed as a high risk for elopement (to leave a locked or secured psychiatric institution without notice or permission), and was experiencing auditory hallucinations (false perceptions of sounds), verbalizing that someone was hurting him and wanted to leave the facility, was monitored and provided a safe and secure environment by failing to: 1. Acknowledged that Resident 1 feeling of being scared that someone would come and hurt him was real to the resident, and provide emotional support and meaningful activity as indicated in the plan of care. 2. Update Resident 1?s elopement plan of care on 5/13/14, when the resident verbalized wanting to leave the facility, and institute one-on-one staffing until the resident's risk of wandering/elopement subsided as indicated in the facility?s policy and procedures. 3. Ensure that Resident 1 was closely monitored as indicated in the doctor?s progress notes dated 5/15/14. 4. Ensure that Resident 1 was evaluated for the use of alert bracelet device that alerted staff when the resident exits the prohibited doors. 5. Ensure that the facility had a system in place to monitor the facility?s cameras at real time to capture and prevent elopement. As a result, on 5/15/14, at 11:20 p.m., Resident 1 used two (2) linen barrels to jump an eight foot metal fence between advanced care unit (ACU which houses independent residents), and special care unit (SCU which houses dementia residents (deterioration of physical and mental function). Resident 1 then used a trash can to jump the fence into the parking lot in order to leave the facility. Four days later, on 5/19/14, Resident 1 was found by a detective, returned to the facility, and was sent out to the general acute care hospital for evaluation. Resident 1 was not re-admitted back to the facility. A review of Resident 1's Admission Records indicated Resident 1 was admitted to the locked facility on XXXXXXX, with diagnoses that included schizoaffective disorder (a mental disorder characterized by abnormal thought processes and deregulated emotions), and depression (feeling sad). The Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/27/14, indicated Resident 1 had short and long term memory problems, usually understands, and moderately impaired in daily decision-making. The resident was assessed as being inattentive, hallucinates (sensing things while awake that appear to be real but instead have been created by the mind), and was delusional (having false or unrealistic beliefs or opinions). A review of Resident 1?s Elopement Risk Assessment dated 5/8/14, indicated the resident had a score of four (4), (total score of 8 or greater, the resident should be considered at risk for potential elopement from the facility). The Elopement Risk Assessment dated 5/13/14, indicated that Resident 1 scored 10, indicating the resident was at risk for elopement. A review of Resident 1?s wandering elopement care plan dated 5/8/14 indicated the resident is at risk for wandering or elopement related to mood problems, delusions, hallucinations, and resident is unaware of safety needs. The interventions included provide the resident with a consistent routine, provide emotional support and meaningful activity, and monitor every 30 minutes as measures to provide safety. On 5/13/14, a new entry was made to the care plan indicating ?related to safety, people are out to hurt him (resident).? There was no new intervention to address this new identified problem. The Licensed Personnel Progress Notes dated 5/10/14, at 1:30 p.m., indicated a police officer came to the facility. The police officer stated that Resident 1 called and complained that someone assaulted him. The notes indicated that Resident 1 stated that a previous apartment manager came to the facility accompanied by a licensed nurse and hit him with a hammer in his head and neck. The notes indicated the resident was assessed and no signs of injury were found. The note indicated that Resident 1 stated ?I?m scared; he will come back and hurt me again.? At 2:30 p.m., the physician was notified and ordered to increased Resident 1 psychotropic (medication capable of affecting the mind, emotions, and behavior) medication. A review of Resident 1?s Social Service Progress notes dated 5/13/14, (untimed) indicated the social service informed the charge nurse to monitor Resident 1 due to resident is very delusional, ?Resident 1 stating that someone wants to hurt him.? The notes indicated that Resident 1 verbalized wanting to leave the facility to return to the previous facility where he resided. On 5/14/14, (untimed) the Social Service Progress notes indicated that the social service designee (SSD) received 5 calls from Resident 1 cell phone. The notes indicated Resident 1 had a concern about his court hearing on 5/15/14. When the SSD called the conservator, the SSD was told that the resident did not need to attend the court hearing. According to the notes, SSD explained this to the resident. The notes indicated that Resident 1 wanted to see a doctor. The notes indicated that per the licensed nurse Resident 1 was seen by a doctor, but the resident was demanding that he did not see the doctor. The notes further indicated that Resident 1 kept calling the SSD from his room on his cell phone, very delusional stating that someone is hurting him. The notes indicated that SSD explained to the resident that he is safe in the facility, and if he feels something to let the charge nurse know. The notes further indicated that the resident was seen by the psychiatrist (branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders) on 5/9/14, and will continue to monitor the resident behavior and for safety. On 5/15/14, (untimed) the Social Service Progress notes indicated that SSD received a phone call again from Resident 1 stating he wanted to leave the facility to go home. The notes indicated that SSD explained to the resident that she needed to talk to his conservator (a guardian appointed by a judge to protect and manage the person's daily life due to physical or mental limitations). On 5/15/14, (untimed) the Social Service Progress notes indicated that the SSD received a call from the Ombudsman stating that Resident 1 called her. The notes indicated that the Ombudsman stated that Resident 1 was saying someone hurt him. The notes indicated that the SSD told the Ombudsman that the resident was delusional and that no one had hurt him. A review of Resident 1?s Doctor?s Progress Notes dated 5/15/14, (untimed) indicated Resident 1 claimed that he was hit with a hammer on the back of his head and neck between 2 a.m. to 3 a.m., two nights ago. The note indicated that the resident had aching pain 8 ? 9 (pain rating 1 ? 10, 10 being the worst pain a person can experience). The note indicated that the assessment was done, no physical injury was found, and the plan was to monitor the resident closely. A review of Resident 1?s Change of Condition dated 5/15/14, for 3 p.m., to 11 p.m., shift indicated the resident continued to feel anxious and paranoid (the unreasonable fear or irrational belief that other people are plotting to harm him) claiming that people were out to hurt him. The notes indicated that the resident stated that he was assaulted a few nights ago and was hit with a hammer on the neck and head region. The notes indicated the resident was assessed with no bruise and bleeding noted. The notes indicated that the staff would continue to monitor the resident closely and monitor the resident?s behavior. A review of Resident 1?s Licensed Personnel Progress Notes dated 5/15/14, at 11:20 p.m., indicated the certified nursing assistant (CNA) reported that he could not find Resident 1 on his initial rounds. The whole facility was searched and the resident was not found. The Interdisciplinary Team Conference dated 5/16/14 indicated on 5/15/14, at around 10:30 p.m., the resident was seen in his room, However , during the every 30 minutes monitoring, at around 11:20 p.m., the CNA reported to the charge nurse that Resident 1 was missing. According to the facility's investigation dated 5/15/14, Resident 1 left absent without official leave (AWOL) and was gone until 5/19/14, when he came back to the facility. The resident was re-assessed and transferred to the general acute care hospital. Resident 1 was not readmitted back to the facility. On 5/30/14, at 9:08 a.m., during an interview and review of Resident 1?s medical record with the ADON, she stated she could not find a care plan addressing the resident's behaviors. There was no care plan developed for Resident 1's behavior of verbalizing wanting to go home, being concerned about a court hearing, believing someone was hurting him or out to hurt him, which increased Resident 1 elopement risks. On 5/30/14, at 8 a.m., during a tour with the maintenance supervisor (MS) of the ACU, resident's room, and the surrounding grounds, the ACU was observed separated from SCU unit by an eight foot metal fence. There were several yellow barrels that were chained to the poles. The barrels were used to store soiled linens in the back of ACU. The MS stated that Resident 1 used the two yellow barrels to jump the gate from ACU into SCU. On 5/30/14, at 8:45 a.m., during the tour and concurrent interview with the assistant administrator, he stated once Resident 1 jumped the fence into SCU, he used a trash can to jump the fence into the parking lot in order to leave the facility. The assistant administrator stated that one of the facility's surveillance cameras did record Resident 1 carrying two yellow soiled linen barrels to the first fence at ACU. The assistant administrator stated it did not show how he jumped the second fence because the camera does not show beyond a certain point. The assistant administrator stated that the facility is only recording and watching the recordings later. He also stated the facility is equipped with an alarm which alerts staff at the nursing station however, the alarm is not installed throughout the facility. According to him right now the alarm is not working in the SCU because facility is waiting to recheck the system in order for it to trigger faster. A review of 1/1/12, revised facility's policy and procedures titled ?Wandering and Elopement,? indicated that the purpose is to prevent the residents from leaving the facility without following procedures: The procedures included the following: 1. Resident will be assessed by the interdisciplinary Team (IDT, a coordinated group of experts from several different fields who work together toward a common goal.) to determine their risk of wandering/elopement. This assessment will take place upon admission, quarterly, and when behavior charges. A. If the resident appears likely to wander or elope, the facility staff should provide diversions and increase monitoring of the resident. i. The facility may institute one-on-one staffing until the resident's risk of wandering/elopement subsides. ii. If this is not adequate, the IDT may consider outfitting the resident with an alert device. B. Nursing staff will update the resident's care plan to include interventions to prevent wandering/elopement, including, but not limited to: i. Outfitting the resident with an alert bracelet; ii. Assigning the resident to a room away from commonly utilized exits; iii. Placing a sign on resident?s room with his/her name in large letters; iv. Placing a ?stop? sign on exit doors; v. Engaging the resident in supervised group activities; vi. Assigning the resident to a supervised dining programs; vii. Distracting the resident with items he/she enjoys (e.g. photos, games, television program), conversation, tasks meaningful to the resident (i.e., folding clothing, food preparation, use of safe tools, etc.). The facility failed to ensure Resident 1 who was admitted to a locked unit, and assessed as a high risk for elopement, and was experiencing auditory hallucinations verbalizing that someone is hurting him and wanted to leave the facility was monitored, provided a safe and secured environment by failing to: 1. Acknowledge that Resident 1 feeling of being scared that someone will come and hurt him was real to the resident, and provide emotional support and meaningful activity as indicated in the plan of care. 2. Update Resident 1?s elopement plan of care on 5/13/14, when the resident verbalized wanting to leave the facility, and institute one-on-one staffing until the resident's risk of wandering/elopement subsided as indicated in the facility?s policy and procedures. 3. Ensure that Resident 1 was closely monitored as indicated in the doctor?s progress notes dated 5/15/14. 4. Ensure that Resident 1 was evaluated for the use of alert bracelet device that alerted staff when the resident exits the prohibited doors. 5. Ensure that the facility had a system in place to monitor the facility?s cameras at real time to capture and prevent elopement. As a result, on 5/15/14, at 11:20 p.m., Resident 1 used two linen barrels to jump an eight foot metal fence between ACU and SCU. Resident 1 then used a trash can to jump the fence into the parking lot in order to leave the facility. Four days later, on 5/19/14, Resident 1 was found by a detective, returned to the facility, and was sent out to the general acute care hospital for evaluation. Resident 1 was not re-admitted back to the facility. This violation presented a substantial probability of death or serious physical harm to Resident 1. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940012879 |
A |
13-Jan-17 |
SYW011 |
9451 |
?483.13(b) Abuse
The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
On 10/14/15, at 8 a.m., an unannounced visit was made to the facility to investigate an entity reported incident (ERI) regarding an allegation of staff that roughly restrained a resident while administering an IM medication.
Based on observation, interview and record review, the facility failed to ensure Resident 1 was free from physical abuse and involuntary seclusion (restrained against her will) by failing to:
1. Ensure that Resident 1 was not forcefully handled and physically restrained by four staff members on 10/1/15 while receiving intramuscular (IM, injection given through the muscle) injection.
2. Ensure that Resident 1 was not pulled roughly on 10/6/15 from the exit door that resulted in the Resident 1?s loss of balance and her subsequent fall against the wall.
3. Conduct mandatory facility staff orientation and training programs on abuse prevention, and address resident violent behavior as indicated in the facility?s policy and procedure.
As a result of these failures, Resident 1 sustained bruises to her left eye, arm and a fall without injury. These failures also had the potential for emotional distress to Resident 1.
a. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on XXXXXXX2015 with diagnoses that included schizoaffective disorder (a mental disorder characterized by abnormal thought processes and deregulated emotions), epilepsy (a disorder in which nerve cell activity in the brain is disturbed), and osteoporosis (bones become weak and brittle).
A review of Resident 1?s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/16/15, indicated Resident 1 had clear speech and was able to express needs and wants, and able to transfer, eat, and use the toilet with extensive assistance from the staff.
A review of the facility's Investigation interview report dated 10/7/15 with licensed vocational nurse 1 (LVN 1) indicated that Resident 1 approached the Nurses? Station and asked about her mail. LVN 1 explained to Resident 1 that there was no mail. The report indicated that Resident 1 started to scream and yell. The certified nurse assistants (CNAs) brought the resident to her room. The investigation report indicated LVN 1 received an order from the physician for Ativan (anti-anxiety medication to relieve agitation) 2 milligrams (mg) IM for a one time order of Haldol (antipsychotic medication use to treat certain mental/mood disorders), and Benadryl (relieves allergic reactions) to give once. There were four staff member that held Resident 1?s legs, arms and head, while LVN 1 gave the IM medication.
A review of the facility's Investigation Report dated 10/8/15, at 8 p.m., indicated that a written interview by CNA 1 revealed that on 10/1/15 between 7 and 8:30 p.m., Resident 1 tried to take the phone away from LVN 1 at the West Nursing Station. Resident 1 was then brought to her room by CNAs. After 30 minutes CNA 1 and four other staff members went back into the resident's room to help LVN 1 administer the IM injection to Resident 1. CNA 2 got on top of Resident 1, CNA 3 held the resident's face and arm and CNA 4 held Resident 1's legs. The next day CNA 1 indicated that there was a bruise on Resident 1?s left cheek and left arm.
A review of the Medication Administration Record (MAR) on 10/1/15, at 7:50 p.m. Indicated that Diphenhydramine Benadryl) 50 mg, Lorazepam (Ativan) 2 mg and Haldol 5 mg were given intramuscularly on Resident 1?s right arm.
On 5/31/16, at 3:30 p.m., during an interview, with CNA 1 she stated that she could not remember the exact dates, but there were two incidents that happened in October 2015. The first incident happened when Resident 1 was administered a medication through an IM injection. CNA 1 stated Resident 1 tried to take the phone away from LVN 1, so the staff took the resident to her room. After a few minutes, Resident was still very agitated. CNA 1 stated LVN 1 administered an IM injection to calm Resident 1 down. CNA 1 stated, "The resident was skinny and there were three people holding her.? CNA 1 stated that the following day Resident 1 had bruises on her left eye and hand.
A review of the undated facility's Summary of Investigation indicated that on 10/1/2015, licensed vocational nurse (LVN 1) observed Resident 1 was sitting on a male resident?s lap. The investigation indicated that Resident 1 was asked to get up from the male resident's lap but refused. CNA 1 and CNA 2 in the presence of the charge nurse and LVN 1 forcefully removed Resident 1 from the male resident's lap and took her to her room. Resident 1 remained agitated, kicking, yelling, and subsequently, IM medication was administered forcefully by physically restraining the Resident 1.
The facility?s impression of the Summary of Investigation was that the force applied to the resident was excessive.
b. On 5/24/16, at 3:30 p.m., the DSD stated on 10/7/15, at 1 p.m., she received an anonymous call regarding an incident that was witnessed on 10/6/15 around 9 p.m. The anonymous caller stated there was a rough interaction between LVN 2 and Resident 1. Resident 1 was standing by the exit door requesting to "Get out of here." LVN 2 was responding to an emergency call on another unit and was trying to exit the same door where Resident 1 was standing. LVN 2 forcefully removed Resident 1 from the door as she tried to exit through the door. And a result, Resident 1 fell against the wall.
A review of the facility's Investigation report and interview with CNA 1 on 10/8/15, at 8 p.m., indicated that on 10/6/15 CNA 1 saw Resident 1 by the door to the entrance to the East wing. CNA 1 and LVN 2 were trying to exit the East wing, but Resident 1 tried to get out too. CNA 1 stated when she tried to exit the East wing, she saw LVN 2 holding Resident 1's shoulder to prevent her from exiting. When CNA 1 turned around she heard a loud bang. CNA 1 turned back to the resident and LVN 2 and saw that Resident 1 was on the floor crying.
A review of the facility's Statements of Victim and Witness indicated LVN 2 thought he pulled on Resident 1 too roughly when he was trying to stop Resident 1 from leaving the locked unit. LVN 2 stated the resident lost her balance and fell down.
A review of the facility's interview with CNA 5, on 10/6/15 indicated that as she monitoring the halls in the East wing, she saw Resident 1 trying to get out of the unit. LVN 2 and another CNA were trying to leave the East wing for the West wing when Resident 1 took hold of the arm of LVN 2. CNA 5 saw LVN 2 push Resident 1 off him. Resident 1 fell and hit her back and head against the wall.
The facility?s impression of the Summary of Investigation was that the force applied to the resident was excessive.
On 9/19/16, at 2 p.m., during an interview with the director of staff development (DSD), she stated that there was no staff training on what to do including level of force to be applied when a resident is manifesting an uncontrolled behavior. DSD stated that after the incident on 10/2015, the facility started training the staff.
According to the 1/1/2012, facility?s revised policy and procedures titled, ?Abuse Prevention Program,? indicated to ensure the health, safety, and comfort of residents by preventing abuse and mistreatment. The policy indicated the facility does not condone any form of resident abuse, neglect and/or mistreatment, and continually monitors facility policies, procedures, training programs, and systems in order to maintain an environment free from abuse and mistreatment. The procedures included:
i. Conducts mandatory facility staff orientation and training programs on abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, conflict resolution, and other related topics.
ii. Assist or rotates facility staff working with difficult or abusive residents and allows facility staff to express frustration with their job, or in working with difficult residents.
According to the 3/2013, facility's policy and procedures titled, "Reporting Abuse," meant; the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.
The facility failed to ensure Resident 1 was free from physical abuse and involuntary seclusion (restrained against her will) by failing to:
1. Ensure that Resident 1 was not forcefully handled and physically restrained by four staff members on 10/1/15 while receiving IM, injection.
2. Ensure that Resident 1 was not pulled roughly on 10/6/15 from the exit door that resulted in the Resident 1?s loss of balance and her subsequent fall against the wall.
3. Conduct mandatory facility staff orientation and training programs on abuse prevention, and address resident violent behavior as indicated in the facility?s policy and procedure.
As a result of these failures, Resident 1 sustained bruises to her left eye, arm and a fall without injury. These failures also had the potential for emotional distress to Resident 1.
This violation presented a substantial probability of death or serious physical harm to Resident 1. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940012909 |
B |
26-Jan-17 |
O38L11 |
5790 |
?483.13(b) Abuse
The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
?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.
On 10/14/15, at 8 a.m., an unannounced visit was made to the facility to investigate an entity reported incident (ERI) regarding an allegation of residents? abuse.
Based on observation, interview and record review, the facility failed to ensure Resident 6 was free from any form of abuse including but not limited to:
1. Ensure Resident 6 was not forcefully handled during care, which was witnessed by her roommate, Resident 8.
2. Conduct mandatory training programs on abuse prevention and address agitated/violent behavior manifested by resident and related topics (such as resident refusal of medication/treatment to avoid staff forceful approach) as indicated in facility?s policy and procedure.
This deficient practice had a potential for Resident 6, and her roommate, Resident 8 to have increased anxiety and to suffer from emotional distress.
During an interview on 5/23/16, at 3:30 p.m., the director of staff development (DSD) stated that she received an anonymous call about residents? abuse. The DSD stated the facility started asking residents if they had any issues with their care and safety with any staff members. The DSD stated when Resident 8 was interviewed she stated she witnessed LVN 2, roughly handled Resident 6, her roommate. DSD stated the facility started an investigation regarding Resident 8 allegations.
A review of Resident 6's Admission Record indicated that the resident was admitted to the facility on XXXXXXX13 with diagnoses that included hypertension (high blood pressure), and anemia (a condition in which the blood does not have enough healthy red blood cells).
A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/25/15, indicated that Resident 6 had clear speech and was able to express ideas and wants. Resident 6 required supervision from staff for transfer, ambulation and eating.
A review of Resident 8's Admission Record indicated the resident was admitted to the facility on XXXXXXX15 with diagnoses that included schizophrenia (abnormal social behavior and failure to recognize what is real), insomnia (inability to sleep), and anxiety (feelings of worry, anxiety, or fear that can affect daily life).
A review of Resident 8's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/22/16, indicated Resident 8 had clear speech and was able to express needs and wants. According to the MDS, Resident 8 required supervision from the staff for transfer, ambulation and eating.
During an interview, on 11/3/15 at 8:40 a.m., Resident 8 stated she saw LVN 2 being rough with her roommate, Resident 6. Resident 8 stated last month she saw LVN 2 pushing Resident 6, and was very aggressive. Resident 8 stated that her roommate (Resident 6) was agitated.
During an attempted interview with Resident 6 on 11/3/15, at 8:42 a.m., Resident 6 declined to speak with the surveyor.
In another interview on, 5/24/16, at 10:45 a.m., Resident 8 stated LVN 2 shoved Resident 6 on the bed at least two times. Resident 8 stated ?LVN 2 used excessive force; he could have done it differently.?
A review of the facility's, Investigation Interview Report dated 10/15/15, indicated that Resident 8 witnessed LVN 2 and LVN 3 grab Resident 6's arm while taking her to her room. Resident 8 stated LVN 2 and LVN 3 tossed Resident 6 on her bed. Resident 8 stated no other staff was present during this incident.
During an interview on 9/19/16, at 2 p.m., the director of staff development (DSD) she stated that there was no staff training on what to do including level of force to be applied when a resident is manifesting an uncontrolled behavior. DSD stated that after the incident on 10/2015, the facility started training the staff.
According to the 1/1/2012, facility?s revised policy and procedures titled, ?Abuse Prevention Program,? indicated to ensure the health, safety, and comfort of residents by preventing abuse and mistreatment. The policy indicated the facility does not condone any form of resident abuse, neglect and/or mistreatment, and continually monitors facility policies, procedures, training programs, and systems in order to maintain an environment free from abuse and mistreatment. The procedures included:
i. Conducts mandatory facility staff orientation and training programs on abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, conflict resolution, and other related topics.
ii. Assist or rotates facility staff working with difficult or abusive residents and allows facility staff to express frustration with their job, or in working with difficult residents.
The facility failed to ensure Resident 6 was free from any form of abuse including but not limited to:
1. Ensure Resident 6 was not forcefully handled during care, which was witnessed by her roommate, Resident 8.
2. Conduct mandatory training programs on abuse prevention and address agitated/violent behavior manifested by resident and related topics as indicated in facility?s policy and procedure.
This deficient practice had a potential for Resident 6, and her roommate, Resident 8 to have increased anxiety and to suffer from emotional distress.
The above violation had a direct or immediate relationship to the health, safety, and/or security of Resident 6 and Resident 8. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940012910 |
B |
26-Jan-17 |
O38L11 |
7393 |
?483.13(b) Abuse
The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
?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.
On 10/14/15, at 8 a.m., an unannounced visit was made to the facility to investigate an entity reported incident (ERI) regarding an allegation of residents? abuse.
Based on observation, interview and record review, the facility failed to ensure Resident 4 was free from any form of abuse including but not limited to:
1. Ensure that Resident 4 was not forcefully handled while administering medications by mouth.
2. Ensure that Resident 4?s request to have a female nurse to apply her Elimite (topical cream used to treat scabies [mite]) cream treatment on 8/24/15 was honored.
3. Conduct mandatory training programs on abuse prevention and address agitated/violent behavior manifested by resident and related topics (such as resident refusal of medication/treatment to avoid staff forceful approach) as indicated in facility?s policy and procedure.
As a result, Resident 4, felt as though she was drowning, when the staff forcefully administered her medication and felt that she was raped when a male nurse applied the Elimite cream all over her body. These deficient practices had potential for Resident 4 to suffer psychological distress and potential to aggravate her current depression (feeling of sadness and loss of interest).
During an interview on 11/3/15, at 9 a.m., Resident 4 stated the incident happened at night between 8 and 9 p.m. The resident stated that there were three ladies who stood and watched while the staff forcefully gave her the medications. The resident stated that she felt like she was drowning and also felt violated. Resident 4 stated that she told the doctor what happened.
During an interview on 5/23/16, at 10:30 a.m., Resident 4 stated that the licensed vocational nurse (LVN 2) forced himself on her by applying a medication on her body. The resident stated she felt like she got raped. Resident 4 stated she asked for a female nurse, but LVN 2 ignored her. Resident 4 stated LVN 2 also forced her to take medications when she did not want to.
A review of Resident 4's Admission Record indicated the resident was admitted to the facility on XXXXXXX15 with diagnoses that included schizophrenia (a mental disorder characterized by abnormal social behavior and failure to understand what is real), diabetes mellitus (a metabolism disorder that affects the body's ability to use blood sugar), depression, and muscle wasting.
A review of Resident 4?s Physician?s order, dated 8/24/15 indicated Elimite cream was ordered to be applied to resident's whole body and to wash off in 10 hours.
A review of a Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/31/15, indicated Resident 4 had clear speech and was able to express needs and wants. According to the MDS, Resident 4 was totally dependent on staff for transfer.
A review of the ?Psychological Services? progress Note dated 10/9/15 indicated that, Resident 4 reported to the physician that there was physical abuse perpetrated by the night nurses. Resident 4 stated as indicated in the Progress Notes that a male nurse was the aggressor who held her head down on the bed and forced her to take the medications.
A review of the facility's Investigation Interview Report dated 10/15/15 with Resident 4 indicated that LVN 2 forced her mouth open and administered the medications to her. Resident 4 stated that juice and water was spilling all over her during the force-medicating process. The investigation summary indicated LVN 2 applied Elimite to Resident 4's body after the resident had asked for a female nurse. The investigation summary indicated per Resident 4, that LVN 2 ignored her request and rubbed medication on her naked body. Resident 4 stated that she felt like she was raped.
During an interview on 5/23/16, at 3:30 p.m., the director of staff development (DSD) stated that she received an anonymous call about residents? abuse. The DSD stated the facility started asking residents if they had any issues with their care and safety with any staff members. The DSD stated when Resident 4 was interviewed she stated she had issues with LVN 2. DSD stated the facility started an investigation regarding Resident 4 allegations.
During a telephone interview on 6/1/16, at 10:30 a.m., LVN 2 stated he was not aware that Resident 4 did not want male nurse to provide care to her.
On 9/19/16, at 2:13 p.m., during an interview with LVN 3, she stated that she had been working in the facility for a year. LVN 3 stated that when she first started to work in the facility she was told that Resident 4 preferred female CNA/nurses. A review of Resident 4?s medical record indicated that a care plan was initiated 10/2015 after the incident which indicated that Resident 4 preferred female staff.
During an interview on 9/19/16, at 2 p.m., the director of staff development (DSD) she stated that there was no staff training on what to do including level of force to be applied when a resident is manifesting an uncontrolled behavior. DSD stated that after the incident on 10/2015, the facility started training the staff.
According to the 1/1/2012, facility?s revised policy and procedures titled, ?Abuse Prevention Program,? indicated to ensure the health, safety, and comfort of residents by preventing abuse and mistreatment. The policy indicated the facility does not condone any form of resident abuse, neglect and/or mistreatment, and continually monitors facility policies, procedures, training programs, and systems in order to maintain an environment free from abuse and mistreatment. The procedures included:
i. Conducts mandatory facility staff orientation and training programs on abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, conflict resolution, and other related topics.
ii. Assist or rotates facility staff working with difficult or abusive residents and allows facility staff to express frustration with their job, or in working with difficult residents.
The facility failed to ensure Resident 4 was free from any form of abuse including but not limited to:
1. Ensure that Resident 4 was not forcefully handled while administering medications by mouth.
2. Ensure that Resident 4?s request to have a female nurse to apply her Elimite cream treatment on 8/24/15 was honored.
3. Conduct mandatory training programs on abuse prevention and address agitated/violent behavior manifested by resident and related topics as indicated in facility?s policy and procedure.
As a result, Resident 4, felt as though she was drowning, when the staff forcefully administered her medication and felt that she was raped when a male nurse applied the Elimite cream all over her body. These deficient practices had potential for Resident 4 to suffer psychological distress and potential to aggravate her current depression.
The above violation had a direct or immediate relationship to the health, safety, and/or security of Resident 4. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940013041 |
B |
10-Mar-17 |
EFHM11 |
5708 |
483.12(a) The facility must ?
(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
?483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries or unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
?483.13(c)(3) The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress.
?483.13(c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
On 10/24/16 at 12:00 p.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse.
Based on interview and record review, the facility failed to implement the facility's abuse policy and procedure by not promptly investigating and report immediately to State survey and certification agency and other officials in accordance with State law an incident of unwitnessed falls with injury and a fall that originated from a ?resident-to-resident? altercation.
These deficient practices resulted in the facility?s failure to promptly identify the cause of the falls and prevent further occurrence this constituted neglect that may have the potential to jeopardize the health and safety of Resident 1.
A review of the Admission Record indicated that Resident 1 was admitted to the facility on XXXXXXX 16, with diagnoses that included paranoid schizophrenia (a mental disorder in which a person has false beliefs or some individuals are plotting against them) and psychosis (a mental disorder creating impaired relationships with reality by having hallucinations or delusions).
A review of the Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 11/26/16 indicated Resident 1 was severely impaired with cognitive skills for daily decision-making and required extensive assistance from the staff with the carrying of the activities of daily living.
During a general tour of the facility on 10/24/16 at 3:40 p.m. Resident 1 was observed lying in bed. During an interview on the same date and time, Resident 1 refused to respond to any of the evaluator?s questions.
A review of the general acute care hospital (GACH) Emergency Room Nurses? Progress notes dated 8/28/16 and 8/29/16, indicated that Resident 1 sustained laceration to the left eye, abrasions to the bilateral lower extremities and ecchymosis (purplish patch) to bilateral arms and left eye secondary to a fall.
A review of Resident 1's medical records indicated that Resident 1 had the following five fall incidents that were not reported to the department with no documented investigation:
1. The Fall Risk Prevention and Management care plan dated 8/12/16 indicated that, Resident 1 was found out of bed unassisted and sitting on the floor.
2. The SBAR note dated 8/15/16 indicated that Resident 1 had an unwitnessed fall with a laceration (cut) that measured 3.5cm by 0.5 cm to the back of her head. Resident 1 was transferred to GACH where the laceration was treated and stapled.
3. The Psychosocial Well-Being care plan dated 9/23/16, and the nurse's progress note both indicated that Resident 1 was pushed by another resident in the dining room and fell.
4. The SBAR note dated 9/28/16 and the Nurse's Progress Note both indicated that Resident 1 was found on the floor in a hallway. The resident?s legs were observed on the wall with back to the floor.
5. The SBAR note dated 11/3/16 indicated that Resident 1 was found on the landing pad next to her bed, lying on her right side, and complaining of left shoulder pain. The resident was later transferred to a GACH for evaluation.
During an interview on 12/1/16 at 4 p.m., the director of nurses (DON) responded that all falls are not reportable and the facility knew of the causes of the unusual occurrences. The DON was not able to provide documentation that the incidents of unwitnessed falls with injury were promptly investigated, and reported to the department.
A review of the facility's undated policy and procedure titled, ?Abuse - Reporting and Investigation? indicated to protect the health, safety, and welfare of facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, or injuries of an unknown source are promptly and thoroughly investigated. ?The facility will report all allegations of abuse as required by law and regulations to the appropriate agencies.?
According to the facility's, policy and procedure revised 11/7/16 and titled, "Fall Management Program," indicated that the administrator will notify appropriate local authorities for unwitnessed falls and when abuse, neglect or mistreatment is suspected.
The facility failed to implement the facility's abuse policy and procedure by not promptly investigating and report immediately to State survey and certification agency and other officials in accordance with State law an incident of unwitnessed falls with injury and a fall as a result of resident to resident altercation.
The failure of the facility to implement the facility's abuse policy and procedure by not promptly investigating an incident of unwitnessed falls with injury, constituted neglect that had a direct or immediate relationship to the health, safety, and/or security of Resident 1. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940013042 |
B |
10-Mar-17 |
EFHM11 |
3552 |
?483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries or unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
?483.13(c)(3) The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress.
?483.13(c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
On 10/24/16 at 12:00 p.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse.
Based on interview and record review, the facility failed to implement the facility's abuse policy and procedure by not promptly investigating and report immediately to State survey and certification agency and other officials in accordance with State law Resident 1 left arm abrasion of unknown source.
This deficient practice resulted in the facility?s failure to promptly identify the cause of the left arm abrasion and prevent further occurrence that may have the potential to jeopardize the health and safety of Resident 1.
A review of the Admission Record indicated that Resident 1 was admitted to the facility on 8/5/16, with diagnoses that included paranoid schizophrenia (a mental disorder in which a person has false beliefs or some individuals are plotting against them) and psychosis (a mental disorder creating impaired relationships with reality by having hallucinations or delusions).
A review of the Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 11/26/16 indicated Resident 1 was severely impaired with cognitive skills for daily decision-making and required extensive assistance from the staff with the carrying of the activities of daily living.
During a general tour of the facility on 10/24/16 at 3:40 p.m. Resident 1 was observed lying in bed. During an interview on the same date and time, Resident 1 refused to respond to any of the evaluator?s questions.
A review of Resident 1's Situation Background Assessment and Request (SBAR-nursing assessment) dated 8/14/16 indicated that Resident 1 had a left arm abrasion of unknown source.
During an interview on 12/1/16 at 4 p.m., the director of nurses (DON) was not able to provide documentation that Resident 1 left arm abrasion of unknown origin was promptly investigated, and reported to the department.
A review of the facility's undated policy and procedure titled, ?Abuse - Reporting and Investigation? indicated to protect the health, safety, and welfare of facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, or injuries of an unknown source are promptly and thoroughly investigated. ?The facility will report all allegations of abuse as required by law and regulations to the appropriate agencies.?
The failure of the facility to implement the facility's abuse policy and procedure by not promptly investigating and report immediately to State survey and certification agency and other officials in accordance with State law Resident 1 left arm abrasion of unknown source, had a direct or immediate relationship to the health, safety, and/or security of Resident 1. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940013043 |
B |
10-Mar-17 |
EFHM11 |
3388 |
?483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries or unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
?483.13(c)(3) The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress.
?483.13(c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
On 10/24/16 at 12:00 p.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse.
Based on interview and record review, the facility failed to promptly investigate and report immediately to State survey and certification agency and other officials in accordance with State law two incidents of ?resident-to-resident? altercations involving Resident 1 as indicated in the facility's abuse policy and procedures.
A review of the Admission Record indicated that Resident 1 was admitted to the facility on 8/5/16, with diagnoses that included paranoid schizophrenia (a mental disorder in which a person has false beliefs or some individuals are plotting against them), and psychosis (a mental disorder creating impaired relationships with reality by having hallucinations or delusions).
A review of the Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 11/26/16 indicated Resident 1 was severely impaired with cognitive skills for daily decision-making and required extensive assistance from the staff with the carrying of the activities of daily living.
During a general tour of the facility on 10/24/16 at 3:40 p.m. Resident 1 was observed lying in bed. During an interview on the same date and time, Resident 1 refused to respond to any of the evaluator?s questions.
A review of Resident 1's Psychosocial Well-Being care plan dated 9/23/16, and the nurse's progress note both indicated that Resident 1 was pushed by another resident in the dining room and fell.
A review of a plan of care developed and dated 9/29/16 indicated that Resident 1 pushed a resident and was striking out at staff.
During an interview on 12/1/16 at 4 p.m., the director of nurses (DON) was not able to provide documentation that the incidents of resident-to-resident altercations were promptly investigated, and reported to the department.
A review of the facility's undated policy and procedure titled, ?Abuse - Reporting and Investigation? indicated to protect the health, safety, and welfare of facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, or injuries of an unknown source are promptly and thoroughly investigated. ?The facility will report all allegations of abuse as required by law and regulations to the appropriate agencies?.
The failure of the facility to implement the facility's abuse policy and procedure by not promptly investigating incidents of resident-to-resident altercations, had a direct or immediate relationship to the health, safety, and/or security of Resident 1. |
| 940000056 |
Long Beach Healthcare Center |
940013164 |
A |
28-Apr-17 |
VGI511 |
12690 |
42 CFR 483.24(d) Accidents.
The facility must ensure that -
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
Based on observation, interview, and record review, the facility failed to implement the plan of care and the facility?s policy and procedure by failing to:
1. Transfer Resident 1 from the motorized wheelchair to the bed using a patient lift machine (a machine that allows a person to be lifted and transferred with minimum physical effort) with the assistance of two persons.
2. Unbuckle the safety belt of the motorized wheelchair from Resident 1?s waist prior to lifting the resident from the motorized wheelchair using the patient lift machine to transfer the resident to the bed.
On 2/15/16, while Resident 1 was still buckled (with seat belt on) in the motorized wheelchair, a certified nursing assistant (CNA 1) used the patient lift machine to lift the sling of the machine that the resident was sitting on, to transfer the resident from the motorized wheelchair to her bed. As the resident was being lifted up by the machine, the weight (350 pounds or more) of the motorized wheelchair was pulling down on Resident 1's hip/thigh area where the seat belt was still buckled.
This deficient practice resulted in Resident 1, who was known to the facility to have osteoporosis (porous bone that is characterized by too little bone formation or excessive bone loss, leading to bone fragility and increased risk of fractures), to sustain a right proximal femur fracture (broken thigh bone nearest to the hip), requiring the resident to be hospitalized and to undergo a surgical repair of the right femur fracture.
A review of Resident 1's record titled, "Admission Record," indicated Resident 1 was a 57-year-old female, who was admitted to the facility on XXXXXXX06 and was readmitted on XXXXXXX16, with diagnoses that included multiple sclerosis (MS, a disabling disease of the brain and spinal cord that causes nerves to be permanently damaged and can cause loss of the ability to walk, numbness or tingling, and weakness), osteoporosis, muscle weakness, and dementia (a condition that affects memory, thinking and social abilities severely enough to interfere with daily functioning).
A review of Resident 1's care plan, initiated on 11/14/15 and titled, "Resident has activities of daily living (ADL) self-care deficit due to MS and dementia," indicated interventions that included safe resident handling and transfer resident with a full body lift with two person assist.
A review of the facility's policy and procedures, dated 10/2010 and titled, "Using a Portable Lifting Machine," indicated if the resident cannot participate in the lifting procedure, then two nursing assistants are required to perform the procedure.
A review of Resident 1's record titled, "Minimum Data Set (MDS, a resident assessment and care screening tool)," dated 12/5/15, indicated Resident 1's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 1 required full staff performance for transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, and standing position) with two person physical assist. Resident 1 had impairment to both lower extremities (hip, knee, ankle, foot) and required wheelchair for mobility.
A review of Resident 1's record titled, "Weekly Summary," indicated Resident 1 was totally dependent on staff for transfers and the support provided was one person assist for the week of 2/1/16, 2/8/16, and 2/15/16. On 2/15/16, the Weekly Summary indicated that Resident 1 required a patient lift machine to use during transfer and that Resident 1 was "up in electric wheelchair daily as tolerated."
During an observation, on 4/14/16, at 1:20 p.m., Resident 1's wheelchair was observed right outside Resident 1's room and was labeled "Quantum" motorized power wheelchair. The motorized wheelchair was equipped with a safety seat belt.
During an interview, on 3/21/17 at 1 p.m., the director of nursing (DON) stated Resident 1 was using Quantum motorized power wheelchair.
During an interview, on 3/21/17 at 12:25 p.m., Consumer Care Representative (CCR 1) stated average Quantum wheelchair weighs about 350 pounds and more when added the weight of the accessories.
A review of Resident 1's record titled, "SBAR (Situation Background Assessment Recommendation, a technique provides a framework for communication between members of the health care team)/COC (Change of Condition)," dated 2/20/16, indicated that Resident 1 was assessed with "bluish skin discoloration to right groin going up to right thigh with swelling." The SBAR/COC indicated that the affected area was tender on palpation (using one's hands to examine the body area) and worsened with range of motion (joint mobility), and required pain management with medication.
A review of Resident 1's record titled, "Medication Administration Record (MAR)," for February 2016 indicated Resident 1 was administered Norco (a combination of acetaminophen and hydrocodone, an opioid [narcotic] pain medication) 5/325 milligrams (mg), one tablet orally for right thigh pain with pain rating of 7 out of 10 (pain rating scale from 0, meaning no pain to 10, meaning worst pain) on 2/20/16 at 2 p.m.
A review of Resident 1's record titled, "Order Summary Report," dated 2/20/16, indicated to obtain an x ray to right femur and pelvis (a large bony structure near the base of the spine to which the legs are attached).
A review of Resident 1's diagnostic imaging result, dated 2/20/16, indicated Resident 1 had an acute (occurred suddenly) right femur fracture with marked angulation (rotation or change in bone length caused by loss of bone alignment) and displacement (the bone snaps into two or more parts and moves so that the two ends are not lined up straight).
A review of Resident 1's physician's order (on 2/20/16) indicated to transfer Resident 1 to the hospital.
A review of Resident 1's hospital x ray result, dated 2/20/16, indicated Resident 1 had a comminuted (bone breaks into several pieces), markedly displaced angulated fracture involving the right femur.
A review of Resident 1's hospital emergency department (ED) physician notes titled, "Trauma, Extremity Injury Major," dated 2/20/16, indicated Resident 1 had a right femur fracture and right hip pain that was described as severe, intermittent (off and on), and unprovoked. The ED physician notes indicated Resident 1's right foot toes were pointing posteriorly (towards the back) and to the right, and pulses (regular throbbing of the arteries that can be felt, caused by the successive contractions of the heart) of either foot were undetectable. The pelvis and right femur x-ray results showed a severely displaced fracture of proximal right femur (thigh bone nearest to the hip bone) with 90 degree angulation. Resident 1 was treated with Dilaudid (an opioid pain medication for the management of moderate to severe pain) 1.5 mg intravenously ([IV], given directly into a vein). An Orthopedic consult (consultation by a physician who specializes in the study of bones and muscles) was requested immediately (STAT). The ED physician notes indicated that Resident 1's sister was at bedside and said that the accident occurred when moving Resident 1 with a sling between the bed and the motorized wheelchair at the facility.
A review of Resident 1's hospital record titled, "History and Physical (H&P)," dated 2/20/16 at 10:51 p.m., indicated Resident 1 stated that she may have fractured her femur 4 to 5 days ago when she was being transferred from her wheelchair to her bed. The H&P indicated Resident 1's right lower extremity (right leg) had an obvious deformity (major difference in the shape of a body part compared to the normal shape of that part) of the femur (the thigh bone) and an exaggerated external rotation (the leg turned away from the body so the knee or foot faces outward). Resident 1's plan for the displaced right femur fracture included the administration of Tylenol (brand name for acetaminophen medication used to treat pain) for mild pain, Norco for moderate pain, and Dilaudid for severe pain.
A review of Resident 1's hospital progress note, dated 2/21/16 and 2/22/16, indicated Resident 1 was placed on Bucks traction (a pulling force is applied by strapping the resident's affected leg and attaching weights to immobilize [reduce movement], position, and align the bones) to the right leg with a five pound weight.
A review of Resident 1's hospital operative report, dated 2/23/16 at 1:28 p.m., indicated Resident 1 underwent an intramedullary hip nailing (a surgical procedure wherein a metal rod was forced in the cavity of a bone to treat fracture) of the right side on 2/22/16.
A review of Resident 1's hospital record titled, "Discharge Summary," dated 3/7/16, indicated Resident 1 was discharged on XXXXXXX16 with right femoral open reduction internal fixation (ORIF, a surgery to repair the bone by using special metal devices, called internal fixators, to hold the bones in place while they heal).
On 3/2/16 at 3 p.m., during an interview, when asked about the facility?s procedure when using the patient lift machine, CNA 2 stated two staff personnel were required when using the patient lift machine for resident safety. CNA 2 stated that before lifting residents using the patient lifting machine, the belt used to secure residents to the wheelchair should be unbuckled to prevent severe harm to the resident.
On 4/14/16 at 1:43 p.m., during an interview, CNA 1 stated that on 2/15/16, Resident 1, who was on her wheelchair, requested to be placed back onto the bed. CNA 1 stated the safety belt of the wheelchair remained buckled as Resident 1 was being lifted using the patient lift machine. CNA 1 stopped the patient lift machine to unbuckle Resident 1's safety belt. CNA 1 stated the wheelchair was heavy. CNA 1 stated she could not recall the name of the CNA (CNA X) who assisted her in operating the patient lift machine to transfer Resident 1 from wheelchair to bed. CNA 1 described the assisting CNA as being newly hired CNA. CNA 1 stated she observed a bruise on Resident 1's right thigh area that was "purplish discoloration and three centimeters in diameter," and CNA 1 stated that on 2/16/16, she reported to the licensed vocational nurse (LVN 1), who was Resident 1?s primary nurse, Resident 1's right thigh purple discoloration.
According to CNA 1's declaration statement, dated 4/14/16, CNA 1 and CNA X (not identified) were transferring Resident 1 from wheelchair to bed using a patient lift machine on 2/15/16. CNA 1 indicated that she noticed the safety belt was still buckled and told CNA X to stop lifting Resident 1 so that she could unbuckle Resident 1's safety belt. CNA 1 indicated that on the following day (2/16/16), at 8 a.m., CNA 1 observed a bruise on Resident 1's right thigh and reported the bruise to the charge nurse.
On 4/14/16 at 3:20 p.m., during an interview, the director of staff development (DSD) stated the facility was not able to identify the CNA (CNA X) that assisted CNA 1 in the use of the patient lift machine to transfer Resident 1 on 2/15/16. The DSD stated the CNAs that were scheduled on 2/15/16 denied helping CNA 1 in the transfer of Resident 1 using the patient lift machine. The DSD stated the most recently hired CNA was CNA 1.
A review of the facility document titled, "Nursing Staffing Assignment and Sign-In Sheet," dated 2/15/16, on the 7 a.m. to 3 p.m. shift, indicated there were four CNAs assigned to the same Unit (East) with CNA 1. All four CNAs were interviewed and no one could recall assisting CNA 1 transfer Resident 1 using the patient lift machine on 2/15/16. There were a total of 13 other CNAs in other Units and no one could recall assisting CNA 1 transfer Resident 1 using the patient lift machine on 2/15/16.
The facility failed to implement the plan of care and the facility?s policy and procedure by failing to:
1. Transfer Resident 1 from the motorized wheelchair to the bed using a patient lift machine (a machine that allows a person to be lifted and transferred with minimum physical effort) with the assistance of two persons.
2. Unbuckle the safety belt of the motorized wheelchair from Resident 1?s waist prior to lifting the resident from the motorized wheelchair using the patient lift machine to transfer the resident to the bed.
The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940013237 |
A |
1-Jun-17 |
QYLD11 |
14521 |
F323, F309, F279
483.25(D) - 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.
? 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
?483.21(b) Comprehensive Care Plans
(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at ?483.10(c)(2) and ?483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ?483.24, ?483.25 or ?483.40; and
On 5/5/17, an unannounced recertification survey was conducted.
Based on observation, interview, and record review, the facility failed to provide Resident 12 with adequate supervision, assistance devices, and an environment free from accident hazards to prevent fall and/or injury after a fall.
For Resident 12, the facility failed to follow the physician's orders, dated March 29, 2017, and implement the plan of care for fall risk prevention and management, dated January 4, 2017 and March 29, 2017, as follows:
1. Keep bed in a low position.
2. Padded bilateral side rails up.
3. Concave type low air loss mattress with bed bumpers applied.
4. Pads on the floor for protection.
This deficient practice resulted in Resident 12 falling on March 30, 2017, and sustaining a laceration (a deep cut or tear in the skin or flesh) to the head, a nasal (nose) bone fracture (partial or complete break in the bone), and a small subdural hemorrhage (a pool of blood between the brain and its outermost covering usually caused by severe head injury).
A review of Resident 12's admission record (Face Sheet) indicated Resident 12 was a 65 year old male who was originally admitted to the skilled nursing facility (SNF) on June 1, 2016, and was readmitted on March 31, 2017, with diagnoses that included pressure ulcer (bed sore) of sacral (relating to the sacrum which is the lower part of the backbone) region, epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), laceration (a deep cut or tear in skin or flesh) without foreign body of scalp, subdural hemorrhage without loss of consciousness, and attention to gastrostomy tube (G tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach).
A review of the Fall Risk Assessment dated December 28, 2016, indicated Resident 12 scored a 12 (total score of 10 or above represents high risk for falls).
A review of the Fall Risk Prevention & Management care plan dated December 28, 2016, indicated Resident 12 was at risk for fall due to limited mobility, lack of awareness, cognitive (mental processes involved in acquisition and understanding of knowledge, formation of beliefs and attitudes, and decision making and problem solving) deficit, incontinence (lack of voluntary control over urination or defecation) or gets to call/wait for assistance, and history of falls. The care plan goal indicated to provide a safe environment that minimizes complications associated with falls. The listed nursing interventions included to provide an environment that supports minimized hazards over which the facility has control, keep the call light within reach, remind the resident to use the call light, and keep bed in low position.
The Minimum Data Set (MDS, a standardized assessment and care planning tool), dated January 4, 2017, indicated Resident 12 usually understood others and usually made self understood, scored 11 on the brief interview for mental status (BIMS, a score of 8 to 12 means moderately impaired cognition), and required extensive to total assistance from staff with activities of daily living (ADL). The MDS indicated the resident was not steady during surface to surface transfer and only able to stabilize with staff assistance, had impaired range of motion on upper and lower extremities, and used wheelchair for mobility. According to the MDS, the resident had a fall incident with injury except major (includes skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains, or any fall related injury that causes the resident to complain of pain) since admission/entry or reentry or prior assessment.
A review of the Interdisciplinary Team (IDT, a team of staff from different disciplines who determines the appropriate plan of care for the residents) Conference Record/Care Plan s/p (status post) Fall/s, dated January 4, 2017, indicated Resident 12 had an actual unwitnessed fall on January 3, 2017 secondary to generalized muscle weakness, poor safety awareness, unsteady gait, impaired balance and poor judgement. The care plan goal indicated the resident will have least minimal injury from this fall for 72 hours. The listed interventions included call lights within reach at all times, frequent reminders to use the call light as often and to call for assistance from staff, low bed with upper padded side rails up, low air loss mattress (used in the prevention, treatment and management of pressure ulcers), concave type (mattress designed with surface that curves inward to prevent users from rolling out of bed and assist in positioning) with bed bumpers, and pads on the floor for protection to prevent major injuries, and one on one in service training given to the certified nursing assistants (CNAs) and charge nurses regarding safety.
Further review of the clinical record indicated Resident 12 was transferred to the acute care hospital on XXXXXXX 2017, for evaluation and treatment of his pressure ulcer, and was readmitted back to the facility on XXXXXXX 2017.
A review of the physician?s orders for Resident 12, dated March 29, 2017, indicated the following:
1. Low bed for safety.
2. Bilateral side rails up and padded to reduce risk of injury due to history of falls, use for repositioning/turning and ADL care.
3. Low air loss mattress, concave type, with bed bumpers applied for safety and to decrease risk of injury related to history of falls and for wound management.
A review of the Fall Risk Assessment dated March 29, 2017, indicated Resident 12 scored a 10 (total score of 10 or above represents high risk for falls).
A review of the Fall Risk Prevention & Management care plan dated March 29, 2017, indicated Resident 12 was at risk for falls due to poor balance, lack of awareness, cognitive deficit, and gets out of bed without using the call light and asking for assistance. The care plan goal indicated to provide a safe environment that minimizes complications associated with falls. The listed nursing interventions included to provide an environment that supports minimized hazards over which the facility has control, keep the call light within reach, remind the resident to use the call light, and keep bed in low position.
According to a nurse's note dated March 30, 2017, at 12:45 a.m., a certified nursing assistant (CNA 1) found Resident 12 on the floor. The resident was alert and oriented and stated that he was trying to go to the restroom, climbed out of bed and tripped when his feet hit the ground then fell to the floor and hit his head. Resident 12 was assessed with a cut to the forehead which was 5 centimeter (cm) long, 0.2 cm wide and 0.2 cm deep. According to the nurse's note, first aid was provided and Resident 12's physician was notified and gave orders to transfer resident to the acute care hospital.
A review of the Emergency/Urgent Care records from the acute care hospital, dated March 30, 2017, indicated Resident 12 was brought in by ambulance from the SNF for head and facial trauma status post fall. The emergency records indicated the resident had a 5 cm laceration above the right eyebrow and 2 cm laceration on the bridge of the nose, which were sutured (a process of joining two surfaces or edges together along a line by sewing). A computed tomography (CT, a procedure which uses many x rays to create pictures of the head, including the skull, brain, eye sockets, and sinuses) scan of the head was performed and showed a 3 milliliter (mm) subdural hematoma and a nasal bone fracture with minimal associated soft tissue swelling.
During an observation on May 3, 2017, at 7:30 a.m., Resident 12 was observed in bed with eyes closed. The resident's bed had a bed alarm and was in a low position, and floor mats were observed on both sides of the bed.
During an interview on May 3, 2017, at 11 a.m., Resident 12 was alert to self, but confused and unable to answer any questions about the fall incident.
During an interview on May 5, 2017, at 7:13 a.m., Certified Nursing Assistant 3 (CNA 3) stated that on March 30, 2017, he was in another resident's room when he heard someone call for help. CNA 3 stated he went to Resident 12's room and saw the resident on the floor with blood coming from his forehead. According to CNA 3, the resident's bed was in a "high position" and the bed was not working because they were unable to bring it down. When CNA 3 was asked how high the bed was from the floor, he stated as high as the table in the resident?s room. The surveyor and CNA 3 measured the height of the table with a measuring tape and measured the table height to be 2 1/2 feet from the floor.
During an interview on May 5, 2017, at 7:24 a.m., CNA 2 stated that on March 30, 2017, she came to help CNA 1 when Resident 12 was found on the floor in his room. CNA 2 stated she saw the resident on the floor between bed B and C with the G tube feeding pole on top of him. The resident had a "big gush" on the forehead and a cut on the bridge of his nose and was bleeding. CNA 2 stated that the bed was left "really high,? about 3 feet from the floor and did not work when they tried to adjust it down. According to CNA 2, Resident 12?s bed was not a low bed, side rails were not padded, and the resident did not have a concave type low air loss mattress with bed bumpers.
On May 5, 2017, at 7:53 a.m., during an interview, Licensed Vocational Nurse 7 (LVN 7) stated that on March 30, 2017, CNA 1 called her around 12:30 a.m. and told her that Resident 12 was found on the floor face down and was bleeding from the forehead. LVN 7 stated that the resident had a laceration to the forehead where she applied pressure to help stop the bleeding. LVN 7 stated that when she asked Resident 12 what happened, the resident stated that he wanted to go to the bathroom so he got up without using the call light. LVN 7 stated that she called Resident 12's physician and he ordered to transfer the resident to the hospital. When LVN 7 was asked how high the bed was at the time of the fall, LVN 7 pointed to a bed similar to Resident 12's bed and measured the height of the bed with the surveyor. The bed was observed to be 2 feet and 7.5 inches from the floor. LVN 7 confirmed that the height of Resident 12's bed at the time of the fall was too high. LVN 7 further stated that the bed was not working and could not be adjusted up or down and there were no pads on the floor, padded side rails, or a concave type low air loss mattress with bed bumpers. According to LVN 7, Resident 12 came to the unit on March 29, 2017, at around 10 p.m.
During an interview on May 5, 2017, at 8:35 a.m., CNA 1 stated that when he made his rounds on March 29, 2017, at around 11:30 p.m., Resident 12 was in bed sleeping. Between 12 a.m. to 1 a.m., after changing another resident, he went to Resident 12's room to check on the resident and found him on the floor close to bed B, bleeding from the forehead and the nose. CNA 1 stated that he called the charge nurse right away. When CNA 1 was asked about the height of the bed, he stated that it was the same height as the table, which measured about 2 1/2 feet from the floor. CNA 1 stated he did not see any low bed, pads on the floor, padded side rails, or a concave type low air loss mattress with bed bumpers in the resident's room.
On May 5, 2017, at 12:30 p.m., during an interview, the Director of Nursing (DON) stated that they are aware that a lot of the facility beds are old and could not be adjusted up or down. The DON stated that the old beds are too high for residents who are at risk for falls.
During a telephone interview on May 12, 2017, at 9:40 a.m., the DON stated that when Resident 12 was readmitted to the facility on XXXXXXX 2017, the facility staff should have reviewed the previous care plan and continued the interventions to prevent falls.
The facility's policy and procedure titled "Fall Management Program" dated November 7, 2016, indicated the facility will implement a fall management program that supports providing an environment free from hazards to provide a safe environment that minimizes complications associated with falls.
The facility failed to provide Resident 12 with adequate supervision, assistance devices, and an environment free from accident hazards to prevent fall and injury after a fall by failing to follow the physician's orders, dated March 29, 2017, and implement the plan of care for fall risk prevention and management, dated January 4, 2017 and March 29, 2017, as follows:
1. Keep bed in a low position.
2. Padded bilateral side rails up.
3. Concave type low air loss mattress with bed bumpers applied.
4. Pads on the floor for protection.
This deficient practice resulted in Resident 12 falling, on March 30, 2017, and sustaining a laceration to the head, a nasal bone fracture, and a small subdural hemorrhage.
These violations presented a substantial probability that death or serious physical harm would result. |
| 950000066 |
LANDMARK MEDICAL CENTER |
950009975 |
B |
25-Jun-13 |
COWG11 |
3376 |
?483.13(b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Based on observation, interview, and record review, the facility failed to ensure that Resident A was free from sexual assault from Employee 1. Findings: During an unannounced visit to the facility on September 14, 2012, at 6:00 p.m., the administrator reported to the evaluator that Employee 1 was called on September 12, 2012, and was told not to come into work due to an allegation of sexual assault.A review of a facility report dated September 13, 2012, to the Department of Public Health indicated the incident occurred on September 12, 2012, at 3:58 a.m.The report indicated that Resident A alleged Employee # 1 kissed her. She stated she woke up and could not go back to sleep. She asked the employee to hug her because she was scared and nervous about going to court in the morning. They hugged one another and he gave her a kiss on the forehead and peck kiss on the lips. She then stated Employee # 1 hugged her a second time tightly and tried to give her, ?tongue.? She stated that she tried to get away but he was holding her tight. She said this had not happened in the past. During an interview with Resident A on September 27, 2012, at 4:00 p.m., She stated she does not feel safe and she is worried but has not told the staff her feelings. She further stated it made her feel mad and feel like a whore. She also said she was having nightmares and could not sleep. A review of her medical record indicated resident A was originally admitted on November 6, 2008, and was most recently readmitted on October 13, 2011 with diagnoses including Schizophrenia unspecified and mild mental retardation. Her initial treatment plan conference dated October 25, 2011, indicated she has behavioral problems including attention seeking, touching others, and sexually inappropriate behavior. An observation of a taped video from the facility security camera on the West unit indicated on September 11, 2012, at 3:58 a.m., Employee 1 gets up from behind the counter at the nurses? station and opens the door to give resident a hug and a quick light kiss on the lips. Then at 4:35 a.m., Employee 1 gets up from behind the counter at the nurses? station and opens the door again to talk to Resident A standing next to him for 30 seconds then she starts to walk away but then stops and walks toward him and puts her head on his shoulders and he hugs her again then she appears to try to separate from him but he pulls her toward him and with his arm around the back of her neck, she puts her head down toward his chest and he appears to be kissing her forehead and then her lips for fifteen seconds then releases her.A review of an employee statement dated September 13, 2012, signed by Employee 1 read ?I would like to file a resignation effective September 13, 2012. This incident happened with intent not to harm the resident. I?m sorry for what I done.? A review of a facility personnel action request dated September 12, 2012, indicated Employee 1 was terminated from the facility on September 12, 2012. The facility failed to ensure that Resident A was free from sexual abuse from Employee 1. The above violation had a direct relationship to the health, safety, or security of Resident A. |
| 950000066 |
LANDMARK MEDICAL CENTER |
950010968 |
A |
12-Sep-14 |
BZTP11 |
10559 |
F309 each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.On 6/28/10 at 2:15 p.m., an unannounced visit was made to the facility to investigate an allegation that Resident A had swallowed a toothbrush on three separate incidents due to inadequate staff supervision. Based on observation, interview and record review, the facility failed to: 1. Implement its policy and procedures to provide supervision to Resident A, who was diagnosed with a Pica disorder. 2. Revise the plan of care to prevent further incidents of Resident A swallowing a toothbrush.As a result, Resident A had three separate incidents of swallowing a toothbrush at the facility. After each swallowing incident, the resident was transferred to the acute hospital for a surgical removal of the toothbrush on 1/7/10, 2/20/10, and 6/9/10.A review of the medical record indicated that Resident A was a 47 year old male who was originally admitted to the facility on 11/17/09, with diagnoses that included Schizophrenia paranoid type (a mental illness that involves false beliefs of being persecuted or plotted against) and Pica disorder (eating disorder manifested by persistent craving and compulsive eating of non-food substitutes).A review of the comprehensive Minimum Data Set assessment (MDS-a standardized assessment and care planning tool) dated 6/24/10, indicated Resident A had good short and long term memory recall ability, had moderately impaired skills for daily decision-making and required supervision in personal hygiene. A review of Resident A?s initial plan of care dated 11/17/09, indicated a history of swallowing foreign objects due to hearing voices tells him to swallow an object. The care plan goal indicated?Maintain current episodes of ingesting foreign objects.? The care interventions indicated the following: 1. Assist to identify reason for ingesting/placing foreign objects in the body. Assist to identify/discuss alternative ways of dealing with situations/feelings associated with the behavior.2. Praise him for appropriate behavior. 3. Assist him to understand the potential negative ramifications of swallowing or placing foreign objects in body orifices. The care interventions on 11/17/09, did not indicate a specific measure of monitoring Resident A to prevent further incident of swallowing a foreign object. A review of the inter-disciplinary progress notes dated 12/31/09, indicated Resident A claimed that he swallowed a toothbrush three days ago because he heard voices telling him to swallow a toothbrush. The resident had an X-ray of the abdomen on 12/31/09, which showed a toothbrush in the stomach. The physician ordered on 12/31/09, to monitor the resident?s bowel movement if the toothbrush would pass through. On 1/5/10, the physician came to see the resident. The resident told the physician on 1/5/10, that he swallowed a green full size toothbrush and not the orange smaller toothbrush issued by the facility. The physician stated the toothbrush cannot be brought up to the neck and the resident will need surgery to remove the toothbrush. On 1/6/10, the resident was transferred to acute hospital for evaluation and removal of the ingested toothbrush. According to the acute hospital operative procedure report dated 1/7/10, the resident underwent a laparotomy (a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity) with removal of foreign body through gastrostomy (a surgical procedure for inserting a tube through the abdominal wall and into the stomach) and biopsy (removal of a small piece of tissue for laboratory examination) of the stomach wall. The surgical pathology report dated 1/7/10, indicated a green and white handled toothbrush that measured 19 centimeters (7.480 inches) in length was removed from the resident?s stomach. On 1/11/10, the resident was discharged from the acute hospital and was readmitted to the facility.A review of Resident A?s first readmission plan of care dated 1/11/10, indicated a behavior problem of swallowing foreign objects of non- nutritional value including pens and toothbrushes. The care plan goal indicated ?Maintain current episodes of Pica.? The care interventions were the same as previously documented on 11/17/09. The care plan also did not indicate monitoring of the resident to prevent another episode of swallowing a toothbrush. A review of the inter-disciplinary progress notes indicated Resident A stated to the physician on 2/18/10, that he swallowed a toothbrush and a nail two days ago. The X-ray report on 2/18/10, indicated a faint foreign body in the mid stomach region. The resident was transferred to the acute hospital on 2/20/10, for evaluation and treatment due to swallowing of a foreign object. The toothbrush was surgically removed from the resident?s stomach on 2/20/10, through an exploratory laparotomy (a surgical procedure used to visualize and examine the structures inside of the abdominal cavity) and gastrorrhaphy (a surgical operation to suture of a perforation of the stomach) as indicated by the operative procedure from the acute hospital. The resident was discharged from the acute hospital on 2/23/10. A review of the resident?s second readmission plan of care dated 2/23/10, indicated a similar plan of care written as of 11/17/09. There was no revision of the care interventions to prevent a repeat incident of Resident A swallowing a toothbrush. A review of the inter-disciplinary progress notes dated 6/9/10, indicated a transfer order to the acute hospital after Resident A reported to the physician that he swallowed two foreign objects. According to the operative procedure report from the acute hospital, the resident had a laparotomy, gastrostomy and biopsy of the stomach on 6/9/10. There were two toothbrushes removed within the fundus of his stomach (the part of the stomach to the left and above the level of the opening between the stomach and esophagus). The resident was discharged from the acute hospital on 6/12/10. A review of the resident?s third readmission plan of care dated 6/13/10, indicated care interventions were not revised since 11/17/09. The staff continuously allowed Resident A to have access to use a toothbrush without staff supervision. The toothbrush became a hazard to Resident A as he had three separate incidents of swallowing a toothbrush, resulting in surgical removal of the toothbrush in acute hospital.On 6/28/10 at 4:00 p.m., Employee 1 and Employee 2 both accompanied the Evaluator to Resident A?s room. The resident was observed alert and coherent while walking in his room. He stated he cleansed his teeth using a toothbrush. He showed a full size toothbrush with a green and white color on the handle. His toothbrush was on top of his bathroom sink. He stated the last time he brushed his teeth was on 6/28/10 at 9:00 a.m., without staff supervision. He got the toothbrush from another resident two weeks ago because he wanted to brush his teeth. He stated staff allowed him to keep the toothbrush and was never supervised when brushing his teeth. He stated he heard voices telling him to swallow a nail or toothbrush. He further stated, ?I cannot resist the voice.?During an interview on 6/28/10 at 4:10 p.m., Employee 3 stated she was aware that Resident A had previously swallowed a toothbrush. She came in to work at 3:00 p.m. for 3-11 shifts, but did not do her rounds to check on Resident A. She stated no one told her that Resident A required staff supervision while brushing his teeth. In addition, she was aware that the resident was not allowed to keep his toothbrush.During an interview on 6/28/10 at 4:15 p.m., Employee 4 stated she was aware that Resident A was readmitted from the acute hospital after two toothbrushes were removed from his stomach through a surgery. She reported for work at 3:00 p.m. on 6/28/10, and got busy attending to another resident. She stated did not know Resident A had a toothbrush in his room because she did not do her rounds. She was aware that the toothbrush can be given to the resident only when he wants to brush his teeth. She stated the resident was allowed to brush his teeth without staff supervision. During an interview on 6/28/10 at 4:30 p.m., Employee 1, stated Resident A has the right to brush his teeth. She also stated the resident was not on one to one staff monitoring because the resident was being rehabilitated to go back to the community. However, Employee 1 did not respond when asked as to how the staff can prevent the resident from swallowing a toothbrush while brushing his teeth. Employee 1 stated she was not aware the resident?s care plan was not revised since 11/17/09.A review of the facility?s undated policy and procedure titled ?PICA Ingestion of foreign objects into body? indicated ?Upon clients readmission to Landmark Medical Center they will be put on 1:1 supervision until it is determined that they are not are risk for swallowing. It can be determined that a client who has had more than two or more episodes of ingestion of foreign objects maybe determined to require1:1 supervision until a higher level of care can be secured for the client.? There was no documentation the facility staff provided a 1:1 Supervision per their policy and procedure for ?PICA ingestion of foreign objects.?The facility failed to: 1. Implement its policy and procedures to provide supervision to Resident A who was diagnosed with a Pica disorder. 2. Revise the plan of care to prevent further incident of Resident A swallowing a toothbrush.As a result, Resident A had three separate incidents of swallowing a toothbrush at the facility. After each swallowing incident, the resident was transferred to acute hospital for a surgical removal of the toothbrush.The facility?s failure to ensure the environment remains as free from accident hazards as is possible; and to ensure the resident received adequate supervision/monitoring to prevent swallowing a toothbrush, lead to Resident A?s hospitalization on three different occasions to remove the toothbrush through a surgical operation.The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 970000186 |
Legacy Care of Pasadena |
950012052 |
A |
16-Mar-16 |
UXKS11 |
8663 |
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 assessment shall commence at the time of admission of the patient and be completed within seven days after admission.(B) Development of an individual, written patient care plan which indicates the care to be given, the objective to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. 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: (1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. (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) On 3/24/15 at 1:00 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient A who developed pressure sores to both heels.Based on observation, interview and record review, the facility failed to: 1. Develop a care plan to address pressure sore prevention for Patient A who was assessed as being at risk for developing pressure sore. 2. Monitor and report skin changes to the physician. 3. Accurately assess the skin condition on both heels. 4. Develop a care plan for both heels unstageable pressure sores. 5. Obtain a treatment order for unstageable pressure sores to both heels. 6. Offload the patient's heels (to take off pressure from the heels, to suspend) when in bed. As a result, Patient A developed unstageable pressure sores to both heels (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough [yellow, tan, gray, green or brown] and /or eschar [tan, brown or black] in the wound bed).A review of the admission face sheet indicated Patient A's diagnoses included hyperlipidemia (high level of fats in the blood) and schizophrenia (psychotic disorder marked by severely impaired thinking, emotions and behaviors). The Minimum Data Set (MDS-a standardized assessment and care planning tool ) dated 2/20/15, indicated Patient A was assessed with short and long term memory problems, required extensive assistance in bed mobility, transfer and ambulation.A review of the nurses' admission assessment for Patient A indicated his skin to both heels were clear and intact on 11/6/14, when he was originally admitted to the facility. On 11/29/14, Patient A was readmitted from home and the nurses' admission assessment indicated he was assessed as having a black mole to the left heel and his skin to the right heel was clear. A review of the Braden scale assessment (a tool to assess a resident's risk of developing a pressure sore) dated 11/30/14 and 2/20/15, indicated Patient A's score was 16 (a total score of 15-18 represents mild risk), for pressure sore development.On 3/24/15, a body check of Patient A was conducted at 1:20 p.m., in the presence of the Director of Nursing (DON), Treatment Nurse 1 and Certified Nursing Assistant 1 (CNA). The patient was observed lying on his back while in bed. He was awake and non-communicative. His heels were observed with dressings and both heels were resting on the mattress. The patient's heels were observed with large amount of black skin discoloration after the dressings were removed by Treatment Nurse 1. The DON assessed the patient's heels and she stated the black skin discoloration to both heels were unstageable pressure sores due to presence of eschar. The pressure sores to the right heel measured 5 cm x 3 cm and the left heel measured 2 cm x 1.5 cm (2.5 centimeter = 1 inch). On 3/24/15 at 2:15 p.m., the medical record of Patient A was reviewed with Treatment Nurse 1, Treatment Nurse 2 and DON. The "Non-Pressure sore skin Problem Report" indicated Patient A's right medial heel (middle heel) was initially assessed on 3/10/15, by Treatment Nurse 1 as skin redness measured 3 cm x 2 cm. It further indicated that the patient's medial heel was not responding to treatment and the size of the skin redness to the right medial heel on 3/7/15 and 3/24/15, remained 3 cm x 2 cm. The treatment record dated 3/10/15 through 3/24/15, indicated Patient A had received A&D ointment treatment to his right heel skin redness. The treatment record did not contain information that Patient A had received treatment to his right heel and left heel unstageable pressure sores from 3/10/15 through 3/24/15. There was no documented evidence that Patient A's unstageable pressure sores to both heels were assessed and the physician was notified of the pressure sores.During an interview on 3/24/15 at 1:55 p.m., CNA1 stated the black skin discoloration to Patient A's left heel was the same size and appearance when the patient was readmitted in November 2014 (unspecified date). CNA 1 stated the black skin discoloration to Patient A's right heel was developed in the facility. She was not told by any staff to float Patient A's heels on the pillow to prevent pressure to the heels when lying in bed. CNA 1 stated Treatment Nurse 1 was aware of the black skin discoloration to Patient A's both heels. During an interview on 3/24/15 at 2:15 p.m., Treatment Nurse 1 and Treatment Nurse 2 both stated the black skin discoloration to Patient A's left heel was the same size and appearance referred to as black mole on 11/29/14, during his readmission to the facility. They both did not ask the family if the black skin discoloration to Patient A's left heel was a mole or pressure sore. The physician was not notified of the black skin discoloration to the left heel since 11/29/14, because they both thought it was a mole. Treatment Nurse 1 stated she observed Patient A's right heel had black skin discoloration on 3/21/15. Treatment Nurse 1 stated the physician was not made aware of the patient's black skin discoloration to the right heel because she thought it was a "Birthmark" just like on the patient's left heel. Treatment Nurse 1 was asked why Patient A would have a birthmark to his right heel when it was initially assessed as skin redress on 3/10/15. Treatment Nurse 1 responded, "I thought it was a birthmark." During an interview on 3/24/15 at 3:31 p.m., DON stated she was not aware Patient A had unstageable pressure sores to his right and left heels until she did a body check of Patient A on 3/24/15, as requested by the Evaluator. DON stated there was no documented plan of care for pressure sore prevention after the patient was assessed as being at risk for developing pressure sore on 11/30/14 and 2/20/15, according to the Braden scale assessment. DON stated the black skin discoloration to patient?s heels were not birthmarks but unstageable pressure sores. DON stated Treatment Nurse 1 and Treatment Nurse 2 should have reported to her and the physician about the skin changes to Patient A's heels but failed to do so.During a phone interview on 3/25/15 at 9:40 a.m., the family member of Patient A stated the patient had no birthmark to his right and left heels. The family member stated the black skin discoloration to Patient A's right and left heel were pressure sores developed in the facility.The facility failed to: 1. Develop a care plan to address pressure sore prevention for Patient A who was assessed as being at risk for developing pressure sore. 2. Monitor and report skin changes to the physician. 3. Accurately assess the skin condition on both heels. 4. Develop a care plan for both heels unstageable pressure sores. 5. Obtain a treatment order for unstageable pressure sores to both heels. 6. Offload the patient's heels (to take off pressure from the heels, to suspend) when in bed. As a result Patient A developed unstageable pressure sores to both heels.The facility?s failure to provide the necessary care and services had resulted to development of Patient A?s unstageable pressure sores to both heels. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 950000066 |
LANDMARK MEDICAL CENTER |
950012203 |
B |
20-Apr-16 |
RHFF11 |
5453 |
F225 483.13(c)(1)(ii)-(iii), (c)(2) ? (4) Investigation/report allegations/individuals. F225The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Department received a complaint on 12/11/12 forwarded from an Organization/Entity who had received the complaint from a family member with an allegation of physical abuse by the facility?s staff to Resident 1 on 11/23/12. The facility had received the complaint from a family member who called the police on 11/24/2012 while at the facility. The facility did not report to the Department the abuse allegation.On 12/12/12, at 2:40 p.m., and on 9/24/15, at 2:30 p.m., unannounced visits were made to the facility to investigate the allegation of physical abuse by staff (no name or description of the alleged abuser was given), toward Resident 1. Based on interview and record review, the facility failed to immediately report to the Department (State licensing/certification agency) an allegation of physical abuse by staff toward Resident 1. Facility?s nurses? progress notes on 11/23/2012 at 3:45 pm indicated ?During the client assaulting staff in the shower room client got small laceration on right upper cheek. She had some redness around the same area. Client got area cleaned, no bleeding noted.? On 11/24/12 at 8 am, it was indicated in the nurses progress notes, ?During medication pass it was noted multiple bruises and light swollen on L. upper eye lid, L. edge temporal site and middle part of R. cheek, writer asked, what happened, resident stated it was yesterday, while crying and walked away from nursing station to her room.? During an interview on 12/12/12, at 2:40 p.m., the administrator stated that the facility did not report to the Department the abuse allegation because after reviewing the hallway video recording, the facility?s staff determined that Resident 1?s facial injuries (bruises) may have been self-inflicted. During an interview and a visualreview of the facility?s hallway video recording on 12/12/12, at 3:28 p.m., the facility?s Program Director showed this writer how Resident 1 was observed on the video hitting herself with her right hand (unable to determine if closed or open fist) numerous times (video recording dated 11/23/12, from 3:06 p.m. to 3:09 p.m.). During a follow-up interview on 9/24/15, at 2:30 p.m., the facility?s administrator stated that the facility did not report to the Department the allegation of abuse because they determined that Resident 1?s facial injuries may have been caused by the resident hitting herself on the face numerous times. However, she realized that the facility did investigate the abuse allegation and concurred that it should have been reported to the Department. The facility?s undated policy and procedures, titled Facility Management Abuse Reporting, indicated,?4. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incidents: a. The State licensing/certification agency responsible for surveying/licensing facility b. The local/State ombudsman c. The resident?s representative of record d. Law enforcement officials e. The resident?s attending physicians and f. The facility medical director 5. Notices to the above agencies/individuals may be submitted via US mail, special carrier, fax, e-mail, or by telephone. Such notices will include, at a minimum: * The name of the resident * The number of the room in which the resident resides * The type of abuse that was committed (i.e. verbal, physical, sexual, neglect, etc.) * The date and time the alleged incident occurred * The name(s) of all persons involved in the alleged incident and * What immediate action was taken by the facility? The facility failed to immediately report to the Department (State licensing/certification agency) an allegation of physical abuse by staff toward Resident 1. This violation had a direct relationship to the health, safety or security of residents. |
| 950000066 |
LANDMARK MEDICAL CENTER |
950012566 |
B |
8-Sep-16 |
BB8A11 |
6069 |
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. The facility reported to the Department that Resident 1eloped under staff supervision during a shopping outing on 6/19/15. On 6/23/15, at 2:52 p.m., and on 9/24/15, at 2:30 p.m., unannounced visits were made to the facility to investigate how Resident 1 was able to elope while under the direct supervision of staff. Based on interview and record review, the facility?s staff failed to adequately supervise Resident 1 during an outing, leading to the resident?s elopement. Resident 1 was admitted to the facility on 2/18/11 with diagnoses that included anemia, peptic ulcer (painful sores or ulcers in the lining of the stomach), bipolar disorder [formerly called manic depression, causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)]), and schizoaffective disorder (a condition in which a person experiences a combination of schizophrenia symptoms - such as hallucinations or delusions - and mood disorder symptoms, such as mania or depression). A care plan, dated 11/18/14, indicated the resident had a history of AWOL (absent without leave, leaving without notice or permission, elopement) from previous placements, but no episode of elopement from this facility. The approaches included: 1. Assist client to identify/discuss feelings associated with impulsive behavior. 2. Assist client to identify/discuss alternative ways of dealing with situations/feelings associated with impulsive behavior. 3. Praise client for appropriate behavior. 4 .Assist client to associate behaviors with consequences. The care plan did not specify how the resident would be supervised/monitored during outings. The Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/19/15, indicated Resident 1 had no difficulty with performing daily activities (transfers, walking, locomotion) as she had no limitation in range of motion of the lower extremities. Resident 1 had difficulty focusing attention (easily distracted,) had disorganized thinking (rambling or irrelevant conversation). On 6/19/15, the facility reported to the Department that Resident 1 was AWOL during a shopping outing earlier on the same day (6/19/15). The report indicated that after shopping, the staff members and clients (including Resident 1) were getting snacks at a restaurant when Resident 1 requested to use the restroom. A facility staff member (Staff 1) escorted the resident to the restroom and this was when the resident was able to run away. A one-mile parameter search was done by staff, but the resident was not found. During an interview on 6/23/15, at 3:25 p.m., Staff 1 stated that she escorted Resident 1 to the restroom. While Resident 1 was in the first stall, she (Staff 1) went in the third stall to use the restroom also, and this was when Resident 1 was able to run away. Staff 1 acknowledged and verbalized her failure, stating that she should have waited until Resident 1 finished and walked her back to the group (where other residents and another staff member were waiting). She stated that Resident 1 had been in several prior outings but never attempted to elope. Staff 1 added that Resident 1 did not have any money, all the resident had were the clothes she was wearing (blue jeans, white/cream shirt, blue zippered sweater, and black tennis shoes). Staff 1 stated that the police department had been notified, but as of today (four days since the incident), the resident still had not been located. Staff 1 added that Resident 1 may not want to come back and that she may try to lie (to anyone) to prevent from being returned to the facility. During an interview on 6/23/15, at 4 p.m., the facility?s administrator was unable to provide any facility policies and procedures on how to monitor/supervise the residents during outings that would help prevent the residents from elopement. A review of the physician?s order dated 5/29/15 indicated the resident was on the following routine medications: 1. Abilify 400 milligrams (mg) intramuscular injection every 30 days (antipsychotic medicine used to treat the symptoms of schizophrenia and bipolar disorder) 2. Omeprazole 40 mg once daily before breakfast ?[used to treat certain stomach and esophagus problems (such as acid reflux, ulcers). It works by decreasing the amount of acid your stomach makes. It relieves symptoms such as heartburn, difficulty swallowing, and persistent cough. This medication helps heal acid damage to the stomach and esophagus; helps prevent ulcers, and may help prevent cancer of the esophagus].? (http://www.webmd.com/drugs/2/drug-3766-2250/omeprazole-oral/omeprazoledelayedreleasetablet-oral/details). During a follow-up on-site visit on 9/24/15, at 2:30 p.m., the facility?s administrator indicated that there had not been any news (from the police department or community resources) of the whereabouts of Resident 1. The resident?s Conservator had not heard any news from her and had not seen her. On 7/21/2016 at 1:40 pm during a telephone interview with the Director of Nursing she stated she remembers the name and about Resident 1?s elopement and that the resident has not come back to the facility and there has not been any new information that she is aware of as of today (7/21/2016). The facility failed to closely supervise Resident 1 during an outing, leading to Resident 1?s elopement. This violation put the resident at risk for consequences of abrupt discontinuation of her medication Abilify which is for the control of her symptoms of Schizophrenia. She had no money or other clothes than what she was wearing. Her assessment on 2/19/15 indicated the resident had disorganized thinking and had difficulty focusing her attention. The above violation had a direct relationship to the health, safety or security of the resident. |
| 960001210 |
LINDLEY HOUSE ONE |
960010650 |
B |
22-Apr-14 |
H8CJ11 |
3767 |
LINDLEY HOUSE ONE W & I CODE: 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. On June 5, 2013 at 8:00 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding quality of care and treatment. Based on interview and record review, the facility?s staff failed to: 1. Feed Client 1 with the appropriate adaptive equipment, a rubber tip coated metal spoon while eating out in the community. The client ate with a plastic spoon, bit and swallowed pieces of the spoon. According to Client 1?s chart, the client was admitted to the facility on August 17, 2010, with diagnoses that included profound intellectual disabilities, cortical blindness ( loss of vision that results from lesion in the visual center of the cerebral cortex of the brain), cerebral palsy (disorders that impair control of movement due to damage to the developing brain), spastic quadriplegia ( weakness of all four limbs, both arms and both legs), and severe seizures (brain disorder; person with seizures may cry out, fall to floor unconscious, twitch, move uncontrollably, drool or lose bladder control ). Client 1 is non-verbal and wheelchair bound. The client depends on staff to meet his needs of activities of daily living. According to the special incident report dated October 13, 2012 at 3:35 p.m., and a written statement by Staff A, whom no longer works for the facility, on October 13, 2012, the facility?s staff took Client 1 to a restaurant for a snack. Staff A, fed Client 1 a yogurt parfait with a plastic spoon and Client 1 bit the spoon off. Staff A tried to take the pieces of the spoon out of the client?s mouth but the client did not open his mouth and swallowed a piece of the spoon. Staff A called the nurse who instructed staff to take Client 1 to the hospital emergency room (ER). The client had x-rays taken and was discharged home the same day.The hospital report, dated October 13, 2012, indicated Client 1 had swallowed a foreign body. Client 1 was discharged home on the same day with a diagnosis of accidental ingestion. On June 5, 2013 at 10:20 a.m., during an interview with the Qualified Intellectual Disabilities Professional, he stated the staff never took the coated spoon on outings before the incident of biting down on the spoon, because it was never an issue. Review of the dietary update annual report, dated August 22, 2011, indicated the occupational therapist recommended staff to use a coated spoon to feed Client 1, as he tends to clamp hard on the spoon. Review of the dietary update semi-annual report, dated February 13, 2012, indicated the occupational therapist recommended staff to use a coated spoon to feed Client 1, as he tends to clamp hard on the spoon. The facility?s staff failed to: 1. Feed Client 1 with the appropriate adaptive equipment, a rubber tip coated metal spoon while eating out in the community. The client ate with a plastic spoon, bit and swallowed pieces of the spoon. This failure had a direct relationship to the health, safety or security of the client. |
| 630013452 |
Loleta Guest Home, ICF-DDN |
960013142 |
A |
22-Jun-17 |
QGIV11 |
11404 |
Title 22: 76918 Clients Rights
(a) Each client shall have those rights as specified in sections 4502 through 4505 of the Welfare and Institution Code.
4502 Welfare and Institutions Code
Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which received public funds.
It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following:
(d) a right to prompt medical care and treatment
On March 2, 2017 at 6:02 a.m., an unannounced visit was made to the facility to conduct an investigation of an Entity Reported Incident (ERI) regarding the death of Client 1 in the facility.
The facility failed to:
1. Provide cardiopulmonary resuscitation (CPR) when Client 1 was found unresponsive in her bed.
2. Follow the facility's policy and procedure when a client was found unresponsive to implement cardio pulmonary resuscitation (CPR). Direct Care Staff (DCS) A and B did not initiate CPR or call 911 when Client 1 was found unresponsive.
During a review of the clinical record for Client 1 on March 2, 2017, the face sheet (identifying information) indicated Client 1 was admitted to the facility XXXXXXX 2013 with diagnoses of severe intellectual disability (cognitive ability that is markedly below average level and a decreased ability to adapt to one's environment), seizure disorder (brief episode of abnormal brain activity resulting in spontaneous jerking movements of the body), esophageal reflux (a digestive disorder that allows backflow of stomach contents through the esophagus), history of falls, and cerebral palsy (poor coordination, stiff muscles, weak muscles, trouble swallowing or speaking, and tremors, problems with sensation, vision, and hearing).
A review of the clinical record for Client 1, the ?Nursing Quarterly? dated December 1, 2016, indicated Client 1 was progressing well medically. There were no concerns with the puree diet, bowel or bladder output, neither were there concerns with the latest laboratory findings dated November 3, 2016.
A review of the ?Individual Program Plan? (plans regarding the client) dated January 11, 2017, indicated Client 1 was doing well in all aspects of her care and her conditions were all under control. Client 1?s current placement was appropriate for continuous care.
A review of the Qualified Intellectual Disabilities Professional (QIDP) Quarterly Progress Report for October, November and December 2016, indicated the following for Activities of Daily Living (ADLs) needs maximum assistance with bathing, grooming, toileting and feeding. Client 1 wears an adult undergarment due to incontinence of bowel and bladder.
A review of the physician?s order dated November 8, 2016, indicated an order for Client 1 to continue to receive Jevity (fiber-fortified formula supplemental or sole-source nutrition used for oral feeding of patients with altered taste perception), Prostat (develops and distributes nutrition-medicine products for the nutritionally at risk client, who are under medical supervision) and also to increase Megastrol to 20 ml (used mainly as an appetite stimulant) two times a day to increase her appetite.
A review of the physician?s progress note dated January 27, 2017, indicated Client 1 was anorexic.
A review of the RN consultant note dated January 27, 2017, indicated the RN visited the day program to observe how the staff fed Client 1. The RN documented he discussed with the day program supervisor and direct care staff any concerns regarding the care of Client 1, and the importance of continuing to fill out the daily bowel and bladder record as well as the percentage of food consumed.
The following was noted in the facility?s ERI report dated 02/03/17; Client was her usual self. No sudden changes in behavior. NOC shift reported on 1/30/17 client in bed sleeping soundly. 1/31/17 day program reported client sleeping and refused lunch. One can of Jevity was given when the client arrived home from day program. At dinner she refused to eat and one can of Jevity was offered but the client refused. Client 1 stated she wanted to go to bed. The facility?s administrator left the facility at 10 pm. Client 1 was sound asleep, breathing fine with no distress. The facility?s administrator received a phone call at 2:45 am that Client 1 was not responding. At 2:47 a.m., the facility?s administrator arrived, the client had no pulse, no respirations, CPR was initiated and 911 called. CPR continued until the ambulance arrived.
During an interview with DCS B, on March 2, 2017 at 6:35 a.m., he was unable to answer questions from the evaluator because he did not speak English.
During an interview with DCS A, on March 2, 2017 at 6:40 a.m., she stated she worked January 31, 2017 during the evening shift (3 p.m. - 11:00 p.m.), and she stated although she was off duty, she remained on the premises because her husband worked the night shift 11 pm - 7 am. DCS A stated she usually remains in the facility with her husband when he was scheduled to work the night shift. DCS A stated while she was there she helped her husband with the clients by changing their diapers and checking on them throughout the night. DCS A stated she went to check on Client 1 who was put to bed around 7:00 p.m., and at 2:30 a.m., on February 1, 2017 and Client 1 looked asleep. DCS A stated she checked on the client again (unable to explain why she checked on the client 15 minutes later) and stated Client 1 was pale, and purplish in color, cold and non-responsive. DCS A stated she yelled for her husband to come and see Client 1. DCS A called the administrator and told him the client was cold, purple, and unresponsive. DCS A stated neither she nor her husband who was legally on duty called 911. DCS A stated she and her husband did nothing except wait for the administrator to arrive. DCS A stated she did not begin CPR because she forgot but she was sorry. DCS A stated she had a current CPR card and had received training regarding implementing CPR (an emergency procedure that combines chest compression often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest). It is indicated in those who are unresponsive with no breathing or abnormal breathing.
During an interview with the registered nurse (RN), on March 2, 2017 at 8:11 a.m., she stated there was 2 staff present; one staff should have placed the client on a hard surface and immediately began chest compressions while the other staff called 911. The RN stated all staff are trained annually on CPR and are required to have a current CPR card to ensure the wellness of the clients.
During an interview with the administrator, on March 2, 2017 at 9:40 a.m., he stated on February 1, 2017 after 2:30 a.m., he received a call from DCS B who informed him that Client 1 was unresponsive. The administrator stated 5-10 minutes later he arrived at the facility, looked at Client 1 and immediately called 911 then initiated CPR. The administrator stated the staff should have called 911 first while the other staff did CPR.
A review of the ?Paramedic Run Sheet? dated February 1, 2017, indicated a call was placed for emergency assistance at 2:51 a.m. The paramedics arrived on the scene at 2:56 a.m., in the section titled ?Run Disposition,? it was marked that Client 1 was ?dead after arrival,? the body temperature was cool and dry, capillary refill was absent, and Client 1 was apneic (suspension of breathing). The document indicated Client 1 was found on the floor in her bedroom with no sign of trauma, without signs of life, and post mortem lividity (a purple coloration of dependent parts, except in areas of contact pressure, appearing within 30 minutes to 2 hours after death, as a result of gravitational movement of blood within the vessels) present. Pupils were fixed and dilated. CPR was withheld, and death was determined at 3:10 a.m., by fire fighter paramedic.
The facility policy and procedure dated February 5, 2017 titled "BLS (Basic Life Support) Review," indicated all DCS should be familiar with the protocol in the event a patient is unresponsive and needs immediate medical attention. If the patient is unresponsive Staff 1 should call 911 immediately followed by notifying the Administrator and licensed staff on call. Staff 2 and Staff 3 will stay with the patient and start their assessment. If there is no breathing and no pulse perform CPR. During the night shift where there is only 1 staff, the staff must perform compressions and rescue breaths solo until first responders arrive. After first responders arrive, the staff will notify the administrator and licensed staff on call.
According to American Red Cross First Aid CPR/AED participants? manual, CPR is a combination of chest compressions and rescue breaths. For chest compressions to be the most effective, the person should be on his or her back on a firm, flat surface. If the person is on a soft surface like a sofa or bed, quickly move him or her to a firm flat surface before you begin. The following represents the appropriate steps of CPR.
Call 911 for assistance. If it's evident that the person needs help, call or ask a bystander to call 911, then send someone to get an AED (automated external defibrillator). If an AED is unavailable, or there is no bystander to access it, stay with the victim, call 911 and begin administering assistance.
Open the airway. With the person lying on his or her back, tilt the head back slightly to lift the chin.
Check for breathing. Listen carefully, for no more than 10 seconds, for sounds of breathing. (Occasional gasping sounds do not equate to breathing.) If there is no breathing begin CPR.
Push hard, push fast. Place your hands, one on top of the other, in the middle of the chest. Use your body weight to help you administer compressions that are at least 2 inches deep and delivered at a rate of at least 100 compressions per minute.
Deliver rescue breaths. With the person's head tilted back slightly and the chin lifted, pinch the nose shut and place your mouth over the person's mouth to make a complete seal. Blow into the person's mouth to make the chest rise. Deliver two rescue breaths, and then continue compressions. Then continue CPR until first responders arrive
The facility failed to:
1. Provide CPR to Client 1 when Client 1 was found unresponsive in her bed.
2. Follow the facility?s policy and procedure when a patient is found unresponsive to implement cardio pulmonary resuscitation (CPR). DCS A and B did not initiate CPR or call 911 when Client 1 was found unresponsive.
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 960001904 |
LIN-ROS BEST HOME CARE, INC. |
960013277 |
B |
15-Jun-17 |
Q8C011 |
3316 |
1265.5 (f)
(f) Upon the employment of any person specified in subdivision (a), and prior to any contact with clients or residents, the facility shall ensure that electronic fingerprint images are submitted to the Department of Justice for the purpose of obtaining a criminal record check.
On September 22, 2014 at 6:00 a.m., an unannounced visit was made to the facility to conduct an Annual Fundamental Recertification Survey.
The facility failed to:
Ensure a criminal record clearance for one direct care staff (DCS) A was submitted to the Department of Justice prior to DCS A providing care to 6 of 6 clients residing in the facility. This failure placed all 6 clients at risk for harm.
The clinical records for Clients 1, 2, 3, 4, 5 and 6 were reviewed on September 24, 2014, indicating the clients had diagnoses that included range from moderate (developmentally functions below chronological age and can learn elementary health and safety habits), severe (cognitive ability that is markedly below average level and a decreased ability to adapt to one?s environment) and profound (cognitive ability that is markedly below average level, incapable of self-care) intellectual disabilities and depended on staff for all activities of daily living.
On September 23, 2014 at 7:05 p.m., DCS A was observed providing care to the clients including changing Client 3?s soiled adult diaper and providing hygiene care to the client.
On September 22, 2014 at 12:05 p.m., a review of DCS A?s employee file indicated he was hired on August 19, 2013, to work the night shift from 7:00 p.m. to 6:00 a.m. DCS A?s employee file indicated there was no documentation to support a Live Scan application and a Transmittal Application had been submitted to the Department of Justice for the purpose of securing criminal record clearance.
On September 22, 2014 at 12:08 p.m., the Interactive Voice Response Unit (IVRU) was called for verification of Live Scan Application submission for the purpose of securing a criminal record clearance. The IVRU recording indicated there was no record on file for DCS A.
On September 22, 2014 at 12:10 p.m., during an interview with the Qualified Intellectual Disabilities Professional/Administrator (QIDP/ADM) she stated she accepted the Department of Justice Bureau of Criminal Identification information dated February 21, 2010, from Staff A?s prior employment as an Adult Day/Resident/Rehabilitation staff person as proof of criminal clearance. She further stated DCS A has been working in her facility since August 19, 2013.
On September 22, 2014 at 2:51 p.m., during a telephone interview with the program technician from the California Department of Public Health (CDPH) Live Scan Clearance Division, she stated DCS A did not have any information on file.
On September 23, 2014 at 7:36 p.m., during an interview with DCS A he stated he did not have a Live Scan of his fingerprints done prior to employment.
The facility failed to:
Ensure a criminal record clearance for DCS A was submitted to the Department of Justice prior to providing care to 6 of 6 clients residing in the facility. This failure placed all 6 clients at risk for harm.
The above violation had a direct relationship to the safety and security of the clients residing in the facility. |
| 060000042 |
Laguna Hills Health and Rehabilitation Center |
060013696 |
B |
19-Dec-17 |
N5WB11 |
5677 |
484.25(d) (1) (2) (n) (1)-(3) F323: Free of Accident Hazards / Supervision:
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(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.
The facility failed to provide the necessary care and services to ensure adequate assistance was in place to prevent a fall for Resident 1. Resident 1 had been assessed as needing two persons for bed mobility. CNA 1 had not cared for Resident 1 before and was not aware Resident 1 needed to have two staff in attendance during bed mobility. Resident 1 fell off the bed onto the floor while CNA 1 was providing incontinence care with no other staff in assistance. As a result, Resident 1 sustained lacerations to the upper lip, right forehead, and right knee, requiring a transfer to the acute care hospital ED by 911 and sutures.
Findings:
On 10/11/17 at 1210 hours, Resident 1 was observed lying on an air-filled mattress. Resident 1 had yellowish discoloration under her eyes and light purple discoloration on the right side of her forehead.
Medical record review for Resident 1 was initiated on 10/11/17. Resident 1 was admitted to the facility on 8/19/14, and readmitted on 9/23/17, with diagnoses including functional quadriplegia and dementia.
Review of the SBAR Communication Form and Progress Note dated 9/22/17 at 2015 hours, showed Resident 1 sustained a fall from bed onto the floor while being receiving incontinent care. Resident 1 was transferred to the acute care hospital ED by 911.
Review of the acute care hospital Physical Exam and Procedures report dated 9/22/17, showed Resident 1 arrived at the ED at 2116 hours. Resident 1 was assessed to have the following injuries: a laceration to the anterior of her right knee and swelling to the left elbow, a full thickness laceration to her right forehead (measuring 3 cm) and a full thickness laceration to the upper lip (measuring 2 cm), both requiring sutures.
On 10/11/17 at 0912 hours, an interview was conducted with Resident 1's responsible party. Resident 1's responsible party stated Resident 1 was totally bed bound and could not understand how she could have fallen. The responsible party stated the night nurse had informed her she made sure Resident 1 always had two staff assisting to change Resident 1, which clearly did not happen at the time the resident fell.
Review of the MDSs dated 6/8 and 9/5/17, showed Resident 1 had severe cognitive impairment and required extensive assistance of two persons for bed mobility and total assistance of two persons for transfers.
Review of Resident 1's plan of care showed a care plan problem dated 8/14/17, to address Resident 1's claim she had fallen out of bed. One of the interventions dated 8/15/17, showed two persons' assistance with bed mobility and transfers.
On 10/11/17 at 1420 hours and again on 10/12/17 at 1445 hours, the interviews were conducted with LVN 1. LVN 1 stated he considered Resident 1 to need one person's assistance for bed mobility before the fall on 9/22/17. LVN 1 stated he was not aware of any documentation showing Resident 1 needed two persons to assist with bed mobility.
On 1/12/17 at 1503 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 1 was a one person assist before the fall on 9/22/17.
On 10/12/17 at 1130 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified the MDS dated 6/8/17, identified Resident 1 as needing two persons for bed mobility and the care plan problem was updated on 8/15/17, to reflect the need of two persons' assistance with bed mobility and transfers. The MDS Coordinator verified the Documentation Survey Report form for the task of bed mobility from June through September 2017 showed inconsistencies in the number of staff required to provide bed mobility assistance for Resident 1.
On 10/12/17 at 1340 hours, an interview was conducted with the DSD. The DSD stated when a CNA from a nursing registry (business which provides CNAs as needed) was working, it was up to the licensed nurse to inform them of their assignments and give them the reports on the residents they were assigned to care for.
On 10/20/17 at 1500 hours, a telephone interview was conducted with CNA 1. CNA 1 was assigned to care for Resident 1 on 9/22/17, when the fall occurred. CNA 1 verified she was employed by a nursing registry agency. CNA 1 stated she never received any report regarding Resident 1's care needs and was never informed Resident 1 needed two persons' assistance for bed mobility and transfers. CNA 1 stated she was cleaning and changing Resident 1 at the time of the accident. CNA 1 stated Resident 1 was trying to help by turning to her side, but she accidentally rolled too far and fell off the bed onto the floor.
On 11/13/17 at 1420 hours, an interview was conducted with LVN 1. LVN 1 was the licensed nurse assigned to Resident 1 on 9/22/17, when the fall occurred. LVN 1 stated he did not give a report regarding Resident 1 to CNA 1. LVN 1 stated he told the other CNAs to answer whatever questions CNA 1 might have.
These failures had a direct and immediate relationship to the health, safety, and security of the residents. |
| 940000026 |
LA PAZ GEROPSYCHIATRIC CENTER |
940013555 |
B |
20-Oct-17 |
4Y0L11 |
4082 |
? 72541. Unusual Occurrences
Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department.
The Department received an Entity Reported Incident on 6/27/17 alleging a resident (Resident 1), who had a diagnosis of schizoaffective disorder, went AWOL from the facility by removing a window.
The facility failed by not following its policy in reporting to the Department of Public Health (DPH) within 24 hours of Resident 1?s elopement.
This deficient practice resulted in the facility not adhering to its policy and had the potential to jeopardize Resident 1 and other resident?s safety.
A review of Resident 1's Admission Face Sheet indicated Resident 1 was a 67 year-old male who was admitted to the facility on 6/14/17. Resident 1's diagnoses included schizoaffective disorder (a mental condition in which a person experiences symptoms such as hallucinations or delusions) and hypertension (high blood pressure).
A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-planning tool, dated 6/27/17, indicated Resident 1's cognition (thought process) was intact for daily decision-making skills. The MDS indicated Resident 1 was independent requiring no help or oversight supervision of staff needed for locomotion on/off (how resident moves between location in his/her room and adjacent corridor on same floor) unit and resident did not depend on devices for mobility.
A review of the facility's undated document titled, "Adverse Event Report," indicated Resident 1 was noted missing on 6/25/17 at 9 p.m. The document indicated Resident 1 could not be found on the facility premises and the Department of Public Health (DPH), Resident 1's conservator (person appointed by a judge to make decisions on behalf of another), and the local police Department were notified of the incident. According to the document, a missing person report was filed.
During an interview, on 6/28/17 at 1:23 p.m., the Clinical Director (Administrator 1) stated Resident 1's conservator was notified of the elopement and they were told, because of the resident's history, there was a possibility of the resident not returning to the facility.
On 6/28/17 at 1:30 p.m., during an interview, Administrator 1 stated she saw documentation that Resident 1 left the facility against medical advice (AMA) on 6/25/17 at 9 p.m., but the report to DPH regarding the incident was not made until 6/27/17 at 3:26 p.m. (two days later). Administrator 1 verified it was the facility's policy to report any unusual occurrences within 24 hours, which included elopement of a resident.
During an interview, on 6/28/17 at 3:05 p.m., Registered Nurse 1 (RN 1) stated the licensed nurse on duty 6/25/17, saw a male walking in the hallway at 8:45 p.m., the night of the incident, but was unable to determine whether or not it was Resident 1. RN 1 stated when they checked Resident 1's room, his roommates were sleeping and they noticed the bathroom window was hanging from the frame. RN 1 stated she notified the Director of Nurses (DON), Resident 1's physician, the local police department, and the facility's social worker on the same day (6/25/17) that Resident 1 eloped from the facility.
A review of the facility's policy and procedure titled, "Unusual Occurrence Reporting to California Department of Public Health," revised on 1/15/13, indicated it was the policy of the facility to notify the Department of Public Health of any unusual occurrences. The policy indicated the report shall be made within 24 hours either by telephone or by fax to the local health office and the Department of Public Health.
This violation had a direct or immediate relationship to the health, safety or security of the patients. |
| 940000026 |
LA PAZ GEROPSYCHIATRIC CENTER |
940013491 |
B |
12-Sep-17 |
6IWQ11 |
5452 |
Section 72541. Unusual Occurrences.
Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, deaths from unnatural causes or other catastrophes and unusual occurrences, which threaten the welfare, safety or health of patients, personnel, visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department.
Based on interview, and record review, the facility failed to report to the Department (the licensing and certification program) within 24 hours the elopement of Patient 1 from the clinic during a scheduled medical appointment on 5/31/17 and the elopement of Patient 2 from the facility on 3/31/17. These incidents had a potential to expose Patients 1 and 2 to accidents and injuries.
a. A review of Patient 2's face sheet (record of admission) indicated the patient was admitted to the facility on 7/18/16 and readmitted on 5/31/17 with diagnoses that included schizoaffective disorder bipolar type (a category of mental conditions that includes symptoms of schizophrenia and affective disorders. It has features of both schizophrenia, including hallucinations, delusions, and distorted thinking, and a mood component, such as depression or mania), type 2 diabetes mellitus ( blood sugar levels are too high), and hypertension (abnormally high blood pressure).
A review of Patient 2's Minimum Data Set (MDS, a patient assessment tool and care screening tool), dated 2/7/2017, indicated the patient's cognition was intact with no impairment and she was independent in activities of daily living (ADLs).
A review of Patient 2?s Order Summary Report (a summary of physician orders), dated 6/5/17, indicated Patient 2 had an order that she may go out on peer pass (a permission to leave the facility with another patient) on 3/27/17 to 4/2/17 from 10:30 a.m. to 4:30 p.m. on a daily basis.
A review of Patient 2?s Progress Notes, dated 6/5/17, indicated Patient 2 went out for pass on 3/31/17 and was supposed to return at 4:30 p.m. but the patient did not return. The sheriffs were notified and a missing person file was completed. The progress notes indicated that the patient was on AWOL (absence without leave or permission) status from 3/31/17 to 4/14/17. The progress notes indicated Patient 2 was re-admitted from a general acute care hospital on 4/14/17 and that the patient was very uncooperative, severely agitated, and very hard to redirect upon readmission.
During an interview, on 6/6/17at 1:18 p.m., the Director of Nursing (DON) stated Patient 2 eloped on 3/31/17 and the facility never reported the elopement incident to the Department. The DON stated the facility should have reported Patient 2?s elopement from the facility to the Department.
During an interview, on 6/6/17 at 2:10 p.m., the Clinical Director (CD) stated it is the facility's policy to report an AWOL patient to the police, conservator, and ombudsman, department of mental health and the Department. The Clinical Director stated the facility did not report Patient 2?s elopement incident to the Department.
During an observation and interview, on 7/7/17 at 8:32 a.m., Patient 2 was in the hallway and sitting on her wheelchair. The patient stated "I am not allowed to be out on pass anymore.?
A review of the facility?s policy and procedure titled, "AWOL-Absent Without Leave," dated 4/18/13, indicated the definition of AWOL includes any event in which a patient departed without permission and physician order from the building and did not return or did not return from pass within 2 hours. The facility was to notify the local area law enforcement, the patient's conservator, the psychiatrist, the family, administrator and "any other legal entities or persons applicable."
b. A review of Patient 1's face sheet (record of admission) indicated the patient was admitted to the facility on 3/9/17 with diagnoses that included schizoaffective disorder (is a category of mental conditions that includes symptoms of schizophrenia and affective disorders. It has features of both schizophrenia, including hallucinations, delusions, and distorted thinking, and a mood component, such as depression or mania) and paraplegia (paralysis of the legs and lower body).
A review of Patient 1?s behavioral risk assessment, dated 3/14/17, indicated Patient 1 was a low risk for elopement.
A review of Patient 1's Minimum Data Set (MDS, a patient assessment tool and care screening tool), dated 5/9/2017, indicated the patient's cognition was intact with no impairment and was independent in activities of daily living (ADLs).
On 6/3/17 at 1:11 p.m., the facility sent a report titled ?Summary Investigation Report,? to the Department. The report indicated that Patient 1 eloped from a clinic during a scheduled medical appointment on 5/31/17. The facility reported to the Department Patient 1?s elopement three days after the incident.
The facility failed to report to the Department (the licensing and certification program) within 24 hours the elopement of Patient 1 from the clinic during a scheduled medical appointment on 5/31/17 and the elopement of Patient 2 from the facility on 3/31/17. These incidents had a potential to expose Patients 1 and 2 to accidents and injuries.
The above violation had a direct or immediate relationship to the health, safety, or security of Patients 1 and 2. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940013673 |
A |
6-Dec-17 |
VTFV11 |
8885 |
? F323
CFR 485.25(d) Accidents.
The facility must ensure that-
(1) The resident environment remains as free from accidents as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
The facility failed to ensure the residents? environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to:
1. Failure in providing adequate supervision during care to Resident 1, who had a high risk for falls.
2. Failure to create a resident centered plan of care to prevent Resident 1 from falling.
3. Failure to implement their policy on fall prevention.
These failures resulted in Resident 1 being left unattended, falling out of bed, sustaining a head laceration (deep cut or tear in skin or flesh) and cervical C-spine fracture (broken bone), which had the potential for internal bleeding, and transferring to a general acute care hospital (GACH) for evaluation and treatment.
On 8/23/17 at 2:30 p.m., an unannounced complaint investigation was conducted regarding Resident 1?s fall.
A review of Resident 1's Admission Face Sheet indicated the resident was a 65 year-old male who was admitted to the facility on 2/15/17, and readmitted on 3/10/17. Resident 1's diagnoses included epilepsy (seizures; brain disorder that causes people to have recurring seizures), extrapyramidal and movement disorder, and schizoaffective disorder (mental disorder).
A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/29/17, indicated Resident 1 was not able to report the correct year, month, and day of the week. The MDS indicated the resident was moderately impaired in making decisions regarding daily life tasks, and exhibited fluctuating behavior with inattention (difficulty focusing attention, and keeping track of what was said). The MDS indicated Resident 1 required an extensive assistance of a one person physical assist with transferring, toilet use, bathing, and personal hygiene.
A review of Resident 1's Initial History and Physical (H/P), dated June 2017, indicated Resident 1 did not have the capacity to understand and make decisions.
A review of Resident 1's Physician's Orders, dated 3/10/17, indicated 81 milligrams (mg) of oral Aspirin ([ASA] as a blood thinner) was ordered daily, for cardiovascular accident ([CVA] damage to the brain from interruption of its blood supply) prevention.
A review of Resident 1's Medication Administration Record (MAR), dated 3/10/17, and timed at 9 a.m., indicated Resident 1 received oral ASA 81 mg daily.
A review of Resident 1's Fall Risk Assessment, dated 3/10/17, indicated Resident 1's fall risk score was 10 (a score of 10 or above represents High Risk).
A review of Resident 1's care plan titled, "Resident at Risk for Fall," dated 3/10/17, indicated there were no staff interventions documented to prevent Resident 1 from having fall incidents.
A review of the facility's Investigation Report titled, "Incident/Accident Investigation Follow Up," dated 3/11/17, indicated on 3/10/17, Certified Nursing Assistant 4 (CNA 4) left Resident 1 unattended in bed while changing the resident, to get help from another nurse. The report indicated Resident 1 was found on the floor, when CNA 4 returned to the room.
A review of the GACH) records, dated 3/11/17, indicated Resident 1 was unable to follow commands, exhibited poor sitting balance, and weakness. Resident 1?s head/neck CT scan (computed tomography scan, or many X-ray measurements taken from different angles to produce cross-sectional images of specific areas of a scanned object), indicated a C-spine fracture. The GACH records indicated to apply a cervical collar (immobilizer) PRN (as needed) if Resident 1 reported having pain. According to the records, Resident 1 was discharged from the GACH and transferred back to the facility on 3/13/17.
During an interview, on 10/5/17, at 1:58 a.m., CNA 2 stated Resident 1 was usually compliant with care, unless he did not know the person. CNA 2 stated the resident required a two-person assist with transferring for safety. CNA 2 stated, "Sometimes you can change him alone if he knows you or allows you to change him, because he was confused most of the time.?
During an interview on 10/5/17 at 2:34 p.m., CNA 1 stated Resident 1 required assistance from staff for personal hygiene and a two-person assistance for transferring. CNA 1 stated Resident 1 could be cooperative if he was familiar with the staff assisting him, but did not usually exhibit behavioral problems except for repetitive arm motions.
During a telephone interview on 10/6/17 at 10:15 a.m., CNA 3 stated if the resident refused care the staff should report noncompliance to the supervisor, and request help from another staff, especially if the resident's body was exposed. CNA 3 stated that if the staff was in the middle of cleaning or changing the resident, "You do not go out and leave the resident alone, you should yell for help from inside of the room." CNA 3 stated he would not leave the resident alone during care because of risking the resident's safety. CNA 3 stated on the day of incident, he saw CNA 4 outside of Resident 1's door, asking for help, but told CNA 4 he could not provide assistance due to his own resident assignment. CNA 3 stated he thinks Resident 1 fell when CNA 4 stepped out of the room to ask for help. CNA 3 could not recall if Resident 1's side rails were up, or if there was a landing pad on the resident's floor when he entered the room.
During an interview and concurrent record review, on 10/5/17, at 3:05 p.m., Registered Nurse 1 (RN 1) stated on 3/10/17, when he entered Resident 1's room, he found Resident 1 on the floor. RN 1 stated there was blood on the floor from Resident 1's head wound and he cleaned the resident's wound and tried to stop the bleeding on the resident's head. RN 1 stated he was not sure if he could stop the bleeding, due Resident 1 receiving ASA that morning. RN 1 stated the resident was transferred to the GACH after the fall. RN 1 stated Resident 1's care plan titled, "Resident at Risk for Fall," and Initial Plan of Care: Potential for Falls, due to Decreased Safety Awareness and Disease Process, dated 3/10/17, indicated there was no documentation on the staff interventions and resident goals section, which should have been completed.
During a telephone interview, on 10/6/17, at 10:42 a.m., CNA 4 stated while changing Resident 1's adult brief on 3/10/17, the resident became agitated and combative (ready or eager to fight). CNA 4 stated she stepped out of the room to ask for help and when she came back to the room, she found Resident 1 on the floor. CNA 4 stated Resident 1 did not have side rails on the bed, or floor mats at that time to protect him. CNA 4 stated the resident had a history of being combative and she would usually stay with the resident and yell for help if needed.
During a telephone interview, on 10/6/17, at 11:28 a.m., Licensed Vocational Nurse 1 (LVN 1) stated if a resident became combative during care and the CNA needed help, the CNA should not leave the resident unattended. LVN 1 stated that the CNA should use the call light or yell for help.
During an interview, on 10/6/17, at 12:20 p.m., the Director of Nurses (DON) stated if a resident becomes combative during ADL care, the staff should yell from the resident's room, or use the call light to ask for help. The staff should stay with the resident to monitor the behavior closely.
A review of the facility's Policy and Procedure titled, "Fall Management Program," with a revised date of 11/7/16, indicated the Licensed Nurse and /or Interdisciplinary Team ([IDT] a coordinated group of experts from several different fields, working together toward a common goal for the resident), would develop a plan of care for the resident, according to the identified risk factors and root cause, and provide a safe environment that minimized complications associated by falls.
The facility failed to ensure the residents? environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to:
1. Failure in providing adequate supervision during care to Resident 1, who had a high risk for falls.
2. Failure to create a resident centered plan of care to prevent Resident 1 from falling.
3. Failure to implement their policy on fall prevention.
The above violation presented either an imminent danger that death or serious harm would result to Resident 1 or a substantial probability that death or serious physical harm would and did result to Resident 1. |
| 940000006 |
LAKEWOOD HEALTHCARE CENTER |
940013683 |
A |
14-Dec-17 |
UOMZ11 |
11605 |
F 323 ?483.25 (h) Accidents
The facility must ensure that ?
(1) The resident environment remains as free from accident hazards as is possible: and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
F309 ?483.25 Quality of Life
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
The facility failed to ensure residents received the necessary care and services and the environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to:
1. Failure to follow its policy and procedure.
2. Failure to ensure Resident 1 was properly positioned during feeding.
These deficient practices resulted in Resident 1 aspirating (breathing in a foreign object [food] into the airway), having low oxygen levels for an unknown amount of time, and subsequently being transferred to a general acute care hospital (GACH) in acute respiratory distress on 8/16/17. Resident 1 was admitted to the intensive care unit (ICU) for a total of 12 days, and transferred to another GACH (2) for continuation of higher level of care in a vegetative state (severe brain damage).
A review of Resident 1's Admission Face Sheet indicated the resident was a 67 year-old male who was originally admitted to the facility on 11/14/16 and readmitted on 8/10/17. Resident 1's diagnoses included dementia (decline in mental ability and memory which interfere with the ability to perform activities of daily living [ADLs]), epilepsy (neurological disorder resulting in periodic episodes of uncontrolled muscular jerking movements of the body), and chronic obstructive pulmonary disease ([COPD] lung disease resulting in obstruction of airflow to the lungs).
A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 5/22/17, indicated Resident 1 had memory problems, impaired decision-making, but was able to make needs known and usually understood others. Resident 1 had a brief interview for mental status (BIMS) score of 5, indicating the resident was non interviewable (8-15= interviewable). According to the MDS, Resident 1 was assessed as requiring extensive assistance with bed mobility, transferring on and off the unit, and with personal hygiene.
A MDS assessment, dated 8/4/17, under Section G: Functional status, indicated Resident 1 was assessed as requiring supervision for eating.
A review of Resident 1's care plan titled, "Activities of daily living," initiated on 1/9/17, and revised on 8/11/17, indicated Resident 1 required an extensive assistance with eating.
A review of an Emergency Response form by the Fire Department, dated 8/16/17, and timed at 9:55 a.m., indicated 911 response-?found Patient (Resident 1) lying flat in bed chief complaint shortness of breath. Patient normally altered. Staff unable to tell Fire Department how long patient was on oxygen mask, but staff had incorrect liters and had patient lying flat; (-) JVD (a sign of increased measurement of the pressure inside the heart); (-) pedal edema (swelling of the feet and ankles from fluid accumulation in the tissues).?
A review of GACH 1's Emergency Room (ER) provider note, dated 8/16/17, and timed at 11:15 a.m., indicated "General appearance, resident arrived altered (decreased mentation), unresponsive, eyes closed, not responding to verbal communication, and in severe respiratory distress." According to the note, Resident 1 was hypoxic (condition in which the body or a region of the body is deprived of adequate oxygen supply) and hypotensive (low blood pressure) and the physician decided to intubate (flexible tube inserted into throat to assist with ventilation and breathing) the resident immediately; mildly cyanotic (bluish or purplish discoloration of the skin due to the tissues near the skin surface having low oxygen saturation) color improved after intubation."
The ER note indicated during the initial placement of the glide scope (tool used to evaluate the airway prior to intubation) Resident 1 had a large amount of eggs in the posterior larynx (back of the throat) and around the vocal cords. Once the vocal cords were opened they could see eggs around the resident's airway with dried mucous membranes and Resident 1 was not breathing adequately with very slow labored respirations (breathes). The note indicated the food was removed from Resident 1's airway prior to intubation. After intubation, the resident's breath sounds were improved bilaterally with good ventilation with and rales throughout both lung fields.
A review of Resident 1's ER room's GACH radiology results, dated 8/16/17, indicated a 50-60 percent right sided pneumothorax (trauma to the chest wall resulting in a collapsed lung) with multiple right sided rib fractures (broken bones).
A review of GACH 1's ER course/response to treatment, dated 8/16/17, and timed at 11:32 a.m., indicated, "Patient placed in room and examined immediately upon arrival, oxygenated with a bag valve mask ([BVM] a hand-held device used to provide ventilation to patients who are not breathing), suctioned food from mouth, and intubated. The blood pressure was low at 85/67 [normal reference range [NRR] is120/80], 99% oxygen saturation post intubation, The ER Charge nurse spoke with the nurse from skilled nursing facility (SNF), who initially stated the patient was not being fed, but called back and stated he (Resident 1) was being fed eggs that morning and he began to cough so they stopped feeding the resident. The SNF nursing staff informed GACH 1 that the resident had no known fall, no Cardiopulmonary resuscitation ([CPR] act of chest compression and ventilation to revive the resident) performed at the SNF facility. The paramedics who brought patient from facility stated no CPR was performed enroute. The patient arrived in respiratory failure with impending respiratory arrest (cessation of breathing) and patient was not responding. Patient is immediately intubated on arrival due to low oxygen saturation and hypotension (low blood pressure). The patient's (Resident 1) chest x-ray was consistent with right pneumothorax with multiple rib fractures requiring a placement of a chest tube to low suction to keep the lungs completely inflated. The patient was hypotensive and was started on Levophed (intravenous [into the vein]) medication used to sustain normal blood pressure) drip. Resident 1 was admitted to ICU."
On 8/18/17 at 4:40 p.m., during an interview, Licensed Vocational Nurse (LVN 1) who was assigned to Resident 1 the day of the incident stated, "The CNA reported to me that the resident was not swallowing his food during breakfast, I went in and took the vital signs (blood pressure, heart rate, temperature, and respiration) and
the oxygen saturation was out of range. I notified the Registered nurse supervisor (RN 1) on duty and we verified that the oxygen saturation was low at 87 percent (NRR 95 to 100 percent) and we called 911. We then called the doctor to let him know that we sent the resident out." When LVN 1 was asked if CPR was started, LVN 1 stated, "No we did not start CPR because he was breathing."
A review of the facility's staff assignment, dated 8/15/17 and 8/16/17, indicated CNA 1, CNA 2, LVN 1 and RN 3 were assigned to Resident 1's care.
On 8/21/17 at 9:34 a.m., during an interview CNA 1 stated, "I was assigned to Resident 1 on 8/16/17 during the morning shift. That day he was very tired and weak. I started the day with taking the vitals and I passed out the breakfast trays. The resident was asleep, and I did not reposition him. I did not interact with him until I sat down to feed him, while he was laying in the bed. I had to use a pillow behind his back because the bed did not raise up, it was broken."
A review of the SNF facility's policy titled, "Feeding the Resident" indicated residents who are able to receive oral feedings should be properly positioned to facilitate feeding. Assistance is provided with eating for residents as needed. Nursing staff will be observant during the feeding process, watch for signs of choking or anything unusual. Residents are positioned in an upright position to prevent choking or aspiration.
On 8/21/17 at 9:59 a.m., during an observation, in the presence of CNA 1, Resident 1's bed had a rusty broken hand crank at the foot, with two rusty broken springs. The hand crank did not adjust and raise the head of bed (HOB).
A review of a handwritten declaration, written by CNA 1, dated 8/21/17, and timed at 11:53 a.m., indicated CNA 1 fed Resident 1 in bed, and sat on the right side of Resident 1's bed. The declaration indicated after two (2) spoonful of food were given to Resident 1, he spat the food out. CNA 1 documented that the resident did not look well and reported it to the nurse (LVN 1). CNA 1 propped Resident 1 up on a rolled blanket and a pillow behind the back.
On 8/21/17 at 12:12 p.m., during an interview, a registered nurse supervisor (RN 3) stated, "I was informed about the low oxygen saturation by the charge nurse and I went to the resident's bedside. The resident was in a lying position in his bed, I assessed him and heard wheezes (continuous, coarse, whistling sound produced in the respiratory airways during breathing, indicative to part of the respiratory system being narrowed or obstructed) with labored breathing (abnormal respiration characterized by evidence of increased effort to breathe). I did not perform CPR on him (Resident 1), we just called 911 for the paramedics."
A review of a hand written declaration, written by RN 3, dated 8/21/17 and timed at 12:20 p.m., indicated later that afternoon she received a call from GACH 1's emergency department and was asking if CPR was done, and she replied no. I asked CNA 1 if she was feeding him (Resident 1) and she said yes, but he was coughing, so feeding was stopped. I told CNA 1 she should have put the resident (Resident 1) in the wheelchair during feeding. I was also asked by the ER GACH nurse by telephone if the resident had a fall recently, and I replied no. I didn't receive a report that the resident had a fall.
On 8/24/17 at 9:25 a.m., during an interview and observation, the maintenance supervisor (MS 1) stated, "The bed from Resident 1's room was removed three days ago." MS 1 attempted to crank the bed and raise the HOB but it was broken and did not raise.
A review of GACH 2's Admission Note indicated Resident 1 was transferred to the hospital on 8/27/17 from GACH 1 for continued higher level long-term care. As of 11/6/17, Resident 1 remained obtunded (vegetative state [altered level of consciousness], typically as a result of a medical condition or trauma).
The facility failed to ensure residents received the necessary care and services and the environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to:
1. Failure to follow its policy and procedure.
2. Failure to ensure Resident 1 was properly positioned during feeding.
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000056 |
Long Beach Healthcare Center |
940013514 |
B |
22-Sep-17 |
VGWG11 |
18895 |
F223
? 483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms.
483.12(a) the facility must-
(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
The Department received an entity reported incident (ERI) alleging a resident (Resident 2) was be verbally abusive toward her roommate (Resident 1). An unannounced investigation was conducted on 7/24/17.
Based on observation, interview, and record review, the facility failed to:
1. Ensure residents were free from verbal abusive and threatening behavior by Resident 2 for five residents (Residents 1, 3, 4, 6, and 7).
2. Residents 1, 3, 4, 6, and 7 were not protected from Resident 2's ongoing verbal abuse and threatening behavior.
3. The facility failed to assess, monitor, and develop a plan to address and prevent Resident 2's ongoing verbal abuse, after Residents 1, 3, 4, 6 and 7 complained about being abuse by Resident 2.
This deficient practice resulted in Residents 1, 3, 4, 6, and 7 being verbally abused and the residents feeling unsafe and fearful; which resulted in emotional distress, mental anguish, and psychological trauma.
a. A review of Resident 1's Admission Face Sheet indicated Resident 1 was a 74 year-old female who admitted to the facility on September 26, 2003. Resident 1's diagnoses included multiple sclerosis ([MS], a disease that affects the brain and spinal cord), quadriplegia (loss of use of the arms, legs, and torso), and dementia (loss of memory).
A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated July 7, 2017, indicated Resident 1's cognition was intact. The MDS indicated Resident 1 was totally dependent on the staff for mobility, dressing, eating, and hygiene. According to the MDS, Resident 1 had a Brief Interview for Mental Status (BIMS) score of 14 (a score of 8-15 indicated interviewable).
A review of Resident 1's Social Services (SS) Note, dated July 2, 2017, and timed at 4:50 p.m., indicated Resident 2 (Resident 1's roommate) had Resident 1's friend kicked out of the room while he was visiting with Resident 1.
A review of Resident 1's SS Note, dated July 2, 2017, and timed at 5:46 p.m., indicated Resident 1 expressed concern to the Social Services Director (SSD) regarding Resident 2 not wanting religious visitors in their room.
A review of Resident 1's SS Note, dated July 16, 2017, and timed at 3:18 p.m., indicated a Certified Nursing Assistant 1 (CNA 1) heard Resident 2 tell Resident 1, "You can't get out of that bed? You just want this da-n preacher to come here. You're dying! You're dying! You're dying! You're dying!"
A review of Resident 1's SS Note, dated July 16, 2017, and timed at 3:41 p.m., indicated Resident 1 confirmed the remarks made by Resident 2. The note indicated Resident 1 appeared to be in a sad mood and looked at Licensed Vocational Nurse 1 (LVN 1) and stated, "Am I really rotting in bed?" Resident 1 declined a room change and stated, "I've been in this room for 13 years and am pretty comfortable here."
A review of Resident 1's Physician Progress Notes, dated July 19, 2017, and timed at 9 a.m., indicated Resident 1 reported Resident 2 told her she was going to die.
On July 24, 2017 at 9:05 a.m., during an interview, Resident 1, who was a quadriplegic, stated Resident 2 told her that nobody was going to help her and she was going to lie in the bed until she was dead.
On July 24, 2017 at 9:42 a.m., during a telephone interview, CNA 1 stated she heard Resident 2 tell Resident 1, "You talk to the preacher and you are rotting away. You're dying. You're dying." CNA 1 stated Resident 1 got upset because Resident 2 told her visitor to "Get the he-l out of here."
On July 24, 2017 at 9:58 a.m., during a telephone interview, LVN 1 stated while speaking to Resident 1 about the incident with Resident 2, Resident 1 appeared sad and asked her, "Am I really rotting?"
On July 24, 2017 at 1:20 p.m., during an interview, Resident 1 stated, "If I had a visitor, my roommate [Resident 2] would tell them to get out of the room. One was a pastor and the other was my best friend. They would leave because of her. I was really upset and I felt bad."
b. On July 24, 2017 at 8:52 a.m., during the facility's initial tour, Resident 2 was observed in the bed. The resident had a sleep mask covering both eyes and when approached asked, "What time is it?" After being told the time was 8:52 a.m., Resident 2 responded, "Oh Fu-K No! Come back later, 1 p.m. would be a good time to come back."
A review of Resident 2's Admission Face Sheet indicated the resident was a 57 year-old female who was admitted to the facility on November 2, 2011. Resident 2's diagnoses included MS, major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest), anxiety disorder (excessive worry or fear), and insomnia (inability to sleep).
A review of Resident 2's history and physical (H/P), dated September 30, 2016, indicated the resident had the capacity to understand and make decisions.
A review of Resident 2's MDS, dated May 4, 2017, indicated Resident 2's cognition was intact with a BIMS score of 15. The MDS indicated the resident had verbal behavioral symptoms directed toward others on a daily basis and rejected evaluation or care needed to achieve goals for health and well-being on a daily basis. According to the MDS, Resident 2 required supervision for locomotion on the unit and extensive to limited assistance from one staff member for mobility and transferring. Resident 2 received anti-anxiety and anti-depressant medication seven days a week and hypnotic medication six days a week.
A review of Resident 2's Progress Notes indicated the resident had several incidences of profanity, verbal abuse, and aggressive behaviors directed toward residents, staff, and visitors, dating back to October 2014.
A review of Resident 2's care plan titled, "Resident Has a Behavioral Problem," initiated June 21, 2015, without an updated date for review. There was only a target date of 7/31/17. The care plan indicated Resident 2 had a physical and verbal aggressive behavior problem manifested by flicking cigarettes at staff, intentionally banging her motorized wheelchair into the facility's property, being verbally and physically abusive to other residents, and making derogatory comments directed toward staff. The goal was for Resident 2 to have less than one episode per week of verbal or physical aggression directed toward residents and staff.
A review of Resident 2's SS Assessment, dated August 3, 2016, and timed at 12:54 p.m., indicated Resident 2 had a history of angry outbursts, disrobing in public, refusing care, persistent mood swings, and had several psychosocial behavioral incidents with residents and staff. The note indicated Resident 2 always declined psychological and psychiatric services for evaluation.
A review of Resident 2's Initial Psychiatric Evaluation note, dated October 4, 2016, indicated the resident was argumentative with the MD and stated, "Fu-k you, get away from me! You're a son of a bit-h!"
A review of Resident 2's Nurses Progress Note, dated March 19, 2017, and timed at 6:04 p.m., indicated Resident 2 was screaming in the hallway while following a Registered Nurse 1 (RN 1) and called RN 1 abusive and inappropriate names.
A review of Resident 2's SS Assessment, dated May 4, 2017, and timed at 10:11 a.m., indicated after offering to assist Resident 2, the resident became upset and started using profanity towards the SSD. Resident 2 stated the SSD was useless.
A review of Resident 2's Nurses Progress Note, dated June 11, 2017, and timed at 2:28 p.m., indicated Resident 2 was verbally abusive toward two CNAs calling them fat and stupid in the ear shot of other residents.
A review of Resident 2's SS Note, dated June 15, 2017, and timed 3:15 p.m., indicated Resident 2 approached the SSD and yelled, "Don't you ever get the Ombudsman involved again. She is a piece of Sh-t!"
A review of Resident 2's SS Note, dated June 26, 2017, and timed 2:23 p.m., indicated Resident 2 became upset that Resident 1 had a religious visitor. Resident 2 raised her voice and told the SSD she did not want any religious visitors in her room without her permission.
A review of Resident 2's SS Note, dated July 2, 2017, and timed 4:47 p.m., indicated Resident 2 kicked Resident 1's visitor out of the room while he was visiting with Resident 1. The note indicated Resident 2 did not want a man in her room while she was sleeping.
A review of Resident 2's Nurses Progress Note, dated July 9, 2017, and timed at 10:07 p.m., indicated Resident 2 asked if Resident 1 had any visitors and then stated, "Fu-k, I have to stay in bed tomorrow so no one comes in."
A review of Resident 2's Nurses Progress Note, dated July 14, 2017, and timed at 4:39 p.m., indicated while Resident 2 was speaking to LVN 2 in the hallway, the resident stated another employee was a "Di-k and a muffin top eater." After LVN 2 told Resident 2 she was not being nice, the resident stated, "I don't give a fu-k, it's true," In the ear shot of other residents.
A review of Resident 2's Nurses Progress Note, dated July 16, 2017, and timed at 2:10 p.m., indicated Resident 2 stated she had the right over the entire room and wanted Resident 1 out of the room when Resident 1's friends or pastor came to visit.
A review of Resident 2's SS Note, dated July 16, 2017, and timed 2:54 p.m., indicated during a meeting with the SSD and LVN 1, Resident 2 was adamant she had the right to kick anyone out of the room, even if it was the roommate's visitor. The SSD was later informed that Resident 2 was overheard by CNA 1 telling Resident 1, "You can't get out of that bed? You just want this Da-n preacher to come here. You're rotting away. You're dying. You're dying. You're dying!"
A review of Resident 2's Situation Background Assessment and Recommendation (SBAR) / Change of Condition (COC) Note, dated July 16, 2017, and timed at 3 p.m., indicated Resident 2 verbally abused Resident 1.
A review of Resident 2's SS Note, dated July 16, 2017, and timed at 3:41 p.m., indicated Resident 1 confirmed the remarks made by Resident 2. The note indicated Resident 1 appeared to be in a sad mood and looked at LVN 1 and stated "Am I really rotting in bed?" The Resident declined a room change and stated "I've been in this room for 13 years and am pretty comfortable here."
On July 24, 2017 at 9:58 a.m., during a telephone interview, LVN 1 stated Resident 2 was verbally abusive to other residents and staff. LVN 1 was tearful and stated the resident (Resident 2) "Harassed me all day for two days," in the earshot of other residents.
On July 24, 2017 at 1:25 p.m., during a telephone interview, the ADON stated, When the resident (Resident 2), has an outburst we let her vent and yell after that she becomes calm. If not, we send her to the social worker. We try to keep the other residents out of the resident's (Resident 2) way for the most part."
On July 24, 2017 at 4:31 p.m., during an interview, Resident 2 stated, "I don't get along with patients here except two. The rest of them are A-S HOL-S and idiots. They are jealous because my MS is not as bad, as theirs, and I can get up and move."
On July 25, 2017 at 9:39 a.m., during a telephone interview, MD 1 stated Resident 2 was independent, impolite, and verbally abusive to him and others.
On July 25, 2017 at 9:58 a.m., during an interview, Resident 2 stated, "If they disrupt me sleeping, I have the right to kick other people's visitors out of the room. The visitation policy only applies to family."
On July 26, 2017 at 4 p.m., during an interview, Resident 2 stated she told Resident 1 she was going to die.
c. On July 24, 2017 at 8:58 a.m., during the facility's initial tour, Resident 3, who was a roommate to both Residents 1 and 2, was observed in the hallway outside of the room. CNA 2 was assisting Resident 3 into a seated walker.
A review of Resident 3's Admission Face Sheet indicated the resident was a 81 year-old female who was admitted to the facility on December 11, 2014. Resident 3's diagnoses included dementia, osteoarthritis (joint disease that results from breakdown of cartilage and underlying bone), and blindness to one eye.
A review of Resident 3's MDS, dated June 20, 2017, indicated the resident's cognition was intact with a BIMS score of 15.
On July 24, 2017 at 10:50 a.m., during an interview, CNA 2 stated Resident 2 would yell bad words if Resident 3 was in the bathroom when Resident 2 needed to use it.
On July 24, 2017 at 11:05 a.m., during an interview translated by CNA 2, Resident 3 tearfully stated the resident (Resident 2) "talks bad to me and makes me cry. I wish it was her who changed rooms instead of my other roommate (Resident 1) so I can feel safer, I don't feel safe."
d. A review of Resident 4's Admission Face Sheet indicated the resident was a 60 year-old male who was initially admitted to the facility on August 7, 2012, and readmitted on August 5, 2016. Resident 4's diagnoses included quadriplegia (partial or total loss of use of the arms, legs, and torso) and major depressive disorder.
A review of Resident 4's MDS, dated June 16, 2017, indicated the resident's cognition was intact with a BIMS score of 15.
A review of Resident 4's H/P, dated August 10, 2016, indicated the resident had the capacity to understand and make decisions.
On July 24, 2017 at 1:53 p.m., during an interview, Resident 4 stated, "The resident (Resident 2) attacked me at the train station (while they were out on pass). She kept slamming the gate on me and laughing. She calls me names, tells everyone that I'm gay and says my mother sucks my CO-K. I've notified the old and the new Administrator, the DON, and social services, but they blow me off and nothing was done. I had a restraining order filed against her (Resident 2). She has been horrible to me and has made my life HE-L. Sometimes I don't feel safe here."
e. A review of Resident 6's Admission Face Sheet indicated the resident was a 56 year-old female who was initially admitted to the facility on October 15, 2012, and readmitted to the facility on February 1, 2017. Resident 6's diagnoses included MS, quadriplegia, and major depressive disorder.
A review of Resident 6's MDS, dated May 14, 2017, indicated the resident's cognition was intact with a BIMS score of 15.
A review of Resident 6's H/P, dated February 8, 2017, indicated the resident had the capacity to understand and make decisions.
On July 24, 2017 at 4:55 p.m., during an interview, Resident 6 stated the resident (Resident 2) "Makes a vomit sound each time I pass by. She says really nasty things to me. This has been going on since 2013. I notified social services and the past Administrator. I would cry and was scared to come out of my room for a long time. It's intimidating."
f. A review of Resident 7's Admission Face Sheet indicated the resident was a 63 year-old female who was initially admitted to the facility on August 23, 2007 and readmitted to the facility on June 12, 2012. Resident 7's diagnoses included MS, quadriplegia, and insomnia.
A review of Resident 7's MDS, dated July 4, 2017, indicated the resident's cognition was intact with a BIMS score of 15.
A review of Resident 7's H/P, dated June 14, 2017, indicated the resident had the capacity to understand and make decisions.
On July 24, 2017 5:45 p.m., during an interview, Resident 7 stated the resident (Resident 2) "Bullied me for four months. She would say terrible things to me. I had skin cancer on my nose and she would say "Pinocchio," looks like somebody stomped on your nose. She (Resident 2) would whisper into my ear "too bad you can't use your arms" because I'm a quadriplegic. I have seen her do the same to other residents here. She is very rude, even to her own nurse."
g. A review of Resident 5's Admission Face Sheet indicated the resident was a 60 year-old male who was initially admitted to the facility on March 20, 2012 and readmitted to the facility on June 29, 2016. Resident 5's diagnoses included MS and quadriplegia.
A review of Resident 5's MDS, dated July 12, 2017, indicated Resident 5's cognition was intact with a BIMS score of 15.
A review of Resident 5's H/P, dated July 12, 2017, indicated the resident had the capacity to understand and make decisions.
On July 24, 2017 at 12:15 p.m., during an interview, Resident 5 stated he was the facility's resident's council president. Resident 5 stated Resident 2 could be heard from the facility hallway cursing and yelling at four to five different facilities' staff. Resident 5 stated Resident 2's cursing could be heard by a lot of the residents and it had been going on for over a year.
A review of the facility's policy and procedures titled, "Abuse Prevention Program," with a revision date of August 2006, indicated the facility was committed to protecting its residents from abuse by anyone, including other residents. The policy indicated the facility's abuse prevention program provided policies and procedures that govern, as a minimum the implementation of changes to prevent future occurrences of abuse.
A review of the facility's policy and procedures titled, "Resident to Resident Altercations," with a revision date of December 2007, indicated the facility's staff would monitor residents for aggressive/inappropriate behavior towards other residents, visitors, or staff. The staff would review the events, including interventions to prevent additional incidents and make any necessary changes in the care plan approaches. Staff would also document in the resident's clinical record, all interventions and their effectiveness.
The facility failed to:
1. Ensure residents were free from verbal abusive and threatening behavior by Resident 2 for five residents (Residents 1, 3, 4, 6, and 7).
2. Residents 1, 3, 4, 6, and 7 were not protected from Resident 2's ongoing verbal abuse and threatening behavior.
3. The facility failed to assess, monitor, and develop a plan to address and prevent Resident 2's ongoing verbal abuse, after Residents 1, 3, 4, 6 and 7 complained about being abuse by Resident 2.
The above violation had the direct relationship to the health, safety, or security of patients. |
| 940000056 |
Long Beach Healthcare Center |
940013469 |
A |
22-Sep-17 |
None |
11160 |
F323
? ?483.25 (h)
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 that the resident's environment remained as free from accident hazards as possible, and each resident received adequate supervision to prevent accidents; to provide Resident 2 with supervision to ensure she adhere to the facility's policy and procedure to prevent incidents and accidents including but not limited to:
1. Failure to provide Resident 2 with the necessary supervision and adequate monitoring to prevent accidents and hazards.
2. Failure to ensure Resident 2, who was wheelchair bound, was supervised when leaving the facility, after receiving several narcotic medications and driving the motorized wheelchair out on pass (OOP).
3. Failure to ensure Resident 2 adheres to the facility's smoking policy and procedure and be supervised while smoking in the facility's designated smoking areas.
4. Failure to ensure Resident 2 operated her motorized power wheel chair with caution throughout the facility.
These deficient practices resulted in near-miss accidents and had the potential to result in serious injury to Resident 2, and other residents, staff, and visitors; and posed a fire hazard to residents who resided in the facility due to Resident 2 smoking unsupervised in undesignated areas, as well as attempting to set the linen cart on fire.
A review of Resident 2's Admission Face Sheet indicated the resident was a 57 year-old female, who was initially admitted to the facility on November 2, 2011, and readmitted on September 29, 2016. Resident 2's diagnoses included multiple sclerosis (a disease that affects the brain and spinal cord), major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest), anxiety disorder (excessive worry or fear), and insomnia (inability to sleep).
A review of Resident 2's History and Physical (H/P), dated September 30, 2016, indicated the resident had the capacity to understand and make decisions.
A review of Resident 2's Minimum Data Sheet (MDS), a standardized assessment and care-screening tool, dated May 4, 2017, indicated Resident 2's cognition was intact. The MDS indicated Resident 2 required supervision for locomotion on the unit and extensive to limited assistance from one staff member with mobility and transfers. The MDS indicated Resident 2 used a wheelchair for mobility. Resident 2 received anti-anxiety and antidepressant medication seven days a week and hypnotic medication six days a week.
A review of Resident 2's care plan, with an initiation date of July 22, 2015, without an update indicated the resident would leave the facility late at night and early in the morning.
A review of Resident 2's physician's telephone order, dated September 29, 2016, and timed at 8:33 p.m., indicated Resident 2 to go out on pass (OOP).
A review of Resident 2's Nurses Note, dated June 22, 2017, and timed at 11:12 a.m., indicated on June 21, 2017, Resident 2 did not sign the out on pass book and returned to the facility at 9 p.m.
On July 24, 2017 at 1:25 p.m., during an interview, the Assistant Director of Nursing (ADON) stated, "The resident (Resident 2) should sign out, but half of the time she doesn't. We don't know where she goes, but she comes back to the facility to receive her narcotic medications (a class of substances that blunt the senses [affects the brain])."
A review of Resident 2's care plan, with an initiation date of January 16, 2017, indicated the resident was non-compliant with the facility's smoking regulations and did not wear a smoking apron, did not follow the smoking schedule, and did not smoke in the facility's designated smoking areas.
A review of Resident 2's Smoking Assessment, dated May 11, 2017, and timed at 12:56 p.m., indicated the resident could maintain her own smoking and lighting materials, could smoke with periodic supervision, but the assessment indicated Resident 2 refused to wear a smoking apron.
A review of Resident 2's care plan, titled "At Risk for Safety Hazard," with an initiation date of September 15, 2015, indicated on May 12, 2017 the resident was seen with a lighted cigarette inside the facility and when the resident was told it was not allowed, she threw the lit cigarette inside of the facility's linen cart. The staff's intervention on the care plan indicated for the staff to encourage Resident 2 to follow safe smoking policy and procedures.
A review of Resident 2's Smoking Interdisciplinary Team (IDT) Note, dated July 12, 2017, and timed at 10:30 a.m., indicated the resident declined to participate in the meeting and stated, "You are wasting your time. We all know the risks of smoking. That's kindergarten SH-T." According to the note, the staff was to continue encouraging the resident to follow the facility's smoking policy to ensure the safety of all residents in the facility.
A review of Resident 2's Nurses Note, dated July 7, 2017, and timed at 7:52 p.m., indicated there was a strong marijuana smell permeating from Resident 2's room, and her body when she passed the staff in her electric wheelchair in the hallway.
A review of Resident 2's Nurses Progress Note, dated July 9, 2017, and timed at 12:31 a.m., indicated the resident smelled of a strongly of marijuana.
On July 24, 2017 at 9:58 a.m., during an interview, a Licensed Vocational Nurse 1 (LVN 1) stated, "The resident (Resident 2) goes out on pass frequently and smoke Marijuana."
On July 24, 2017 at 11:08 a.m., during an interview, Resident 3 stated Resident 2 "Uses drugs outside, at the other facilities (Skilled Nursing) and then comes back to the facility high."
On July 24, 2017 at 1:25 p.m., during an interview, the ADON stated the certified nursing assistants (CNAs) told her they often smell drugs on Resident 2.
On July 24, 2017 at 4:31 p.m., during an interview, Resident 2 stated, "I smoke marijuana, but not on these premises."
On July 25, 2017 at 9:39 a.m., during an interview, Resident 2's Medical Doctor (MD 1) stated Resident 2 had a medical marijuana card, smoked marijuana, and because she knew her rights as a patient, he could not stop her from smoking.
On July 26, 2017 at 3:40 p.m., during an interview, the Director of Nursing (DON) stated Resident 2 had smoking privileges and should only smoke in the designated smoking area, which was the large patio.
A review of the facility's policy and procedures titled, "Smoking Policy," with a revision date of April 2012, indicated the facility would maintain safe resident smoking practices. Residents were to be informed of any limitations on smoking, including designated smoking areas prior to or upon admission. Smoking restrictions were to be enforced in all non-smoking areas. The policy indicated the facility could impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely.
A review of Resident 2's care plan titled, "Episodes of Speeding Electric Wheelchair," with an initiation date of July 22, 2015, without any review dates, indicated the resident had episodes of speeding in her electric wheelchair. The care plan had no staff interventions documented.
A review of Resident 2's Care Plan (C/P) Conference Summary, dated June 28, 2017, indicated the resident often drove her powered wheelchair at unsafe speeds through the facility. The Summary indicated risks included injury to the resident and others. According to the C/P Summary, Resident 2 declined participation in the meeting and when staff attempted to discuss her unsafe speeds, Resident 2 stated, "Get out of my face, you don't know SH-T."
On July 24, 2017 at 11:22 a.m., during an interview, the Social Services Director (SSD) stated, "There was an incident where a nurse practitioner (NP) was seeing a resident (Resident 3) and the resident (Resident 2) ran into the NP with her power wheel chair." The SSD stated Resident 2 would leave the facility a lot unsupervised and refused to sign out.
On July 25, 2017 at 9:39 a.m., during an interview, MD 1 stated, "It's not good judgement that she (Resident 2) takes pain pills and gets into her power chair. She drives so fast in that wheel chair in the facility that she almost ran my foot over one time. I refused to prescribe her pain medicine, because she uses a power wheelchair, but I did refer her out to pain management physician."
A review of the facility's policy and procedures titled, "Signing Residents Out," with a revision date of August 2006, indicated each resident leaving the premises must be signed out and indicate the expected time of return. The policy and procedure indicated the staff who observed a resident leave the premises without being properly signed out was to notify their supervisor at once.
A review of the facility's policy and procedures titled, "Safety and Supervision of Residents," with a revision date of December 2008, indicated resident safety, supervision, and assistance to prevent accidents were the facility's priorities. The policy indicated the type and frequency of resident supervision was determined by the individual residents assessed needs and identified hazards.
The facility failed to ensure that the resident's environment remained as free from accident hazards as possible, and each resident received adequate supervision to prevent accidents; to provide Resident 2 with supervision to ensure she adhere to the facility's policy and procedure to prevent incidents and accidents including but not limited to:
1. Failure to provide Resident 2 the necessary supervision and adequate monitoring to prevent accidents and hazards.
2. Failure to ensure Resident 2, who was wheelchair bound, was supervised when leaving the facility, after receiving several narcotic medications and driving the motorized wheelchair out on pass (OOP).
3. Failure to ensure Resident 2 adheres to the facility's smoking policy and procedure and be supervised while smoking in the facility's designated smoking areas.
4. Failure to ensure Resident 2 operated her motorized power wheel chair with caution throughout the facility.
The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000056 |
Long Beach Healthcare Center |
940013470 |
A |
22-Sep-17 |
None |
20286 |
F329
?483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used--
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
F428
?483.45(e) Psychotropic Drugs.
Based on a comprehensive assessment of a resident, the facility must ensure that--
(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;
(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;
c) Drug Regimen Review
(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.
(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic.
(4) The pharmacist must report any irregularities to the attending physician and the
facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.
(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
The facility failed to ensure Resident 2 did not receive unnecessary drugs, without adequate indication for its use, in the presence of adverse consequences including but not limited to:
1. Failure to ensure Resident 2 was free of unnecessary drugs, such as
2. Failure to do gradual dose reductions (GDR).
3. Failure to ensure the pharmacist consultant's (PC) recommendations was acted upon, per the facility's policy.
4. Failure to ensure narcotic medications was not given in conjunction with illicit (unlawful) drugs.
These deficient practices resulted in Resident 2 continuing to receive high doses of narcotics, psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) without adequate monitoring and dose reduction in the present of adverse consequences (agitated behavior) after the PC recommended reduction and changes in the prescribed medications, which had the potential for adverse reactions, injury, and or/death.
A review of Resident 2's Admission Face Sheet indicated the resident was a 57 year-old female, who was initially admitted to the facility on November 2, 2011, and readmitted on September 29, 2016. Resident 2's diagnoses included multiple sclerosis (a disease that affects the brain and spinal cord), major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest), anxiety disorder (excessive worry or fear), and insomnia (inability to sleep).
A review of Resident 2's History and Physical (H/P), dated September 30, 2016, indicated the resident had the capacity to understand and make decisions.
A review of Resident 2's Minimum Data Sheet (MDS), a standardized assessment and care-screening tool, dated May 4, 2017, indicated Resident 2's cognition was intact. The MDS indicated Resident 2 had verbal behavioral symptoms directed toward others on a daily basis and rejected evaluation or care needed to achieve goals for health and well-being on a daily basis. Resident 2 received anti-anxiety and antidepressant medication seven days a week and hypnotic medication six days a week.
A review of Resident 2's PC's Notes to the Prescriber indicated multiple GDR (gradual dose reduction) requests dating back to January 26, 2016 was not acted upon, MD 2 only checked the box indicating current dose was the minimal effective dose and reduction was not indicated at that time. MD 2 also documented Resident 2 wished to continue the same amount of medications.
A review of Resident 2's PC's Medication Regimen Review, dated November 29, 2016, indicated the resident was receiving a hypnotic drug on a routine basis and used Ambien whenever necessary (PRN) every night. The PC's recommendation was to attempt to wean Resident 2 off of the medication and document attempts to do so in the care plan. The MRR indicated the following:
1. MD may need to adjust the pain medication Percocet due to frequent use.
2. Valium and Xanax were both for anxiety and may be considered duplicative therapy.
3. Xanax and Valium were ordered to be administered PRN, but were given on a daily basis.
4. Ambien and Valium needed clarification on how close they can be administered at bedtime and using both at bedtime may be considered duplicative therapy.
A review of Resident 2's Physician's Order Summary Report, for the month of July 2017, indicated the resident was prescribed the following medications:
1. Ambien (hypnotic for sleep) 10 milligrams (mg) every 24 hours as needed (PRN) at bedtime for inability to sleep. The order date was listed as December 23, 2016.
2. MS Contin (strong narcotic pain reliever) Extended Release (ER) 15 mg every 12 hours for chronic pain. The order date was listed as March 17, 2017.
3. Percocet (strong narcotic pain reliever) 10/325 mg every four hours PRN for moderate pain with a maximum of four tablets per day. The order date was indicated as October 25, 2016.
4. Valium (anti-anxiety/muscle relaxer) 10 mg at bedtime PRN for anxiety. The order date was listed as October 25, 2016.
5. Xanax 0.5 mg every four hours PRN for anxiety with a maximum of four tablets (tabs) per day may take it with Percocet. The order date was listed as October 25, 2016.
6. Lexapro (anti-depressant) 20 mg at bedtime for depression. The order date is listed as September 29, 2016.
A review of Resident 2's Medication Administration Record (MAR) for the month of January 2017 indicated the following:
a. Ambien was administered daily except for the following dates: January 11, January 15, January 24, January 27, January 28, January 29, January 30, and January 31, 2017.
b. Lexapro was administered daily except for on the following date: January 14, 2017.
c. MS Contin was administered daily except for on the following date: January 14, 2017.
d. Percocet was administered daily except for the following dates: January 1, January 9, January 19, and January 20, 2017.
e. Valium was administered daily except for the following dates: January 1, January 17, January 19, January 25, and January 29, 2017.
f. Xanax was administered daily except for the following dates: January 1, January 9, January 19, January 20, January 23, and January 29, 2017.
A review of Resident 2's MAR for the month of February 2017 indicated the following:
a. Ambien was administered on the following dates: February 8, February 9, February 14, February 15, February 20, and February 28, 2017.
b. Lexapro was administered daily.
c. MS Contin was administered daily.
d. Percocet was administered daily.
e. Valium was administered on the following dates: February 3, February 4, February 5, February 17, and February 20, 2017.
f. Xanax was administered daily except for the following dates: February 19, and February 21, 2017.
A review of Resident 2's MAR for the month of March 2017 indicated the following:
a. Ambien was administered daily.
b. Lexapro was administered daily except for the following dates: March 3 and March 4, 2017.
c. MS Contin was administered daily.
d. Percocet was administered daily except for the following dates: March 17 and March 18, 2017.
e. Valium was not administered.
f. Xanax was administered daily.
A review of Resident 2's MAR for the month of April 2017 indicated the following:
a. Ambien was administered daily.
b. Lexapro was administered daily except for the following date: April 27, 2017.
c. MS Contin was administered daily.
d. Percocet was administered daily except for the following dates: April 24, April 25, and April 28, 2017.
e. Valium was not administered.
f. Xanax was administered daily except for the following dates: April 7, April 11, April 12, April 24, and April 29, 2017.
A review of Resident 2's MAR for the month of May 2017 indicated the following:
a. Ambien was administered daily except for the following dates: May 8, May 9, and May 10, 2017.
b. Lexapro was administered daily.
c. MS Contin was administered daily.
d. Percocet was administered daily.
e. Valium was administered daily except for the following dates: May 6, May 11, May 12, May 15, May 21, May 29, May 30, and May 31, 2017.
f. Xanax was administered daily except for the following date: May 5, 2017.
A review of Resident 2's May 2017 Medication Administration Record (MAR) indicated the following:
1. Ambien administered a total of 28 times.
2. Xanax administered a total of 30 times.
3. Valium administered a total of 22 times.
4. Lexapro administered a total of 31 times.
A review of Resident 2's MAR for the month of June 2017 indicated the following:
a. Ambien was administered daily except for the following date: June 2, 2017.
b. Lexapro was administered daily.
c. MS Contin was administered daily except for the following dates: June 21, June 25, June 27, June 28, and June 29, 2017.
d. Percocet was administered daily except for the following dates: June 23 and June 24, 2017.
e. Valium was administered daily except for the following dates: June 1, June 7, June 10, June 12, June 13, June 14, June 19, June 25 and June 30, 2017.
F. Xanax was administered daily.
A review of Resident 2's June 2017 Medication Administration Record (MAR) indicated the following:
1. Ambien administered a total of 29 times.
2. Xanax administered a total of 30 times.
3. Valium administered a total of 21 times.
4. Lexapro administered a total of 30 times.
A review of Resident 2's MAR for the month of July 2017 indicated the following:
a. Ambien was administered daily except for the following dates: July 3, July 8, July 9, July 12, July 13, July 14, July 15, July 20 and July 21, 2017. Resident 2 received Ambien 10 mg for seven months for a sum total of 1,690 mg.
b. Lexapro was administered daily.
c. MS Contin was administered daily except for the following date: July 15, 2017.
d. Percocet was administered daily.
e. Valium was administered daily except for the following dates: July 1, July 6, July 7, July 11, July 13 and July 19. 2017. Resident 2 received Valium 10 mg for five months for a sum total of 990 mg.
f. Xanax was administered daily.
A review of Resident 2's July 2017 Medication Administration Record (MAR) indicated the following:
1. Ambien administered at total of 15 times.
2. Xanax administered a total of 24 times.
3. Valium administered a total of 18 times.
4. Lexapro administered a total of 23 times.
According to an online site Lexicomp (provider of drug information and clinical content for the healthcare industry), the black box warnings for Percocet indicated users were exposed to the risks of opioid addiction, abuse, and misuse, which could lead to overdose and death. The site indicated concomitant use of opioids with benzodiazepines or other CNS depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of oxycodone/acetaminophen and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation.
A review of Resident 2's care plan, with an initiation date of February 11, 2016, indicated the resident had chronic pain. The staff's interventions included monitoring Resident 2 for side effects of pain medication such as constipation, new onset or increased agitation, restlessness, confusion, nausea, vomiting, dizziness, and falls.
A review of Resident 2's Psychotropic IDT meeting, dated May 25, 2017, indicated there were no changes to Resident 2's psychotropic medication due to the resident refusing because of past GDR failed attempts.
A review of Resident 2's care plan, with an initiation date of July 8, 2015, without any review dates, only a target date of July 31, 2017, indicated the resident was at risk for drug interactions after staff found Resident 2 with non-prescription marijuana in her room.
A review of Resident 2's Nurses Note, dated July 7, 2017, and timed at 7:52 p.m., indicated there was a strong marijuana smell permeating from Resident 2's room, and her body when she passed the staff in her electric wheelchair in the hallway.
A review of Resident 2's Nurses Note, dated July 9, 2017, and timed at 12:31 a.m., indicated the resident smelled of a strongly of marijuana.
On July 24, 2017 at 9:58 a.m., during an interview, LVN 1 stated Resident 2 went out on pass frequently to smoke marijuana.
On July 24, 2017 at 11:08 a.m., during an interview, Resident 3, who was alert, stated Resident 2 uses drugs outside, at the other facilities and comes back to the facility high.
On July 24, 2017 at 1:25 p.m., during an interview, the ADON stated the CNAs told her they often smell drugs on Resident 2.
On July 24, 2017 at 5:32 p.m., during an observation and a concurrent interview, Licensed Vocational Nurse 3 (LVN 3) was observed administering medication to Resident 2. Resident 2 was observed leaving the facility immediately after receiving the medication from LVN 3. LVN 3 stated, "I gave her Xanax and Percocet. I know I should monitor her (Resident 2) after administering those medications."
On July 25, 2017 at 9:39 a.m., during a telephone interview, MD 1 stated Resident 2 told him she smoked marijuana and had a medical marijuana card and he stated he could not stop her because she knew her rights.
On July 25, 2017 at 5 p.m., during a telephone interview, MD 2 stated, "I don't feel comfortable with continuing these medications for the long term, but I don't know what will be next. The resident [Resident 2] refuses a lower dose and anytime I mention a lower dose, she refuses."
On July 26, 2017 at 3:40 p.m., during a record review with the DON, the DON was unable to locate the MD's response to the pharmacist consultants' MRR recommendations, dated November 2016 (eight months prior). The DON was unable to locate any documented GDRs done for Resident 2.
A review of the facility's policy titled, "Administering Medications," indicated residents using PRN meds frequently needed to be evaluated to consider whether a standing dose of medication is indicated.
A review of the facility's policy titled, "Psychotherapeutic Drug Management Program," indicated the purpose of the policy was to avoid any unnecessary medication. The policy indicated orders for PRN psychotherapeutic drugs would be time limited. The facility's nursing responsibilities included monitoring residents using psychotherapeutic medication for adverse effects. The pharmacist responsibilities included monitoring psychotherapeutic drug use in the facility to ensure medications were not used in excessive dose, excessive duration and to avoid duplicate therapy.
A review of the facility's policy titled, "Medication Utilization and Prescribing," with a revision date of April 2013, indicated the physician would provide and document a rationale when indication, dose, duration, or frequency of a prescribed medication differs from accepted practices, manufacturers recommendations, or the medication was high risk compared to relevant alternatives.
According to DailyMed MS Contin (an opioid medication for severe pain) has a black box warning (BBW) - the strongest warning that the Food and Drug Administration [FDA] requires which indicate under Warning: addiction, abuse, and misuse; life-threatening respiratory depression; and risks from concomitant use with benzodiazepines (e.g. Valium and Xanax) or other CNS depressants (e.g. Ambien and Percocet), including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of MS Contin and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation. The monograph for Percocet indicated a BBW with similar side effects for opioid addition, abuse, and misuse, which can lead to overdose and death, and cautioned against concomitant prescribing of Percocet and benzodiazepine or other CNS depressants.
According to DailyMed, peak blood concentrations of oral (by mouth) Valium were achieved two hours after administration and for Xanax were achieved in one to two hours following administration. Both medications included BBWs that indicated: Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Most common side effects included sedation, dizziness, weakness and unsteadiness ...The monograph for Ambien indicated similar side effects of sedation and dizziness, and cautioned against use at bedtime with other sedative medications.
A review of Resident 2's care plan, with an initiation date of November 14, 2015, without any follow-up reviews, indicated the resident was at risk for falls related to receiving multiple psychotropic and narcotic medications. The staff's listed interventions were to monitor for side effects of any medications that can cause gait disturbance, orthostatic hypotension (low blood pressure when changing positions), weakness, sedation, lightheadedness, dizziness, and change in mental status.
A review of Resident 2's Medication Administration Record (MAR) for the months of January 2017 through July 2017, indicated Resident 2 continued to receive multiple medications without reduction, which included Ambien, Lexapro, MS Contin, Percocet, Valium, and Xanax as prescribed by the physician.
The facility failed to ensure Resident 2 did not receive unnecessary drugs, without adequate indication for its use, in the presence of adverse consequences including but not limited to:
1. Failure to ensure Resident 2 was free of unnecessary drugs, such as
2. Failure to do gradual dose reductions (GDR).
3. Failure to ensure the pharmacist consultant's (PC) recommendations was acted upon, per the facility's policy.
4. Failure to ensure narcotic medications was not given in conjunction with illicit (unlawful) drugs.
The above violations, jointly, separately, or in any combination presented an imminent danger that death or serious physical harm would result, or a substantial probability that death or serious physical harm would result. |
| 970000186 |
Legacy Healthcare Center |
950013667 |
B |
1-Dec-17 |
P6EM11 |
3433 |
Title 22 Section 72541 Unusual Occurrences
Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal.
On 8/8/17 at 9:56 a.m., an unannounced visit was conducted to investigate a complaint that Resident 1 tested positive for legionella (type of bacteria) pneumonia (lung infection) also referred as Legionella disease (LD, a severe type of infection obtained from water sources).
Based on interview and record review, the facility failed to implement its policy and procedure in reporting unusual occurrence by failing to:
1. Report to the Department within 24 hours that Resident 1 was tested positive for legionella pneumonia (a type of atypical pneumonia obtained from water sources).
This deficient practice had the potential to result in an uncontrolled legionella outbreak in the facility.
A review of the face sheet indicated Resident 1 was admitted to the facility on 1/1/14 and readmitted on 5/25/17 with diagnoses that included pneumonia (infection in the lungs) unspecified organism, heart failure, difficulty walking, and muscle weakness.
A review of the general acute care hospital?s partial patient discharge report indicated Resident 1 was admitted from the skilled nursing facility (SNF) on 5/17/17 and discharged to the SNF on 5/25/17. On 5/22/17, the hospital received a positive lab result for legionella antigen.
During an interview, on 8/8/17 at 9:56 a.m., the Assistant Administrator (AA) stated that on 5/27/17 the facility was notified by the hospital of the positive legionella result for Resident 1 and the facility did not report the case to the Department. AA stated that a positive case of legionella was an unusual occurrence and should have been reported within 24 hours (to the Department). AA stated the facility did not report because they wanted to obtain more solid test results.
A review of the Unusual Occurrence Reporting policy and procedure revised on December 2007 indicated "Unusual occurrences shall be reported via telephone to appropriated agencies as required by current law and/or regulation within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations."
The facility failed to implement its policy and procedure in reporting unusual occurrence by failing to:
1. Report to the Department within 24 hours that Resident 1 was tested positive for legionella pneumonia (a type of atypical pneumonia obtained from water sources).
This deficient practice had the potential to result in an uncontrolled legionella outbreak in the facility.
These violations had a direct relationship to the health, safety, or security of all residents in the facility. |
| 970000186 |
Legacy Healthcare Center |
950013666 |
B |
1-Dec-17 |
P6EM11 |
17487 |
F441 ? 42 CFR ?483.80 Infection Control
The facility must ?
Establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
On 8/8/17 at 9:56 a.m., an unannounced visit was conducted to investigate a complaint that Resident 1 tested positive for legionella (type of bacteria) pneumonia (lung infection) also referred as Legionella disease (LD, a severe type of infection obtained from water sources). The facility received guidance from the Department of Public Health (DPH) to control or stop the spread of infection; the facility did not implement measures to protect all residents from potential infection of LD.
Based on observation, interview, and review of records, the facility failed to implement infection control measures to prevent an outbreak of LD by failing to:
a. Conduct water testing throughout the facility, including high-risk areas, immediately after the facility was notified that Resident 1 was infected by legionella (the bacteria) on 5/27/17.
b. Contract an HVAC (heating, ventilation, and air conditioning) specialist/Industrial hygiene company to disinfect the facility's air conditioning (AC) system.
c. Ensure residents in the facility's patios were not exposed to the AC unit's mist/condensation.
d. Stop the showers of residents to ensure the residents did not inhale the mist from the showers.
e. Develop a water management program or a policy and procedure that inhibit microbial growth in building water system.
f. Maintain the water heater 1's temperature above 140 degrees Fahrenheit (F).
g. Initiate a surveillance for LD.
These deficient practices had the potential for other residents to be exposed to the LD.
On 7/13/17 from 10 a.m. to 12 p.m., the DPH conducted a facility site inspection in response to a reported positive LD case. During this visit, DPH provided the facility with a toolkit, the California Department of Public Health (CDPH) Healthcare-Associated LD Investigation Quicksheet, and the following verbal instructions:
- DPH made the facility aware that there were two at risk areas of concern where LD (bacteria) could settle: the water heaters and the AC units (total of six).
- DPH recommended to consult with an industrial hygienist and/or HVAC technician to disinfect the HVAC system.
- DPH instructed the facility to develop a water management program and provided the facility with the Centers for Disease Control and Prevention (CDC) toolkit.
- DPH provided the California DPH Healthcare-Associated Legionnaires' Disease Investigation Quicksheet, this included water testing recommendations.
- DPH recommended to maintain the water heaters above 140 degrees Fahrenheit (F) and install thermostatic mixing valves to ensure the water was delivered at 120 F to all residents (showers and sinks).
These deficient practices had the potential for other residents to be exposed to the LD.
On 8/3/17 at 9:57 a.m., the Department of Public Health (DPH) reported to the Department (State Survey Agency) that Resident 1 had tested positive for LD during a hospital transfer. Prior to hospital discharge, Resident 1 did not leave facility premises.
A review of the face sheet (admission record) indicated Resident 1 was admitted to the facility on 1/1/14 and readmitted on 5/25/17 with diagnoses that included: pneumonia (infection in the lungs) unspecified organism, heart failure, difficulty walking, and muscle weakness.
The nurses notes dated 5/17/17 at 6 p.m., indicated the physician wrote a transfer to the hospital order for Resident 1 for general weakness and failure to thrive.
A review of the hospital partial patient discharge report indicated that on 5/22/17, the hospital received a positive lab (laboratory) legionella antigen result for Resident 1, and on 5/25/17, Resident 1 was sent back to the facility.
On 8/8/17 at 9:56 a.m., during an interview with the Assistant Administrator (AA), AA stated that on 5/27/17 the hospital notified the facility of Resident 1's positive legionella result.
a. On 8/8/17 at 9:45 a.m., during an interview, the Assistant Administrator (AA) stated that the facility had not conducted water testing and "today it will be done."
On 8/8/17 at 9:50 a.m., an interview was conducted with Infection Control Nurse (ICN, holds the same title of Director of Staff Development, DSD). ICN/DSD stated that the facility contacted the water testing company on 8/4/17 and someone was scheduled to come to the facility on 8/8/17 at 11 a.m.
On 8/8/17 at 9:57 a.m., an interview was conducted with the AA. The AA stated that she was aware that LD was transmitted through water sources and the water testing had not been done because the Administrator had to talk to the corporate offices and get approval to contract a water testing company.
On 8/8/17 at 10:05 a.m., an observation was conducted. The Water Testing Member (WTM) arrived at the facility and obtained water samples for the following areas: two shower rooms, the nursing station, and the ice machine. The water samples were obtained 73 days after the hospital notified the facility of the positive LD case, 26 days after DPH's first visit, and did not include water testing for the water heaters or the AC units. The WTM stated that when the water testing company was hired by a facility, the company could conduct the water testing "within the next day."
On 8/17/17 at 9:42 a.m., during the Department's second visit to the facility, an interview was conducted with the Administrator. The Administrator confirmed that DPH (during the 7/13/17 visit) made the facility aware that the water heaters and AC system were two areas of concern and most at risk where the legionella bacteria could settle. The Administrator stated that the water testing company was scheduled to be back to the facility on 8/17/17 at 11:30 a.m.
A review of an email dated 8/17/17 at 1:38 p.m., sent to the facility from the WTM indicated that on 8/17/17 water samples were conducted from water heaters 1 and 2. WTM also conducted water samples for AC units that were found to have standing water. The AC units tested were AC unit 2 servicing the lobby, AC unit 3 servicing the south hallway, AC unit 4 servicing the southeast hallway, and a swamp cooler on the roof servicing the kitchen. The water testing were completed 82 days after facility was notified of the positive legionella case. The facility did not conduct water testing throughout the facility in a timely manner.
b. A review of the DPH's inspection report dated 7/13/17 (given to the facility on the same day) indicated the "Facility [was] equipped with a total of 6 air conditioning units located on the roof of the building. The recommendation was to consult an Industrial Hygienist and/or an HVAC Technician on how to properly disinfect the HVAC System."
On 8/8/17 at 1:36 p.m., during an interview, the Administrator was asked why the facility had not followed DPH's recommendations to hire an HVAC technician and the administrator stated, "I don't know." Administrator stated an HVAC technician would come to the facility Thursday 8/10/17.
A review of the facility's Maintenance Work Request send to the corporate office indicated that on 8/3/17, the facility requested a licensed HVAC technician to check the facility's HVAC system. On 8/4/17, the request was granted and indicated "We have scheduled [Company A] for Thursday 8/10 to diagnose the facility and provide us with a survey of current HVAC system."
c. A telephone interview with Epidemiologist 1 (E1) was conducted on 8/8/17 at 12:13 p.m. E1 stated that when a facility's AC units were poorly maintained and not disinfected or flushed, there was a risk for legionella bacterial growth. The bacteria would grow, because of the AC's hot air and could travel through the unit's vapor down to the resident's located in the patios.
During an observation, on 8/8/17 at 12:19 p.m., the facility had two patios (west and east) located across from each other on the second floor. When walking down the hall, a resident (not able to identify) was observed sitting on a wheelchair in the east patio. The west patio had two industrial AC units located on opposite roof tops. The east patio had three industrial AC units, two on the same side and one on the proximal wall of the roof top. All AC units were observed looking up from the patios, and Maintenance Supervisor (MS) was present during the observations.
On 8/8/17 at 12:30 p.m., the MS was interviewed and stated that the patios were maintained open to the facility's residents.
On 8/8/17 at 2:05 p.m., the Administrator stated that any residents that were in the facility's patios would be removed and the patios would be closed until the facility was cleared by the DPH and Department.
d. On 8/2/17, DPH provided additional written instructions for the facility that indicated "Avoid using showers in the area of concern; patients/residents may receive sponge baths with tap water." The CDPH LD Investigation Quicksheet that DPH gave to the facility on 7/13/17 also indicated the same recommendations.
On 8/8/17 at 10:30 a.m. during an interview, DSD/ICN stated that there were a total of five Certified Nursing Assistants (CNA) working on that day.
On 8/8/17, interviews were conducted with the five CNAs:
- at 11:00 a.m., CNA 1 stated that at 7 a.m. Licensed Vocational Nurse 1 (LVN 1) notified her that all residents in the facility were to receive bed baths only and no showers. CNA 1 stated that on 8/7/17, residents she was assigned to receive showers.
- At 11:11 a.m., CNA 2 stated that "one week ago" (could not recall exact date), the facility announced that the residents were to receive bed baths only and no showers. CNA 2 stated that prior to "one week ago," all residents were being showered in the shower rooms.
-At 11:25 a.m., CNA 3 stated that about one week ago, the DSD/ICN met with the staff and notified them that the residents were to receive bed baths and no showers. CNA 3 stated that prior to this meeting, the residents were receiving showers in the shower rooms.
- at 11:43 a.m., CNA 4 stated that one week ago, during a meeting, DSD/ICN told the staff not to shower the residents and instead provided bed baths only. CNA 4 stated that prior to this meeting, residents were getting showered.
- At 11:49 a.m., CNA 5 stated that during a meeting on 8/3/17, the facility announced that residents were to receive bed baths only and no showers. CNA 5 stated that prior to 8/3/17 all assigned residents were receiving showers.
A review of the in-service meeting minutes dated 8/2/17 indicated the staff was notified that the use of the showers were on "hold...No showers for now" and the staff was to provide bed baths for the residents. CNA 2, 3, and 4, were not present during the in-service as indicated by the absence of their signatures in the in-service form.
e. On 7/13/17, the DPH visit the facility and provided the Centers for Disease Control and Prevention (CDC) step by step toolkit titled ?Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide to Implementing Industry Standards.? The facility was to use this toolkit to help develop a water management program.
On 8/8/17 at 12:50 p.m. the Administrator stated that DPH had not recommended development of a water management program. Administrator was asked if he had reviewed the toolkit left by DPH and he stated, "No." The Administrator was reminded that the toolkit would assist the facility with developing the program and the administrator stated, "We will start today."
An interview was conducted with Director of Nursing (DON) and AA on 8/9/17 at 12:40 p.m. The DON and the AA stated that during the 7/13/17 DPH's visit to the facility, DPH left a packet (toolkit) that was given to the Administrator. The DON and AA stated that the facility had not developed a water management program and they would discuss with the Administrator so that the facility could develop a program.
During a follow-up visit to the facility on 8/17/17 at 9:35 a.m., the Administrator stated that the water management program was in progress but not completed. E1, Public Health Nurse (PHN), AA, were also present during the interview.
f. A review of the DPH inspection report, dated 7/13/17, indicated "Maintenance manager stated water heater is maintained at 120F" and the following recommendations were made: "Maintain water inside of water heaters at a minimum of 140 F [to] prevent scalding install thermostatic mixing valves to ensure water is delivered at 120F or below."
On 8/9/17 at 3:16 p.m., during an observation, the water heater 1's temperature gauge indicated 138 degrees Fahrenheit (F). MS was present and verified the temperature.
On 8/17/17 at 9:35 a.m., during an interview, E1 stated that the reason for the above recommendation: maintaining the water heater's temperature at a minimum of 140F and the installation of anti-scalding devices on the shower heads was because the water should be hot up until the point of delivery (the shower head). The bacteria would most likely not survive at the recommended temperature.
On 8/17/17 at 9:42 a.m., during an interview, the Administrator stated that the water heater's temperature needed to be high "to kill bacteria." The Administrator was asked why the facility had not yet acted upon the DPH's recommendations and stated the anti-scalding devices would be purchased by "today."
On 8/17/17 at 10:51 a.m., during an observation, the MS opened water heater 1's valve and allowed the water to run into a bucket, the water temperature was 120 F.
On 8/17/17 at 11:01 a.m., the MS stated water heater 1 delivered water to all resident and shower rooms. The MS stated that in order to insure the water was not too hot for the residents, the temperature for water heater 1 was set up at 121 F and the temperature would be raised when the facility installed the anti-scalding shower head devices.
g. A review of the step by step toolkit's cover letter dated 7/13/17 indicated a "Request for Information for Disease Control and Prevention...requesting facility surveillance for Legionnaires' disease." The facility was to "identify any possible healthcare-associated LD cases in the past 6 months. Cases include[d] laboratory-confirmed cases AND any patients with unexplained healthcare-associated pneumonia. If possible, those cases should be reviewed and sent for Legionella testing...Identify and report all patients with healthcare-associated Legionella for the next two months. Patients should be tested for Legionella by ordering both a culture of lower respiratory secretions and urine antigen test.
A review of the CDPH LD Investigation Quicksheet, dated March 2017, and given to the facility on 7/13/17, indicated similar recommendations, "Retrospective and prospective surveillance should also be considered for a facility with one case of '"possible'" healthcare-associated LD [pneumonia]...Recommend that all new cases of lower respiratory tract infection (LRTI) at the facility be assessed by a medical provider for the possibility of LD...Review medical records and logs to identify patients with respiratory symptoms during the two months prior to identification of the index case. Test residents for Legionella who developed LRTI while continuously residing in the facility."
On 8/17/17 at 10 a.m., ICN/DSD was interviewed and stated the facility had not initiated/developed specific surveillance to monitor LD. ICN/DSD stated that a new log: Stop and Watch Early Warning Tool was developed. This log was available in the nursing station, filled out by the staff, and turned into the ICN/DSD.
A review of the Stop and Watch Early Warning Tool dated 2014 (no month available) indicated the following: If you have identified a change while caring for or observing a resident, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can. This tool, however did not include lower respiratory tract infection signs and symptoms.
The facility failed to implement infection control measures to prevent an outbreak of LD by failing to:
a. Conduct water testing throughout the facility, including high-risk areas, immediately after the facility was notified that Resident 1 was infected by legionella (the bacteria) on 5/27/17.
b. Contract an HVAC (heating, ventilation, and air conditioning) specialist/Industrial hygiene company to disinfect the facility's air conditioning (AC) system.
c. Ensure residents in the facility's patios were not exposed to the AC unit's mist/condensation.
d. Stop the showers of residents to ensure the residents did not inhale the mist from the showers.
e. Develop a water management program or a policy and procedure that inhibit microbial growth in building water system.
f. Maintain the water heater 1's temperature above 140 degrees Fahrenheit (F).
g. Initiate a surveillance for LD.
These deficient practices had the potential for other residents to be exposed to the LD.
These violations had a direct relationship to the health, safety, or security of all residents in the facility. |
| 060000715 |
Lake Forest Nursing Center |
060013507 |
B |
22-Sep-17 |
694711 |
8902 |
Based on the findings during the Abbreviated Survey a Class B State citation was written at F333.
483.45(f) Medication Errors
The facility failed to ensure Resident 1 was free from a significant medication error. Licensed Vocational Nurse (LVN) 3 administered another resident's (Resident A) morphine sulfate (narcotic pain medicine) 60 mg (milligrams) ER (extended release) and Synthroid (thyroid product) 150 mcg (micrograms) to Resident 1. This resulted in Resident 1 experiencing extreme drowsiness and low oxygen saturation (amount of oxygen in the blood) levels, requiring her to be transferred and subsequently admitted to the acute care hospital.
Findings:
According to Lexicomp online, a pharmacy resource used by healthcare professionals, morphine sulfate ER should be swallowed intact and should not be broken, crushed, or chewed. Administration of a broken or crushed tablet may result in too rapid a release of the drug from the preparation and absorption of a potentially toxic dose of morphine sulfate. Cutting, breaking, crushing, chewing, or dissolving ER formulations may result in uncontrolled delivery of morphine, leading to overdose, and death. The mixture of applesauce or pellets should not stored for future use. Warning for respiratory depression, the major toxicity associated with morphine occurs most frequently in geriatric and debilitated patients, and those with conditions accompanied by hypoxia (a dangerous condition that happens when your body doesn't get enough oxygen) or hypercapnia (presence of excess carbon dioxide in the blood) when even moderate therapeutic doses may dangerously decrease pulmonary ventilation (the process of exchange of air between the lungs and the ambient air). May be severe, requiring maintenance of an adequate airway, use of resuscitative equipment, and administration of oxygen, an opiate antagonist (drugs that block the effect of opioids. narcotics medication that contain opium), and/or other resuscitative drugs.
Medical record review for Resident 1 was initiated on 7/14/17. Resident 1 was admitted to the facility on 1/12/14, and readmitted on 7/13/17.
Review of the MDS (minimum data set) dated 6/12/17, showed Resident 1 was cognitively impaired and not able to make her needs known. Resident 1 was identified to be totally dependent on staff for all care needs.
Review of a Progress Note dated 7/7/17, showed an investigation was conducted regarding a medication error. Resident 1 was administered morphine sulfate 60 mg ER which had been dissolved in apple sauce. Documentation showed Resident 1 was administered morphine sulfate 60 mg ER at approximately 0630 hours on 7/6/17. Resident 1 was identified by the oncoming 7am-7pm shift staff to have a change of condition; Resident 1 had a decreased level of consciousness, was not responsive, and had a drop in her oxygen saturation (77% on room air), requiring the administration of oxygen. At approximately 0800 hours, the 911 paramedic team was called. The paramedics arrived and transported Resident 1 to the acute care hospital emergency department at approximately 0815 hours.
Review of Resident 1's medication orders showed no order for morphine sulfate.
Review of the physician's order dated 7/6/17 at 0740 hours, showed to send Resident 1 to the acute care hospital emergency department for evaluation.
Review of the Nursing Home to Hospital Transfer form dated 7/6/17, showed Resident 1 was sent to the acute care hospital due to being lethargic, altered level of consciousness, and low respiratory rate. The Nursing Home to Hospital Transfer form showed Resident 1 was administered morphine sulfate 60 mg ER at 0630 hours, which was intended for another resident.
Review of the acute care hospital's medical record dated 7/6/17, showed Resident 1's admitting diagnoses including opiate overdose. The emergency department documentation identified Resident 1 was inadvertently given morphine sulfate 60 mg at the nursing home facility.
The Emergency Department Report dated 7/6/17 at 0911 hours, showed the Emergency Medical Service (911 paramedic team) administered Narcan (opioid antidote - a reversal agent) 2 mg IM (intramuscular) injection at 0812 hours.
Review of Resident 1's laboratory tests dated 7/6/17, showed the PCO2 (partial pressure of carbon dioxide (carbon dioxide concentration in the arterial blood) Pulmonary ventilation - the process of exchange of air between the lungs and the ambient air) was 50 (normal level: 35-45) while Resident 1 was being administered two liters of oxygen. The toxicology results showed Resident 1's urine was positive for opiate drug. The physician's progress note showed Resident 1 became somnolent (drowsy) and required a Narcan drip. Resident 1 was admitted to the Coronary Intensive Care Unit for frequent reassessment and monitoring.
Resident 1 was readmitted to the facility on 7/13/17. Review of the Patient and Transfer Referral Record from the acute care hospital dated 7/13/17, showed Resident 1 was transferred back to the skilled nursing facility after seven days with a primary diagnosis of opioid overdose.
Review of the facility's Medication Error Report dated 7/6/17, showed Resident 1 was accidentally given morphine sulfate 60 mg ER, intended for another resident (Resident A). Due to the medication error, Resident 1 became lethargic but arousable; the oxygen saturation level was 77% (normal range: 95-100%), the respiratory rate was 14 respirations per minute, the heart rate was 114 bpm (beats per minute), and the blood pressure was 112/58 mmHg (millimeters of mercury).
On 7/14/17 at 0925 hours, an interview and concurrent facility document review was conducted with the Director of Nursing (DON). The DON was asked about the Medication Error Report for Resident 1 dated 7/6/17. The DON confirmed LVN 3 administered Resident A's morphine sulfate 60 mg ER to Resident 1.
On 7/14/17 at 1625 hours, an interview was conducted with RN (Registered Nurse) 1. RN 1 was asked about the medication error report for Resident 1. RN 1 stated LVN 4 asked her to assess Resident 1 who was lethargic and wearing an oxygen cannula, which was unusual for Resident 1.
On 7/17/17 at 1205 hours, a telephone interview was conducted with LVN 3. LVN 3 was asked about the medication error for Resident 1. LVN 3 stated she crushed Resident A's Synthroid 150 mcg tablet and put the morphine sulfate 60 mg ER tablet in the same medication cup with apple sauce and the tablets "melted in there." LVN 3 stated Resident A refused the medications. LVN 3 stated she placed the medication cup in the medication cart drawer but did not label the medication cup with Resident A's name. LVN 3 stated she planned to offer Resident A her morphine sulfate and Synthroid a second time a little later. She said the facility's policy was to offer the refused medications three times.
LVN 3 stated she crushed Resident 1's Synthroid 50 mcg tablet and placed it in a medication cup and added apple sauce to help dissolve it. However, Resident 1 was asleep so she placed Resident 1's medication cup in the medication cart drawer. LVN 3 stated she did not label the medicine cup with Resident 1's name. LVN 3 stated a CNA (certified nursing assistant) got Resident 1 up in her gerichair and placed her by the nurses' station and that was when she noticed Resident 1 was snoring and very sleepy, which was not normal for her. LVN 3 stated that was when she realized she might have accidentally administered Resident A's medications to Resident 1. LVN 3 stated she took Resident 1's blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation level. LVN 3 stated she informed LVN 4 and Resident 1's attending physician who was at the facility at that time. Resident 1's attending physician initially instructed LVN 3 to monitor Resident 1's vital signs. LVN 3 stated she informed RN 2 she had accidentally administered morphine sulfate 60 mg ER, the wrong medication, to Resident 1 and asked RN 2 to assess Resident 1. LVN 3 stated Resident 1's attending physician called the nursing unit a few minutes later and ordered to transfer Resident 1 to the acute care hospital emergency department for evaluation.
On 7/17/17 at 1650 hours, a telephone interview was conducted with RN 2. RN 2 stated on the morning of 7/6/17, Resident A refused the morphine sulfate 60 mg ER and LVN 3 accidentally administered the morphine sulfate 60 mg ER to Resident 1. RN 2 stated he assessed Resident 1 with RN 1 and LVN 3. Resident 1 was lethargic, but her eyes would open when her name was called. They called 911 and the paramedics transported Resident 1 to the acute care hospital emergency department.
This violation had a direct or immediate relationship to the health, safety, or security of residents. |
| 940000036 |
LYNWOOD HEALTHCARE CENTER |
940013527 |
B |
4-Oct-17 |
RG7311 |
3864 |
?1418.91. Reports of incidents of alleged abuse or suspected abuse of residents.
(a)A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b)A failure to comply with the requirements of this section shall be a class ?B? violation.
On June 9, 2017, an unannounced visit was made to the facility to investigate a complaint regarding an incident of an Employee to Resident abuse.
Based on interview and record review, the facility failed to implement its abuse policy and procedure to investigate and immediately report two allegations of staff to resident mistreatment to the Department of Public Health (DPH) involving Resident 1 within 24 hours.
This deficient practice had the potential to put other residents at risk for unreported abuse.
A review of Resident 1's Admission Record, indicated the resident was a 63 year-old male who was admitted to the facility on 9/20/16. Resident 1's diagnoses included chronic pain, muscle weakness, and multiple myeloma (cancer).
A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 6/22/17, indicated the resident's cognition (ability to think and reason) was intact and had no problem with memory. The MDS indicated Resident 1 exhibited verbal behavioral symptoms directed toward others.
On 6/9/17, at 3:30 p.m., during an interview, Resident 1 stated a medication nurse (Licensed Vocational Nurse 1 [LVN 1]) "assaulted" him during a medication pass. Resident 1 stated LVN 1 roughly attempted to remove a medicine cup from the resident's hand, leaving a scratch on the resident's skin.
On 7/19/17, at 3:30 p.m., during an interview, the Social Services Director (SSD) stated Resident 1 informed her seven months after the incident occurred that LVN 1 stuck him with a finger nail. The SSD stated she did not report and investigate Resident 1's allegation as an abuse incident.
On 7/19/17, at 3:40 p.m., during an interview, the Administrator stated Resident 1's allegation was not reported and investigated as an abuse case, because he did not see the incident as abuse.
On 7/19/17, at 4 p.m., during an interview, the Social Services Assistant (SSA) stated the incident was not investigated and should have been investigated according to their abuse policy.
On 7/21/17, at 10:55 a.m., during a telephone interview, the SSD stated Resident 1's allegations should have been treated as potential abuse or mistreatment and investigated and reported according to their facility's abuse policy and procedure. The SSD stated, "Everyone is a mandated reporter."
A review of the facility's Abuse Log Book, indicated there were no allegations of abuse reported for Resident 1 from the months of 9/2016 to 12/2016, and from 1/2017 to 6/2017.
A review of the facility's Policy and Procedure titled, "Abuse Investigations," revision dated 4/2014, indicated should an incident or suspected incident of resident abuse or mistreatment be reported, the administrator or his/her designee, would appoint a member of management to investigate the alleged incident. The policy and procedure indicated the individual in charge of the abuse investigation would notify the ombudsman that an abuse investigation was being conducted. The policy and procedure indicated employees accused of resident abuse would be suspended immediately pending the outcome of the investigation. The policy and procedure indicated the administrator would provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five working days of the reported incident. |
| 970000139 |
Lakeview Terrace |
910013537 |
A |
25-Oct-17 |
TKZ611 |
9277 |
CLASS A CITATION-ABUSE
F 223 Abuse ?483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical
restraint not required to treat the resident?s symptoms.
(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
On June 28, 2017, an announced visit was made to the facility to investigate an entity reported incident (ERI) regarding Resident A striking Resident B in the back of his head. Upon investigation it was determined that Resident A had a history of agitation, aggression and assaultive behavior; and on two separate occasions physically assaulted two other residents. On June 26, 2017, Resident A was on the facility's patio area, unsupervised, when Resident A struck Resident B in the back of his head; Resident B then struck Resident A in his face causing Resident A's nose to swell and bleed. Resident A was transferred to a general acute care hospital (GACH) where he was assessed and diagnosed with an acute fracture to his nose.
The facility's nursing staff failed to:
Ensure they effectively monitored Resident A, whose physical assault on another resident resulted in him being struck in the face resulting in his nose being fractured.
The Admission Records indicated Resident A was readmitted to the facility on February 6, 2017, with diagnoses including cerebral infarction (a stroke), toxic encephalopathy (a brain disorder caused by exposure to toxic substances) and dementia (progressive loss of mental ability).
A Minimum Data Set (MDS, an assessment and screening tool), dated May 3, 2017, indicated Resident A's speech was clear; he was able to understand others and make himself understood. The MDS indicated Resident A?s Brief Interview for Mental Status (BIMS) scored a seven out of 15suggesting a severe cognitive (mental ability) impairment.
Resident A's clinical records indicated the following incidents:
1. A Situation Background Assessment Request (SBAR, a form of communication between members of a health care team), dated March 13, 2017, indicated Resident A punched another resident.
The Social Work Progress Notes, dated March 17, 2017, indicated at 2:30 p.m., Resident A was having a verbal altercation (argument) with his roommate (Resident C). Resident D rolled his wheelchair between Resident A and Resident C and yelled, "Shut up" to both residents. Resident A then hit Resident D on his chin.
A Care Plan, dated March 17, 2017, indicated Resident A allegedly pushed another resident. The goals for Resident A indicated he would have no further episodes of pushing other residents. The approaches used included monitoring Resident A, hourly.
2. An SBAR, dated June 16, 2017, indicated Resident A pulled another resident by the legs. A review of the assessment under "Progress Notes" indicated at 9:15 p.m., a security guard was standing outside, in the smoking patio, supervising the residents. Resident A was sitting in his wheelchair talking to Resident E, who was sitting on a bench. Resident A suddenly hit/slapped Resident E on his left shoulder with his fist. The security guard tried to separate the residents by pulling Resident A's wheelchair away from Resident E. While pulling Resident A away, Resident A bended over, grabbed Resident E by his legs, and tried to pull him off the bench. Resident E fell on his knees. As the security guard was trying to help Resident E up from the ground, Resident A tried to hit/slap the security guard with his fist.
A Care Plan, dated June 19, 2017, indicated Resident A slapped the left shoulder of a resident and pulled his legs. The goals set for Resident A included having no further incidents daily. The approaches included monitoring for any episodes of slapping other residents or pulling their legs. The activity staff would monitor/supervise Resident A in the patio/smoking area and monitor him hourly.
3. An SBAR, dated June 26, 2017 (10 days after the 2nd assault), at 6 p.m., indicated Resident A had a bloody and swollen nose. A review of the assessment under "Progress Notes" indicated a Licensed Vocational Nurse (LVN) was passing by Station I and heard someone, from the patio, calling for help. When the LVN got to the patio, she found Resident A with swelling and discoloration on the bridge of his nose. Resident A reported Resident B hit him.
An Investigation Report, dated June 26, 2017, indicated Resident B reported he was talking to other residents when Resident A approached him, told him to shut up, and hit him in the back of his head. Resident B then stood up and hit him back.
The Hourly Monitoring report, dated March 17 through June 26, 2017, indicated Resident A was monitored (observed), at the top of each hour, in one of eight different locations. The documentation did not indicate where Resident A was the remainder of the time. On June 26, 2017, the Hourly Monitoring report indicated Resident A was observed in the front patio/smoking area at 6 p.m., but assaulted Resident B at 6:35 p.m.
The Physician's Order, dated June 26, 2017, indicated to transfer Resident A to a General Acute Care Hospital (GACH) for further evaluation of the swelling and bleeding on his nose.
A Radiology Report from the GACH, dated June 26, 2017, indicated a Computerized Tomography (CT) Scan (a special x-ray that produce cross? sectional images of the body using x-rays and a computer) of the brain that showed evidence of an acute (occurred quickly) nasal bone fracture.
On June 28, 2017, at 3:44 p.m., during an interview, the Director of Nursing (DON) stated LVN 1 heard someone calling for help from the patio. When LVN 1 got to the patio, she saw Resident A with a nosebleed and Resident A stated Resident B hit him. The DON stated Resident A was confused and he was the one who hit Resident B on the back of his head. Resident B retaliated and hit Resident A in his face.
The DON stated Resident A was monitored and transferred to the GACH for evaluation.
Resident B's Admission Records indicated he was admitted to the facility on April 21, 2017.
On September 18, 2017, at 3:15 p.m., Resident B was observed in his room, lying in bed. He was alert and oriented to name, date, time, and place. During an interview, Resident B stated he was sitting on the patio talking to a few residents, not Resident A. Resident B stated Resident A came up to him, told him to shut up then hit him in the back of his head. Resident B then hit Resident A in his face. Resident B stated he did not know why Resident A hit him; he had not had any problems with him before then.
On September 21, 2017, at 3:50 p.m., during a telephone interview, the Activity Director (AD) stated the security guards are scheduled to monitor the residents on the patio area and the activity room after hours, until 11 p.m. The AD stated during a stand-up meeting, with the department heads, a general statement was made about the incidents with Resident A. Nothing was specifically directed at her, except to monitor Resident A when on the patio and in the activity room.
On September 21, 2017, at 4:40 p.m., during a telephone interview, the DON stated the purpose of monitoring Resident A hourly was to know his whereabouts and what he was doing. The DON stated she could not answer how knowing where the resident was and what he was doing, at the top of each hour, would prevent him from random assaultive behavior the remainder of the time.
On September 21, 2017, at 5:03 p.m., during a telephone interview, LVN 1 stated she was pushing another resident in the lobby on June 26, 2017, at approximately 6 p.m., when she heard someone on the patio yelling for help. LVN 1 stated she, a Certified Nursing Assistant (CNA), a Registered Nurse, and the DON went to the patio area and saw Resident A with a bloody nose. LVN 1 stated there was no staff members on the patio watching the residents.
On June 26, 2017, Resident A, who had a history of agitation, aggression, and assault behaviors, unprovoked, slapped Resident B in the back of his head. Resident B retaliated by punching Resident A in his face. Resident A sustained bleeding and swelling on his nose. Resident A was transferred to a general acute care hospital (GACH) where he was assessed and diagnosed with a fractured nose.
The facility's inability to purposefully monitor Resident A with the intention of preventing further incidents from occurring, thus protecting other residents, including Resident A from abuse, resulted in Resident B being attacked by Resident A and Resident A sustaining a fractured nose at the hands of Resident B.
Therefore, the facility failed to:
Ensure they effectively monitored Resident A, whose physical assault on another resident resulted in him being struck in the face causing his nose to be fractured.
These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |