| 020000808 |
Morton Bakar Center |
020009084 |
AA |
12-Mar-12 |
ILXN11 |
9527 |
F325: CFR 483.25 (i) Nutrition Based on a resident's comprehensive assessment, the facility must ensure that a resident- 483.25(i) (2) Receives a therapeutic diet when there is a nutritional problem. The facility violated the aforementioned regulation by failing to provide the therapeutic diet ordered by the physician to ensure that Resident 1 was not given a food that was unsafe to eat. Resident 1 had no teeth, and a history of choking on foods. A facility staff person gave Resident 1 a cold cheese sandwich that was not suitable for the therapeutic diet. As a result, Resident 1 choked on the cheese sandwich, was unable to breathe and her heart stopped. Resident 1 did not recover from the incident, and she died. Review of the clinical record, on 9/29/11, showed that the facility re-admitted Resident 1, a 66 year old, on 10/15/09. Resident 1 had multiple medical diagnoses that included a history of aspiration pneumonia (a lung and airway infection caused by inhalation of foreign material, usually food, liquid, and/or vomitus).A Licensed Nurse (LVN 1) recorded information about Resident 1's mouth condition on the "Nursing Oral/Dental Assessment," document, dated 10/15/09. According to the record, Resident 1 had no teeth. Review of the Physician's Orders, for the care of Resident 1, that were current for the month of September 2011, showed that Physician 2 instructed the facility to give Resident 1 a Mechanical Soft Diet (diet of modified texture that enables easier swallowing and decreases the risk of choking by changing the texture of foods to soft, chopped or ground). The facility's plan of care for Resident 1, most recently updated on 7/25/11, contained instructions to care for Resident 1's nutritional needs. According to the care plan, Resident 1 had chewing difficulty and the facility was to provide a therapeutic, mechanical soft texture diet. According to the Minimum Data Set (an assessment of residents' health status), dated 9/6/11, Resident 1 needed supervision for decisions due to poor decision making.A review of the facility's kitchen snack plans, for 7 p.m. daily, showed that Resident 1 was to receive a mechanical soft consistency, "Fruit," snack.Nurses' notes, dated 9/6/11 at 7:40 p.m., reflected that Resident 1 was, "Eating snacks," at the nurses' station. A staff person, who was not a licensed nurse, called out to licensed staff that Resident 1 was, "Choking." Resident 1 was unable to talk and had food in her mouth. Resident 1 lost consciousness and facility staff began CPR (cardiopulmonary resuscitation) and called 911. Review of EMP (Emergency Medical Personnel) records, dated 9/6/11, showed that at the time of the arrival of the EMPs, 7:41 p.m., Resident 1 was not breathing and her heart was not beating. EMPs found Resident 1's airway obstruction was, "Complete." EMPs used a long, special tool to remove food from Resident 1's airway and used suction to clear her airway. The record reflected, "Patient has large amount of food in airway." Resident 1 was rushed to the nearest hospital for emergency care as EMPs provided CPR.According to the Admission History and Physical, dated 9/6/11, upon arrival at the hospital emergency department (ED), Resident 1's heart was beating but she did not breathe on her own. Resident 1 did not respond when spoken to and did not open her eyes. At the time of admission to the hospital from the ED, Physician 3 documented that Resident 1 was, "Comatose on ventilator" (Resident 1 did not breathe without a machine). Resident 1, "Had a very low probability of survival following her massive arrest."A summary of Resident 1's neurological status was dated 9/7/11. According to Neurologist 1, Resident 1 was, "Deeply comatose." Her brain had been severely damaged due to a lack of oxygen. Resident 1 did not respond to verbal or painful stimulus. "(Resident 1's) outlook and survival expectancy is dismal." Resident 1 did not regain consciousness and did not regain the ability to breathe without a machine. The machine supported breathing was discontinued on 9/11/11 and Resident 1 died.In an interview, on 9/29/11 at 2:08 p.m., regarding the evening snacks that were provided to facility residents, Cook 1 stated that the evening snack cheese sandwiches were not grilled to soften the cheese.On 9/29/11 at 3:40 p.m., Certified Nurse Aide (CNA) 1 stated that EMP (Emergency Medical Personnel) took out a big piece of cheese sandwich from Resident 1's throat. CNA 1 stated that they showed the piece of sandwich to the facility staff, and that it was approximately a one inch by one inch square piece of cheese sandwich.During an interview, on 9/29/11 at 4:05 p.m., LVN 2 stated that, on 9/6/11 CNA 2 called to him saying Resident 1 was choking. LVN 2 stated that he saw a piece of sandwich bread in Resident 1's right hand.During an interview on 10/3/11 at 12:37 p.m., CNA 3 stated that the kitchen staff put extra cheese sandwiches (not assigned to a particular resident) on the snack cart along with the residents' prescribed snacks. CNA 3 stated that she gave half of a cheese sandwich to Resident 1, and did not stay with Resident 1 while she ate. CNA 3 also stated that she did not check with the Licensed Nurse before giving the sandwich to Resident 1. She stated that the Administrator told her she should have asked the Licensed Nurse, before giving any food to Resident 1.In an interview, on 10/11/11 at 9:36 a.m., FSW 1 (Food Service Worker) stated that the half cheese sandwiches sent out on the cart as extra snacks in the evening were prepared using bread, mayonnaise, and a cold slice of yellow American cheese. The half sandwiches were prepared and served cold with no grilling/cooking and with no texture alteration.In a telephone interview and concurrent record review of the facility's dietary manual's definition of what was allowable for someone on a Mechanical Soft Diet, on 10/11/11 at 10:10 a.m., the RD (Registered Dietician) stated that an American cheese sandwich, that was not grilled to soften the cheese, was not to be given to someone on a Mechanical Soft diet. The cheese slice would be too hard to chew.On 10/11/11 at 10:38 a.m., in an interview, the ADON (Assistant Director of Nurses) confirmed that Resident 1 had no teeth, no dentures, and had a history of choking. ADON stated that Resident 1 was on a Mechanical Soft diet because she had no teeth to chew her food. In a concurrent interview and record review, on 10/11/11 at 11 a.m., Physician 1 stated she had seen Resident 1 earlier that day, on 9/6/11, and she (Resident 1) had looked great, was interactive and talkative.In an interview, on 2/1/12 at 1:44 p.m., the Medical Director stated that the way the facility ensured that residents received the appropriate snack for their diet was by using labels that were pre-selected according to their diet cards and physician orders. If the resident wanted a substitute or extra food for their snack, the Medical Director stated that he depended on the Licensed Nurses to know what would be appropriate for that resident.In an interview, on 2/1/12 at 1:46 p.m., the ADON confirmed that the Certified Nurse Aides should check with the Licensed Nurses to see if the snack or extra food that the resident requested was appropriate for the resident's prescribed diet.In an interview, on 2/1/12 at 1:50 p.m., the DSS (Dietary Services Supervisor) stated that the snack labels printed from the computer were updated whenever there was a change in the physician's orders. The snack labels listed the resident's intended snack for that day that was in accordance with the ordered diet. DSS explained that every day the kitchen prepared the prescribed snacks as well as extra snacks for any new admission or for residents who were hungry during the night. These extra snacks were made according to regular diet specifications (no alteration to the texture/consistency of the food). The prescribed snacks and extra snacks were placed on two carts (one cart per nursing station).In an interview, on 2/1/12 at 1:53 p.m., the ADON (Assistant Director of Nurses) stated that CNAs (Certified Nurse Aides) would then pick up the carts and distribute the prescribed snacks to the residents. The ADON explained that the facility's procedure was that if a resident would ask for extra food or a different snack than the one prescribed by their physician, the Certified Nurse Aide would check with the Licensed Nurse if the snack requested was appropriate for the diet prescribed for the resident .In an interview, on 2/1/12 at 2:01 p.m., the Medical Director stated that Resident 1 was not medically competent to make her own treatment decisions. Resident 1 had a history of impulsive behavior and poor judgment.In an interview on 2/1/12 at 2:06 p.m., the ADON stated that the Certified Nurse Aide should have gone to the Licensed Nurse to ask regarding Resident 1's extra food/snack request since Resident 1 had a history of swallowing problems and because of Resident 1's specific diet orders.Therefore, facility staff gave Resident 1 a cold cheese sandwich that was not appropriate for the therapeutic diet, a mechanical soft diet. Resident 1 could not safely eat the sandwich. Resident 1 died as a result of choking on the food that she should not have been given to eat. These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient. |
| 020000040 |
Masonic Home |
020011580 |
B |
25-Jun-15 |
F0SB11 |
5658 |
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 violated the aforementioned regulation by failing to ensure staff supervised Resident 1 when he was out of bed, resulting in Resident 1 being left alone in the bathroom, falling off the toilet, and sustaining a fractured hip. On 4/24/15, the facility reported that Resident 1 fell in the bathroom and sustained a fractured hip. During an initial investigation and observation on 4/30/15 at 9:35 a.m. while in the presence of the Director of Nursing (DON), Resident 1 was in a semi-reclined geriatric chair with his right leg elevated. Resident 1 was pleasantly confused as to his whereabouts and believed that he was still in the acute care hospital setting.During a tour of Resident 1's room, along with the DON, on 4/30/15 at 10:00 a.m., the DON stated, "The Certified Nursing Assistant had him here in the bathroom and then she walked across to the closet to get his pants and he got up from the toilet." In the corner next to Resident 1's closet was an assistive walking device; a forward wheeled walker. Resident 1 had a lowered bed with a bed alarm to indicate to staff if Resident 1 was attempting to get out of his bed unassisted, and there was no fall mat present at his bedside. On the outside of Resident 1's door was a blue sticker. When asked what the blue sticker meant, the DON stated, "That is to indicate to us that the Resident is a fall risk because Resident 1 gets up on his own and he's confused and unsteady." In an interview on 4/30/15 at 10:30 a.m., Family Member 1(FM1) stated that Resident 1 had to be transferred to the facility two to three years before because "he kept falling and he needed more focused care." "He walks leaning forward and he also forgets that he can no longer do certain things, he will be 90 years old this year." Review of the medical record showed that Resident 1 was 89 years old and was originally admitted to the facility on 9/30/12. Resident 1 had diagnoses which included the following: unspecified cerebral degeneration (brain deterioration), dementia (organic brain disease), personal history of falls, and a fracture of the neck of the right femur (thigh bone; pertaining to the hip). According to Resident 1's Minimum Data Set (MDS- an assessment tool used to determine resident care needs) dated 3/30/15, Resident 1's "Brief Interview for Mental Status" (BIMS) showed that Resident 1 has severe impairment of his ability to process information.Additional review of the MDS showed Resident 1 required extensive assistance with 2 staff persons, in order to use and transfer from the toilet, to take care of his personal hygiene and to walk in his room. Review of Resident 1's nursing "Care Plan" dated on 4/2/15 showed that Resident 1 was "at risk for falls", and that the staff would provide the following interventions: "Set-up supplies, assist with activities of daily living care...toileting and personal hygiene, assist with transfers as needed, and would not leave him alone in his room when awake during the day.".Continued review of the medical record showed that Resident had falls on the following dates 3/18/15, 4/5/15, and on 4/20/15, Resident 1 fell fracturing his right hip which required surgery. Resident 1 was readmitted to the facility on 4/24/15 following surgery on his right hip.In a concurrent observation and interview on 4/30/15 at 1:20 p.m. with Certified Nursing Assistant 1 (CNA1), CNA1 stated, "I took him to the bathroom, watched him go urinate, he was sitting on the toilet. I usually gather all of his things before I help him in the bathroom. His walker was with him, but we never leave him to use his walker by himself because he's confused and unsteady. I forgot his pants that day...." CNA1 then showed where she had retrieved Resident 1's pants from in his room. CNA1 indicated that she went back to get Resident 1's pants from his bed and not his closet while Resident 1 was still sitting on the toilet, out of her view. In an interview with the DON, on 4/30/15 at 1:20 p.m., the DON stated that "Resident 1 was moved closer/across from the nursing station in 3/2015 and had been on "Fall Risk "precautions since his original admission on 9/30/12. In an interview on 4/30/15 at 3:00 p.m. with the DON while in the presence of the Quality Assurance Nurse Supervisor (QANS), the DON stated, "We counseled CNA 1, he (Resident 1) cannot be left alone." Review of the facility's policy and procedure entitled, "Fall Management Program"; revised on 10/20/14, showed that the facility would, "Identify risk factors in the environment for individual residents and minimize those risk factors. Licensed nursing staff would report at the beginning of each nursing shift in the presence of the CNA's that a resident is at moderate to high fall risk. Interventions may include: locating the resident closer to the nursing station, increased observation of the resident, and protection measures such as use tab alarm on bed or wheelchair, fall mat, low bed and positioning devices, etc. A blue dot will be place by the resident's name on their door as well as on their identification band to heighten staff awareness for residents who are at risk for falls." Therefore the facility failed to ensure that staff supervised Resident 1 when he was out of bed, resulting in Resident 1 being left alone in the bathroom, falling off the toilet, and sustaining a fractured hip. This violation had a direct relationship to the health, safety or security of patients. |
| 020000808 |
Morton Bakar Center |
020013082 |
B |
27-Mar-17 |
FXHD11 |
4846 |
483.13(c) DEVELOP/IMPLMENT 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. This REQUIREMENT is not met as evidenced by:
The facility failed to follow the aforementioned regulation by failing to follow their policy and procedure for prevention of further abuse. The facility allowed Certified Nursing Assistant (CNA) 2 to continue to provide resident care after CNA 2 witnessed CNA 1 physically abused Resident 1 and did not report the incident. This failure could potentially result in unreported physical or psychological harm to all the residents of the facility
A review of the facility video surveillance camera record with the Administrator and the Regional Director of Operations on 6/14/16 showed CNA 2 observed a physical abuse of Resident 1. CNA 2 did not report to the facility and denied she observed the incident. The facility allowed her to remain in the facility to continue providing care for residents during an investigation of abuse.
By interviews with the staff members and record reviews of the facility's in-service records, the facility showed they initiated the plan of correction through in-services regarding abuse and mandated reporting of employees on 6/21/16 and the remaining employees will received the training by 6/24/16. CNA 2 was placed on administrative leave on 6/21/16. With the presence of Regional Director of Operations (RDO), the Administrator and Director of Nursing, the IJ was abated on 6/21/16 at 3:01 p.m.
During observations of facility's surveillance video with Administrator and the RDO, on 5/30/16 CNA 1 was assisting a resident with lunch. Resident 1 was seen approaching CNA 1. CNA 1 reached up with her left arm and in a swinging motion towards Resident 1's face. CNA 1's left hand pushed at Resident 1's cheek on the right side of the face. CNA 1 repeated the swinging motion towards Resident 1's face. At the second time, before touching Resident 1's face, CNA 1 lowered her arm and pulled on Resident 1's shirt. CNA 2 was present in the video directly in front of CNA 1 and Resident 1. In the video, CNA 2 was present during the incident. CNA 2 walked forward between Resident 1 and CNA 1 when CNA 1 had her left hand on Resident 1's sleeve. CNA 2 reached her hand between Resident 1 and CNA 1 to separate them. CNA 2 gestured with her hand to call Resident 1 to come with CNA 2. When CNA 2 walks away with Resident 1, she looked up directly and pointed at the camera.
During an interview on 6/14/16 at 10:00 a.m., CNA 2 stated "I didn't see anything but sensed an issue so I put my arm around Resident 1 and led her away."
During an interview with Licensed Vocational Nurse (LVN) 1 on 6/16/16 at 10:30 a.m., she stated she went to CNA 2 and asked her about physical abuse incident. LVN 1 further added that CNA 2 denied seeing the incident of abuse. LVN 2 confirmed that CNA 2 did not come to her to report the incident.
During an interview with CNA 2 on 6/16/16 at 10:14 a.m., she stated she reported the incident to LVN 1 at, "Same time it happened".
During an interview with the Regional Director of Operations while in the presence of Administrator on 6/21/16 at 1:30 p.m., they acknowledged they did not remove CNA 2 from providing resident care until 6/21/16.
During a record review on 6/14/16 of CNA 2's employee file, a document titled, "Employee Acknowledgment of Elder and Dependent Adult Abuse Reporting Requirements" was signed by CNA 2 on 3/26/15. The document stated: "Failure to report physical abuse of an elder or dependent adult is a misdemeanor, punishable by no more than six months in the county jail or by a fine of not more than one thousand dollars, or by both fine and imprisonment."
Review of facility's "Policy and Procedure on Abuse Reporting" with revision date of 4/10/13, shows: "... The employee must comply with the mandated reporter requirements contained in the Elder Abuse and Dependent Adult Civil Protection Act as well as the Elder Justice Act under section 1150B. Welfare and Institutions Code 15630. Prevention: All reports whether from the residents, family or staff will be reported immediately to the Administrator and DON/designee. Reporting: Mandated reporters are required to report known, suspected or alleged instances of physical abuse, abandonment, isolation, financial abuse, or neglect to the local ombudsman of local law enforcement agency."
Therefore the facility failed to protect residents from further abuse and could potentially result in unreported physical or psychological harm to all the residents of the facility.
The above violation has a direct relationship to the health, safety or security of patients. |
| 020000808 |
Morton Bakar Center |
020013083 |
B |
27-Mar-17 |
FXHD11 |
4206 |
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 follow the aforementioned regulation by failing to provide an environment free of physical abuse and protection from abuse when Resident 1 was physically assaulted by Certified Nursing Assistant (CNA 1). For Resident 1, this failure had the potential for physical and psychological harm.
During an observation and concurrent interview of facility's surveillance video on 6/14/16 with the Administrator and the Regional Director of Operations (RDO), RDO stated the incident occurred on 5/30/16. The video showed CNA 1 was assisting Resident 2 with lunch. Resident 1 was seen approaching CNA 1. CNA 1 reached up with her left arm in a swinging motion towards Resident 1's face. CNA 1's left hand pushed at Resident 1's cheek on the right side of the face. CNA 1 repeated the swinging motion towards Resident 1's face. The second time, before touching Resident 1's face, CNA 1 lowered her arm and pulled on Resident 1's shirt.
During an interview with Licensed Vocational Nurse (LVN 2) on 6/15/16 at 12:55 p.m., she stated CNA 1 came to her and she appeared very angry. LVN 2 added that CNA 1 stated Resident 1 was calling CNA 1 "Black Lady", and spit on CNA 1's face. CNA 1 told LVN 2, "I pushed her". LVN 2 instructed CNA 1 not go to or near Resident 1. LVN 2 stated she went to Resident 1 and found the resident lying in bed. Resident 1 told LVN 2, "Go away". Resident 1 also told LVN 2 that CNA 1 was lying because she did not spit on CNA 1.
During an interview with LVN 1 on 6/14/16 at 9:20 a.m., she stated CNA 1 reported the incident to her. LVN 1 stated "I told CNA 1 not to go near Resident 1. I made up a new care plan."
During a phone interview with Assistant Director of Nursing (ADON) on 6/14/16 at 11 a.m., she stated CNA 1 was reassigned and verbally warned to stay away from Resident 1. ADON confirmed CNA 1 worked in the same unit (where Resident 1's room was located) and up to the end of her shift on 5/30/16. ADON added CNAs had a "Buddy system" (working in pairs); ADON did not directly supervise CNA 1.
During an interview with CNA 3 on 6/24/16 at 11:17 a.m., she stated she worked together with CNA 1 in Station 1. CNA 3 stated the ADON notified her that Resident 1 was transferred to her assignment during the end of shift 5/30/16 at 3:30 p.m. CNA 3 confirmed that CNA 1 stayed in Station 1 where Resident 1's room was located. CNA 3 further added that on 5/31/16, CNA 1 worked in Station 1 in the morning.
During an interview with Director of Nurses (DON) on 6/14/16 at 12:00 p.m., she stated CNA 1 also came back to work the following day 5/31/16 and was sent home around lunch time.
During a phone interview with CNA 1 on 6/15/16 at 10:07 a.m., she stated she worked until the end of shift on 5/30/16 and was instructed not to go near Resident 1. The following day, she worked until midday.
Review of Resident 1's face sheet showed Resident 1 was admitted to the facility in XXXXXXX 2014 with multiple diagnoses that included a disorder that affects thoughts and behavior. Minimum Data Set (comprehensive assessment tool) showed she had Brief Interview for Mental Status of 14 (score 00- 14) which indicate the person was cognitively intact.
During an interview with Resident 1 on 6/14/16 at 9:30 a.m., she stated "I don't want to talk about it anymore. It was a small minute in time."
Review of the facility's policy and procedure titled, "Abuse Reporting" last revised on 4/10/13, showed, "If an employee of facility has been accused of resident abuse, he/she will be immediately removed from contact with the resident."
Therefore the facility failed to protect Resident 1 from physical abuse that could potentially result in physical and psychological harm.
The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to patients. |
| 030000820 |
Manorcare Health Services (Citrus Heights) |
030009418 |
B |
26-Jul-12 |
Y41011 |
17492 |
72311 Nursing Services--General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (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.72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 72527 Patients' Rights (a) 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. The following citation was written as a result of complaint #CA0044628 investigation findings identified during multiple unannounced visits to the facility initiated on 2/19/09. The Department determined that the facility failed to: 1. Prevent abuse. 2. Identify and plan patient care needs based on initial and continuous assessment. 3. Implement patient care policies and procedures. On 3/21/08 at 2:38 p.m., the facility informed the Department of resident-to-resident abuse, after Patient 2, who had a documented history of assaultive behavior, grabbed Patient 1's right breast.A review of the medical record on 02/09/09 revealed that the facility readmitted Patient 2 on 10/29/07 with diagnoses including stroke and pneumonia. The 10/29/07 Nursing Admission Evaluation failed to identify any behavioral concerns on admission.A review of the facility's 4/9/02 Behavior Management Program revealed (in part): "Program-At-A-Glance: (a) complete nursing admission assessment, (b) determine if resident exhibits behavioral symptoms, (c) track behavior on "Behavior Tracking Tool and analyze after 7-14 days, (d) "is behavior problematic?" (e) "Initiate behavior management program education, (f) develop a care plan and implement interventions, (g) monitor and analyze on behavior tracking tool at least every 14 days, (h) if behavior is not managed, modify care plan...."Purpose : The Behavior Management Program enhances the quality of life of the residents through a systematic caring approach. The approach guides staff through a structured assessment and planning process to evaluate behavior symptoms while providing for safety and promoting the highest level of well being...Process: Effective management of behaviors through assessment and interventions is the goal of the program...track behaviors on the behavior tracking tool...identify...when the behavior symptoms occurred, date, and time...what behavior symptoms the resident displayed...what intervention was used...as intervention strategies are modified, the care plan is updated...Inappropriate Sexual Behavior: If one of the participants lacks the ability to understand and freely choose to engage in the behavior, staff intervention is initiated. Inappropriate sexual behavior by the resident is investigated for abuse and immediate intervention is initiated if abuse occurred...Behavior Tracking: Behavior tracking is indicated when a resident exhibits a behavior that presents a safety risk to self or others....Behavior tracking is also indicated for mediation monitoring...." The 11/2/07 Social Work Assessment & History revealed that Patient 2 had a history of "inappropriate behavior" and indicated staff would monitor his behavior. A review of Patient 2's medical record failed to provide documented evidence that staff had initiated the behavior tracking tool to monitor and assess the effectiveness of interventions as directed in the facility's Behavior Management Tool. Despite the social work assessment, the clinical record failed to provide any documented evidence of care planning related to behavioral concerns until 11/6/07, 8-days after his admission. Care plan problem #12 revealed multiple interventions to address his risk for wandering including one dated 9/19/07 (carried over from his previous admission) which directed staff to "avoid leaving unattended or unobserved for long periods of time."The 11/26/07 "Initial Psychological Assessment" identified one of Patient 2's presenting problems as "inappropriate physical... (illegible)...limit contact ... (illegible) residents unsupervised." Despite the assessed behavioral risk, staff still did not initiate the behavior tracking tool to ensure the safety of the patients as directed in the facility's policy. A review of Patient 2's 2/4/08 annual MDS assessment (Minimum Data Set, an assessment and care screening tool) confirmed that Patient 2 had impaired memory and decision making skills related to dementia. According to the MDS, Patient 2 also had impaired communication, such as difficulty communicating and understanding others. The MDS noted the following behavior symptoms/patterns: (a) "repetitive physical movement," (b) "wandering," (c) "physically abusive behavior symptoms," and (d) "socially inappropriate/disruptive behavioral symptoms." However, a review of the medical record failed to reveal any evidence that the behavior tracking tool had been initiated to monitor behavior, assess the effectiveness of the interventions, and ensure the safety of the patients. The 2/12/08 Resident Assessment Protocol Summary (RAPS: a tool used to guide care planning), problem #8 "Mood State" noted "episodes of inappropriate touching, grabbing, and combativeness," had received a psychiatric evaluation, and was on medication for his behaviors. "He is at risk for injuring himself and others due to his behavior...will include mood and behavior issues in the care plan." Problem #9 "Behavioral Symptoms" referred back to the notes documented under problem #8. Eight days after the completion of the MDS assessment, staff still had not operationalized the facility's "Behavior Management Program."A review of the medical record failed to provide any evidence of initial or comprehensive care planning related to Patient 2's behavioral concerns identified through various assessments until 2/12/08. On 2/12/08, a care plan was initiated to address "aggression m/b (manifested by) inappropriate touching, grabbing, combativeness...." One of the interventions directed staff to monitor interactions with others. Even after the RAPS documented risk of assaultive behavior, the medical record failed to reveal any documented evidence that the "Behavior Management Program" tracking tool and weekly analysis had been initiated per the facility's policy.The facility's 2/1/02 "Abuse and Neglect Prevention" policy revealed (in part): "Every resident (patient) has the right to be free from ...sexual, physical and mental abuse...The policy defined neglect as, the failure to provide goods and services necessary to avoid physical harm...Under screening; The center also screens residents and new admissions to determine whether the individual's needs can be appropriately addressed within the center...The policy also indicated that in the case of resident to resident abuse/neglect staff are to: (a) immediate response to the needs of the injured party, (b)redirection of the aggressive resident... (c) evaluate for possible behavior management, referral to appropriate professional or transfer to a more appropriate setting if the resident is evaluated to be a threat to self or others... Under the section titled Protect...The center supports and protects residents...from abuse and neglect during investigation of allegations of abuse or neglect... Documentation of Protection: The medical record of any involved resident reflects all of the following:(a) who was involved, what happened, what was done, interventions used, how the resident responded to the intervention and what was done to prevent further harm to the resident or others, (b) alert or episodic documentation initiated and continued over the next 72-hours, and (c) acute care plan developed identifying methods to minimize further occurrence."The 2/1/02 Abuse and Neglect Prevention System- Action Table revealed the following steps (in part):"Take immediate action to prevent further incidents and provide safety, including separating the resident from the area...remain with the resident.... Document all assessment findings and immediate interventions on Progress Notes...The resident is monitored for a minimum of 72 hours for safety of self and others. Monitoring continues until stable. Begin alert, episodic charting...for a minimum of 72 hours...care plan is developed that identifies methods of preventing future unusual events." The 8/11/06 practice module titled Charting: Alert noted (in part): "Purpose: To provide a guideline for the clinical documentation process that may be needed following a change in patient condition or status. Guideline: The alert charting process includes documentation of a patient's condition that warrants alert charting, the decisions and actions of staff related to the patient's condition and the patients response to interventions implemented, such as behavior symptoms...The alert charting process includes...documentation of patient evaluation findings, physician notification and response, family notification and any new orders or instructions received in the interdisciplinary progress notes....Initiation of an Acute Care Plan including the patient's problem or need, goal and interventions planned to manage the patient's condition," such as 1:1 supervision or monitoring for catastrophic reaction...Documentation for alert charting occurs once a shift for a minimum of 72 hours." A review of the medical record revealed that Patient 1 (victim) was admitted to the facility on 3/20/01 with diagnoses including CVA (stroke), aphasia (difficulty expressing herself), and hemiplegia (one-sided paralysis). The 1/2/08 MDS assessment noted that Patient 1 had impaired memory and cognition. The MDS also noted that she difficulty expressing herself and understanding others. The MDS assessment did not identify any behavioral concerns only altered mood manifested by occasional sadness. According to the MDS assessment, Patient 1 was completely dependent on staff for all of her activities of daily living. Her primary mode of locomotion was wheel chair. A review of Patient 1's medical record and care plans also did not reveal any history of behaviors, such as aggression.On 3/21/08 at 2:38 p.m., the facility notified the Department that Patient 2 grabbed Patient 1's right breast. The form titled "State Report" revealed that on 3/20/08 at 8:20 a.m., Patient 2 "was witnessed by housekeeping staff to have grabbed a female's right breast," Patient 1. Under the section titled, "What actions were taken by the center?" hand written documentation revealed: "Resident involved have (sic) been placed on behavior monitor...." The medical record failed to provide documented evidence that the behavior tracking tool described in the facility's 4/9/02 "Behavior Management Program" was initiated until May 2008, two months after the event. Patient 1's 3/20/08 "Potential for psychological harm" care plan interventions included: "Monitor for and report any changes in mood or behavior r/t (related to) incident." A review of the nurses' progress notes, however, failed to provide documented evidence of "monitoring" and/or alert charting as indicated in the care plan and facility policy. The facilities 3/20/08 investigative report indicated that Patient 1 and 2 would be placed on behavior tracking. However, a review of Patient 1 and 2's medical records failed to provide documented evidence that the behavior tracking tool had been initiated as indicated by facility staff and according to facility policy.A review of Patient 1's 3/20/08 Interdisciplinary Progress Notes revealed that the nurse conducted a head-to-toe assessment. However, the narrative documentation did not describe the reason for the assessment, such as who was involved, what happened, what was done, interventions used, how the resident responded to the intervention and what was done to prevent further harm to the resident or others, as directed in the facility's abuse policy. Additionally, the record failed to provide documented evidence of ongoing 72-hour alert charting and behavior monitoring for a change in behavior/catastrophic reaction. A review of Patient 2's "Interdisciplinary Progress Note" failed to provide any evidence of narrative nursing documentation from 3/14/08-3/21/08. On 3/21/08, one day after the assault, the nurse wrote "spoke with MD ...this am regarding pts (patient's) behavior, MD stated to continue to redirect and keep him updated...situation." Additionally, the medical record failed to provide documented evidence of 72-hour alert charting and acute care planning as directed in the facility's abuse policy. In a 2/23/09 interview, the housekeeper who witnessed the assault was asked to recall the incident. The witness reported that during her daily routine, she passed by Patient 1's room and observed Patient 2 put his hand on Patient 1's shoulder as if to give her a hug and grab her breast. The witness explained that she immediately separated the two patients, who were both in wheelchairs. The witness indicated that after separating the patients, she informed nursing staff and added that both patients were confused at the time of the incident.A review of Patient 2's medical record revealed that staff failed to implement the approaches identified in the care plans, when Patient 2 was left unsupervised and assaulted Patient 1. Additionally, based on a review of the medical record, staff failed to protect both patients when behavioral tracking was not initiated prior to and after Patient 2 assaulted Patient 1. The only documentation noted in the medical record were hash marks on Patient 2's medication administration record (MAR). Staff used hash marks to reflect incidents of inappropriate behavior. However, there was no documentation regarding symptoms, interventions, and outcome as directed in the facility's 4/9/02 "Behavior Management Program." A 3/2/09 review of the facility's 4/2/02 "Social Services Manual Guidelines" revealed the following (in part): Social Work Progress Notes, The guideline revealed; Social work progress notes are the credible evidence that the social worker is providing medically related social work services. The social work progress notes serve as a record of the resident's psychosocial progress and primary source of communication between the social worker and other professionals. The primary purpose of the social work progress note is to document the effectiveness of the care plan.....episodic notes regarding significant events or services are also written subsequent to the event or provision of service...Care Plan Documentation...The care plan includes measurable goals with time frames for the resident, as well as staff interventions to assist the resident with goal attainment. The care plan is developed and implemented as soon as a resident's condition requires. The social worker is key to assessing resident mood and behavioral symptoms."In a 3/2/09 10 a.m. interview, social services staff was questioned about their process for addressing resident to resident abuse. The staff member stated that social services participates in the investigative process, initiates a care plan, and alerts unit staff to monitor for behaviors. The staff member also reported that the patient is monitored for 72-hours following the event. Staff explained that behaviors are documented weekly in the social services progress notes. When asked if staff uses the behavior monitoring tool, she replied that the tool is redundant and that social services tracks behaviors based on documentation on the MAR. When asked if the hash marks reflected behaviors, additional information, interventions implemented and effectiveness, she replied no. The social service representative was asked to review Patient 1 and 2's medical record. The staff member confirmed that alert charting/ monitoring for catastrophic reaction was not completed for Patient 1. Staff also confirmed that acute care planning, behavior tracking, and monitoring was not initiated. When asked why Patient 2's behavioral interventions were not revised based on increased safety concerns, staff reported that family dynamics influenced their decision regarding potential interventions, such as a care giver or maintaining line of sight.In a 3/2/09 1p.m. interview, Management staff was questioned about the facility's procedure for alert charting. The staff member reported that the standard of practice for alert charting was for staff to document in the progress notes. Therefore, the facility failed to: 1. Prevent abuse. 2. Identify and plan patient care needs based on initial and continuous assessment. 3. Implement patient care policies and procedures. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000050 |
Main West PostAcute Care |
030009531 |
B |
04-Oct-12 |
3HU211 |
9521 |
F323 - Free Of Accident Hazards/supervision/devices - 483.25 (h)The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.An unannounced visit was made on 10/1/09 to initiate investigation of Complaint #CA00202315 and an entity reported incident #CA00199717concerning Resident 1's multiple falls while residing in the facility. Based on interviews and record and document reviews, the facility failed to provide Resident 1 with adequate supervision and assistive devices to prevent an accident. Resident 1 fell backward while attempting to ambulate without assistance on 8/23/09, resulting in a subdural hemorrhage (bleed in the brain). Resident 1 died on 8/24/09.The Department determined that the facility failed to: 1. Ensure adequate supervision of transfers and appropriate use of a walker without assistance.2. Provide adequate supervision and documentation that Resident 1's personal alarm was attached and working properly and her call bell was within reach at all times. During a phone interview with Responsible Party (RP) 1 on 10/01/09 at 10 a.m., she related that Resident 1 fell three times while at the facility. She expressed feeling frustrated and verbalized she attributed the falls to no staff being in the room to supervise when Resident 1 had fallen. She indicated that Resident 1 had a history of falls, previously breaking her shoulder and because of these falls was admitted to the skilled nursing facility. After the last fall on 8/23/09, RP stated Resident 1 suffered two large bruises to the back of her head, had a bleed in her head, and was airlifted from one hospital to another where she expired. Resident 1 was a 79 year-old female who was first admitted to the facility on 1/31/08. She had intermittent need for care in the acute hospital over the years and was re-admitted to the facility on 9 different occasions. Her diagnoses when she was readmitted to the facility on 8/19/2009 included: Failure to thrive, generalized weakness, congestive heart failure, kidney impairment, diabetes and recent pneumonia. She had fallen during an admission to the general acute care hospital (GACH) in February 2008 sustaining a fractured upper arm.The Minimum Data Set (MDS- an assessment tool) dated 8/23/09 documented the following characteristics of Resident 1. She had long and short term memory deficit and had moderately impaired decision making ability; required cues and supervision. Her cognitive patterns were determined to have "deteriorated". Her primary language was not English but she usually understood others and was usually able to make her needs known.She required extensive assistance of one staff member for bed mobility, transfers, walking in the room and toilet use. She was frequently incontinent of bowel and bladder function. It was documented that she had fallen in the previous 31-180 days. Medical progress notes documented a fall 5/15/09 with no injury.Review of the Fall Risk Assessment forms from the current and prior admissions revealed that Resident 1 was assessed to be at high risk for falls on 3/4/09, 6/12/09, 7/1/09 and 8/19/09. The point score for a high risk for a fall was above 10. Resident 1's score was 20 points on 6/12/09 and 7/01/09. The Fall Risk score for 8/19/09 was only 12 but the resident's balance while standing or walking was not considered and there was no indication of level of confusion. Physical Therapy Progress Summary Daily Notes documented on 8/20 and on 8/21/09 that Resident 1 required moderate to maximum assistance for sit to stand transfers and moderate assistance with bed to chair transfers. Both days indicated that Caregiver Training for transfers was provided.Physician Orders for 08/01/2009 through 08/31/2009 indicated on 08/19/09 an order for "Precautions and limitations: Fall, over diuresis (fluid loss from medications)" and "PT (Physical Therapy), OT (Occupational Therapy), ST (Speech Therapy) screen prn (as indicated or needed)" and on 08/20/09 "P.T. clarification related to gait abnormality, therapeutic exercises, gait training every day/five times per week and 4 weeks." There was no current physician's order for the use of a walker.The Social Service Assessment dated 8/23/09 documented Resident 1 needed cues and supervision and made poor decisions related to cognitive loss. She was noted to be "easily distracted". She continued to demonstrate short and long term memory loss. The facility initiated a care plan regarding falls on 8/19/09 for Resident 1. According to the care plan, Resident 1's risks for falls and injuries included weakness, unsteady gait, impaired safety awareness, and a history of falls. The care plan also indicated Resident 1 was to have the call light within reach and answered promptly; assist with transfers and ambulation as needed, and to do 1/2 hr. visual checks of resident every shift.The initial nursing assessment dated 5/19/2009 documented the following characteristics (in part): "short term memory loss...mental status varies...rarely understood...rarely understands - language barrier Assyrian speaking...assist with ambulation...assist with transfers...unsteady gait...wheelchair, walker." Another nursing entry on 5/15/09 at 4 p.m., reflected the resident "already has clip alarm on bed and taking off by own . . ." A review of LN (Licensed Nurse) 1's Nurses Notes dated 8/23/09 revealed that at 8:20 p.m. Resident 1 had been found lying on the floor near her bed vomiting. LN 1 stated that she had observed a hematoma (bruising or bleeding into the tissues) on the back of Resident 1's head and that she was alert and oriented to person, place, and time. LN 1 then called for an ambulance, called the MD, the DON (Director of Nursing), and RP 1. The Paramedics arrived at 8:30 p.m. and transported Resident 1 to the emergency department at the closest GACH. Review of a facility Investigative Report written by the Director of Nursing and dated 8/23/09, revealed that on 8/23/09 Resident 1 had gotten up to go to the bathroom using her front wheel walker and had fallen backwards hitting her head on the floor. Resident 2 was outside of Resident 1's room and had observed the fall. Staff assisted Resident 1 and called the Physician and RP. Resident 1 was sent to the Emergency Room at the local GACH for evaluation and was later flown to another GACH Hospital with a diagnosis of subdural hemorrhage on the same day.Review of a facility Investigative report written by the Activities Director (AD) and dated 8/24/09, revealed Resident 2 had stated that on 8/23/09 she had been in the hallway outside Resident 1's room (room 40A) and observed Resident 1 stand up from her recliner with her front wheel walker and fall. The Coroners Report, dated 8/24/09, indicated the cause of death was "Blunt trauma to head with subdural hemorrhage and brain injury." During an interview with Resident 2 on 10/01/09 at 12:30 p.m., she stated that she observed Resident 1 sitting in her chair. She then stated that Resident 1 stood up and took a few steps forward with her walker, and then fell backwards onto the floor hitting her head. Resident 2 did not recall hearing Resident 1's alarm sound. Resident 2 then went to the nurses' station to tell staff about the fall.During an interview with the DON on 10/01/09 at 1:30 p.m., she stated that Resident 1 had a history of getting up on her own and had visual checks by staff every 30 minutes. She also stated that Resident 1 was very quiet and stayed in her room for most of the day.During an interview with the Social Services Director (SSD) on 10/01/09 at 2:30 p.m., the SSD also stated that Resident 1's dementia was increasing and she was requiring more assistance with her activities of daily living. She further stated that Resident 1's health was quickly declining and that the family was having a difficult time with this and her frequent hospital visits.During a phone interview with LN 1 on 4/29/10 at 6:45 p.m., she stated that sometimes Resident 1 would remove her chair alarm. LN 1 was then asked if Resident 1 was wearing her alarm that day, she stated, "I think she had an alarm on and the call light was in reach." When asked if the alarm placement and call light availability was documented she stated, "No I didn't write that in my notes." LN 1 finished by stating "She was supposed to call us for assistance to the bathroom and not get up by herself."During a phone interview with RP 2 on 7/04/10 at 11 a.m. she stated, "I don't think the alarm was on her, sometimes when I came to visit, the alarm was not on her sweater." Resident 1 was known to attempt to get up without assistance to go to the bathroom. The facility had implemented an alarm system to alert staff if she was getting up on her own. It could not be confirmed if the alarm was in place or not at the time of the fall on 8/23/2009. A call bell was to be within reach at all times but it is not confirmed if it was or was not in reach prior to her fall on 8/23/2009.Therefore, the facility failed to:1. Ensure adequate supervision of transfers and appropriate use of a walker without assistance.2. Provide adequate supervision and documentation that Resident 1's personal alarm was attached and working properly and her call bell was within reach at all times. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents |
| 100001535 |
Meadowood A Health & Rehabilitation Center |
030009681 |
B |
27-Dec-12 |
X7YY11 |
8330 |
Nursing Service - General 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 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.An unannounced visit was made to the facility on 2/23/10 and 2/24/10 to initiate an investigation of complaint number CA00218345.As a result of the investigation, the Department determined the facility failed to: 1. Ensure the physician was notified of a significant change in the patient's condition. 2. Develop of a plan of care based upon assessed needs.These failures resulted in delayed treatment for Patient A. On 7/3/09, Patient A was admitted to a local Emergency Room for evaluation and treatment. The admitting diagnoses included Acute Gastroenteritis and C. Difficile sepsis (an overwhelming generalized infection related to C. Difficile bacteria), dehydration, possible heart attack and acute renal failure. Clinical record review was conducted on 2/23/10. Patient A was an 82 year old admitted to the facility on 6/12/09 for rehabilitation following an elective right total hip replacement on 6/09/09. It was expected that Patient A would return home. The physician noted that Patient A's rehabilitation potential was "good".An initial Minimum Data Set (MDS-a comprehensive assessment tool) dated 6/29/09 identified Patient A had no cognition problems, was continent of bowel and bladder and could toilet themself with limited assistance from the staff. A "Cumulative Progress Note" dated 6/25/09 at 11:30 a.m. disclosed Patient A had no signs or symptoms of shortness of breath (SOB), had a soft, non-tender abdomen, remained continent of bowel and bladder, no signs of dehydration, and continued to receive physical therapy and ambulate with a front wheeled walker with a steady gait. An "Activities of Daily Living" form dated "4/25/09" but following an entry dated "6/24/09" was reviewed. At 5:30 p.m., CNA 1 documented, "Patient complaining of dizziness & weakness, vomiting. Always go to the bathroom & the BM is so smelly. Reported to my charge nurse." CNA 1 (Certified Nurse Assistant) was interviewed on 2/23/10 at 2:55 p.m. When asked, "Was the date 4/25/09 supposed to be [written as] 6/25/09?" CNA 1 stated, "Yes." Further review of the "Cumulative Progress Note" section revealed no nursing documentation for the evening shift on 6/25/09 that addressed CNA 1's documentation of Patient A's change in condition. There was no documented evidence that the charge nurse notified or consulted with the Patient's physician.On 2/23/10 at 2:55 p.m., CNA 1 stated during an interview, "I remember the patient. She was weak, complaining of shortness of breath, diarrhea." I asked if she reported the change of condition to the nurse she said, "When I told the nurse, they said they had called the doctor already." LN 1 was also interviewed on 2/23/10 at 3:20 p.m. LN 1 stated, "I may have been working that day." LN 1 checked the Medication Administration Record and determined she was on duty the evening of 6/25/09. LN 1 further stated that she "Had to take care of a lot of patients. I was her nurse that day." LN 1 stated that she "Did not remember him [CNA1] telling me that Patient A had smelly diarrhea, otherwise I would have taken action." A "NOTIFICATION TO PHYSICIAN" policy and procedure dated 3/6/06 read in pertinent part, "It is the policy of [the facility] to notify the attending physician promptly of the following... 2. Any sudden and/or marked adverse changes in signs, symptoms or behavior exhibited by a patient." The "PROCEDURE" section read in pertinent part, a "licensed/registered nurse to assess patient if above situation occurs...Notify patient's attending physician..." Continued clinical record review revealed a "Cumulative Progress Notes" entry dated 6/30/09 at 4 p.m. The entry read, "Patient complained of LBM (loose bowel movement) X (times) 2 days. Received orders of lmodium 2 mg (anti diarrhea medication) every after (sic) loose bowel movement X 5 doses." An entry at 10 p.m. indicated Patient A had "LBM X2" on the evening shift as well. Patient A's vital signs were blood pressure 107/61, temperature of 98.9, heart rate of 78, and breath rate was 20 (All vital signs were within normal range at this time). On 7/1/09 a "Cumulative Progress Notes" entry timed at 9 a.m. indicated that Patient A had LBM X 2. Vital signs for this entry were: blood pressure 101/56, temperature 97.9, heart rate 109, and breath rate was 20. An 11 p.m. entry indicated Patient A again experienced LBM X2 and "was medicated X 1 for abdominal cramps...Will continue to monitor, needs met. MD (Medical Doctor) aware of pt's (patient's) condition." Vital signs were blood pressure lowered to 92/53, temperature elevated to 100.5 , heart rate elevated to 108, and breath rate was 20. On 7/2/09 a Fax was sent at 10 a.m. to the physician which read, "Doctor, pt's loose bowel movements persisted despite lmodium orders. Can we please get an order to check stool for C-diff?" The facility received a faxed response from the physician who ordered a stool culture for C-diff on 7/2/09 sent at 11:54 a.m.A plan of care related to Patient A's continued diarrhea which started 06/25/09 was not developed until 07/02/09. A "Cumulative Progress Notes" entry on 7/2/09 at 6 p.m. revealed "...Patient had another episode of runny and watery stool" and complained of "abdominal cramps and discomfort..." At 6:15 p.m. Patient A "has episode of vomiting." The MD was notified and an anti-nausea medication was ordered. On 7/3/09 at 2 a.m., Patient A's vital signs were blood pressure 90/50, temperature 97.1, heart rate was 108, and breath rate was 20.On 7/3/09 at 9:08 a.m. the on-call physician was "notified of patient change of condition generalized weakness and Gl (gastrointestinal) discomfort (NV-nausea and vomiting) and loose stools...dry mucus membrane...received order send patient to ER (Emergency Room) for evaluation." Patient A's vital signs were blood pressure 102/61, temperature 96.4, heart rate 121, and breath rate was 20. A "PRE HOSPITAL CARE REPORT" (ambulance report) dated 7/3/09 at 9:30 a.m. disclosed Patient A's blood pressure (BP) was 88/50, heart rate of 114, and breath rate was 18. The "PRE HOSPITAL CARE REPORT" indicated an intravenous (IV) line was started and a 300 cubic centimeters (cc) fluid bolus of normal saline was given with the result of "B/P came up to normal limits during transport." The Emergency Room Nursing Clinical Record revealed the Patient's chief complaint was "flu X 5 days, diarrhea X 6 days, [and] "NV (nausea and vomiting) 2 days." The Emergency Room Provider Clinical Record indicated the diagnoses included dehydration, C. Diff diarrhea, possible heart attack and extreme weakness.Patient A had a cardiac arrest in the Emergency Room and was pronounced dead at 3:30p.m. on 7/3/09. Review of a "Certificate of Death" listed the cause of death as "acute gastroenteritis" secondary to "Clostridium Difficile." An interview with the DON on 2/23/10 at 11:45 a.m. revealed that when she asked the staff, the "nurses didn't feel she was that bad and the family never said anything." An interview conducted with Patient A's family member on 4/14/10 at 9:40a.m. disclosed, "We didn't tell the nurses because [Patient A] said she had told them repeatedly." The Department determined the facility failed to: 1. Ensure the physician was notified of a significant change in the patient's condition on 6/25/09 according to facility policy and required by regulation resulting in possible delayed evaluation/testing and treatment of Patient A's persistent diarrhea. 2. Development of a plan of care for Patient A's significant diarrhea based on an ongoing assessment. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000820 |
Manorcare Health Services (Citrus Heights) |
030010044 |
B |
14-Aug-13 |
FUWW11 |
4906 |
72311 - Free of Accident Hazards/Supervision/Devices (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. An unannounced visit was made to the facility on 9/16/10 to investigate complaint # CA00241942 regarding patient safety/falls.The Department determined the facility failed to use an assistance device to prevent an accident when Physical Therapist 1 (PT 1) ambulated Resident 1 without the use of a gait belt. (A gait belt is a belt/strap placed around a resident's waist. It is used for residents that require some level of physical assistance. It provides a firm grasping surface to aid in control for transfer or walking.) This failure resulted in Resident 1 falling and sustaining fractured facial bones and a laceration to the forehead.Review of the medical record on 9/16/10 indicated Resident 1 was a 62 year old admitted on 7/18/10 for rehabilitation after left foot surgery. Review of the admission MDS (Minimum Data Set, an assessment tool) indicated Resident 1 was alert, oriented and able to make daily decisions concerning care but needed assistance with hygiene, bathing, and mobility due to the inability to bear weight on the left foot. In a document titled "Rehabilitation Progress Notes" dated 7/23/10, PT 1 recorded, "Patient fell to right after ambulation 75 feet with four wheeled walker, NWB (non weight bearing) on the left and was sitting down; had right hand on wheelchair but pivoted to right and struck railing." In a document titled "Interdisciplinary Progress Notes" dated 7/23/10 at 3:50 p.m., Licensed Nurse (LN) 1 recorded, "Patient was seen in the hallway, noted with laceration, approximately 2 centimeters on his forehead in between his eyes... Approximately 25 ml (ml=milliliters, 25 ml = approximately 1 ounce) blood loss from forehead laceration (cut or tear in the skin). LN 1 did compress to the laceration with clean towel, ice compresses applied, 911 was called. LN 1 reported seeing patient trying to sit in his wheelchair, being assisted by PT. Patient fell face forward and hit face against hallway rails." The results of Resident 1's Computerized Tomography on 7/23/10 were reviewed. (A CT scan is a diagnostic x-ray scan used to make detailed pictures of structures inside the body). Medical Doctor (MD) 1 indicated Resident 1 sustained multiple facial fractures, soft tissue swelling around both eyes, and swelling in all his sinuses.In a hospital document titled "Adult Procedures, Emergency" dated 7/23/10 at 8:16 p.m., MD 1 described a 4 centimeter laceration repair on the forehead and bridge of the nose to which a liquid skin adhesive (used by doctors to close wounds) was applied.In a physician progress note dated 7/26/10, MD 2 recorded, "Patient had a fall face down on Friday night. Sent to, returned from the emergency room. Patient reports had a CAT (computerized scan that produces two dimensional images and is used to study parts of the body) scan ... Status: nasal fracture."In an interview on 5/10/12 11:45 a.m. PT 1 stated, "This resident was a big, strong guy I had ambulated many times before. His balance was good. I had no previous problems in balance with him. I did not put a gait belt on him for this session. I usually always put a gait belt on. I thought he would be stable without it. I was walking behind him with the wheel chair and on his left side. He was non weight bearing on the left leg/foot. He went about 50 feet and indicated that was enough. He placed his right hand back and took hold of the wheel chair arm to steady himself. I was on his left side. Instead of reaching back with his left hand as I was expecting, he fully collapsed to his right (strong) side hitting his head on the railing. I tried to grab his pajama bottoms. He fell away from me and into the wall." During an interview on 5/12/12 at 11 a.m., the Physical Therapy Director stated, "It is a standard of practice for therapists to use gait belts. My expectation is for all staff to use gait belts with any transfer."Review of the facility's "Gait Belt Policy," dated 2009, established the purpose, "To provide guidance to the rehabilitation staff on the use of gait belts with patients." The procedure was described as, "The therapy staff should apply a gait belt to the patient whenever the patient is receiving therapy services that involve standing, walking, transferring, or sitting unsupported." The Department determined the facility failed to use an assistive device when PT 1 ambulated Resident 1 without the use of a gait belt. This failure resulted in Resident 1 falling and sustaining fractured facial bones and a laceration to the forehead.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000820 |
Manorcare Health Services (Citrus Heights) |
030012175 |
A |
15-Apr-16 |
5X3K11 |
28588 |
F279 - Develop Comprehensive Care Plans 483.20(d), 483.20(k)(i) A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.25; and any services that would otherwise be required under 483.25 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(b)(4). F309 - Provide Care/services For Highest Well Being 483.25 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. An unannounced visit was made to the facility on 4/3/2015 to investigate complaint #CA00436710.The Department determined the facility failed to ensure a comprehensive care plan was developed based on resident assessments and necessary standards of care. Resident 1's assessments revealed evidence of both a urinary tract and respiratory tract infection, neither of which were addressed in her plan of care. Further, services were not provided for Resident 1 to ensure she was monitored and treated appropriately to prevent harm associated with her immune system compromise and multiple infections including the following: 1) immunosuppression (depressed function of the immune system and decreased ability of the body to fight infection due to low white blood cell count) and a decline in health and 2) oral candidiasis (thrush - a fungal infection of the mouth) 3) difficulty swallowing and possible aspiration [entry of food or material from the mouth into the lungs] 4) urinary tract infection.Through interview and clinical record review it was determined that assessments of Resident 1's clinical conditions were not appropriately addressed in Resident 1's comprehensive plan of care. Nor did the facility otherwise provide necessary care and services to Resident 1 as required by regulation.These failures resulted in Resident 1 developing a respiratory infection, a urinary tract infection, and a systemic infection (an infection distributed throughout the entire body not just one organ) which contributed to the resident's death. Resident 1 was admitted to the facility on July 23, 2014 and died on August 13, 2014.Resident 1's medical record was reviewed on 4/3/2015. Resident 1 was admitted with diagnoses including B cell lymphoma (cancer) for which she received chemotherapy medication (at an outpatient clinic) and rehabilitation procedures (physical, occupational, and speech therapy). According to the Comprehensive Minimum Data Set (MDS - an assessment tool) dated 7/30/2014, active discharge planning was occurring to return the resident to the community. An additional document in the record titled Occupational Therapy dated 7/29/2014 established "Pt [patient] & Caregiver goals: ...return back to the community... Potential for Achieving Goals: Patient demonstrates good rehab potential as evidenced by high PLOF [prior level of function], Low number of comorbidities (multiple diseases at the same time), Active participation wPOT [with plan of treatment] and Strong family support." The documented discharge goal was for the resident to return home with family.Review of the document titled Physician Orders for Life-Sustaining Treatment (POLST) dated 7/24/2014 established the following: "Do Not Attempt Resuscitation /DNR...Limited Additional Interventions...In addition to care described in Comfort Measures Only, use medical treatment, antibiotics, and IV [intravenous] fluids as indicated..."1) Upon admission and as reflected in Resident 1's assessment, Resident 1 received medications with the known adverse effect of immune suppression. Yet, care and care planning did not include monitoring of immune function. The Director of Nursing (DON) verified there were no nursing interventions in Resident 1's care plan associated with the high risk for immunosuppression although her assessment revealed the signs and symptoms of both a urinary tract infection and a respiratory tract infection that were subsequently diagnosed. Review of the document in the clinical record of Resident 1 titled Discharge Summary [acute hospital] dated 7/23/2014 included the following notation under Medications: "Rituxan [chemotherapy medication to treat cancer] once a week as per oncology recommendations..." Review of the document titled Order Summary Sheet in the clinical record of Resident 1 included a physician order dated 7/30/2014 which read: " Week 4 Chemo [medicine to treat cancer] apt [appointment] on 8/6/2014 at 8 am...one time only for 1 Day." During a concurrent interview and clinical record review with the DON on 4/23/2015 at 4:20 p.m., Resident 1's care plan was reviewed. The focus area titled "Chemotherapy for treatment of Lung CA [cancer] with Metastatic [spreading of cancer from one part of the body to another ] brain CA: At risk for adverse effects" dated 7/25/2014 included the following interventions: "Administer antiemetic[medicine to prevent vomiting] medications per physician orders...Assist with ADLs [Activities of Daily Living]...Dietary Evaluation for meal and snack plan...Encourage and assist as needed to consume fluids frequently following chemo...Encourage rest after chemotherapy."The DON verified there were no nursing interventions in Resident 1's care plan associated with the high risk for immunosuppression, anemia (low red blood cell count resulting in decreased oxygen carrying capacity of blood), bleeding (due to low platelet cell count- which are the cells that initiate blood clotting), and infection secondary to high risk of potential adverse effect of decreased white, red, and platelet counts commonly associated with chemotherapy. When asked about these potential adverse effects and the plan of care for Resident 1, the DON replied Resident 1 was "in a private room [and had] lab works [sic] [and that the] clinic monitor lab work [sic] [and] would notify the facility of abnormal labs done at the clinic." The DON verified there was no lab work done by the facility to evaluate Resident 1 for potential low blood cell counts that often occur with chemotherapy and can lead to immunosuppression, bleeding, and anemia.During a concurrent interview and record review with the Medical Doctor (MD) 1 on 4/24/2015 at 11:30 a.m., MD 1 verified there was no evidence of any laboratory studies in the clinical record after 7/30/2014. MD 1 stated there should be some from the 8/6/2014 oncology clinic appointment and "we will call the clinic and get copies." During an interview with the DON on 5/1/2015 at 9:15 a.m., she stated she had contacted the clinic to obtain copies of lab work and there was "no lab work done on 8/6/14." The DON also stated that there was no evidence in the record that the facility attempted to obtain any lab work from the oncology clinic prior to 5/1/2015. Review of the document titled Progress Notes in the clinical record of Resident 1 dated 8/11/2014 16:54 (4:54 p.m.) established the following: "Acetaminophen [Tylenol] Tablet 325 MG ...given fo [for] loe [low] grade temp of 99.0 and for headache." According to Management of Infections (Oncology) found at Lexicomp Online: (a comprehensive and trusted online drug and clinical reference website) "Certain oncology patients are at increased risk of morbidity [disease] and mortality [number of deaths] from infectious complications secondary to disease- or treatment related loss of immunity. Impaired immunity is generally associated with malignancies that arise from hematologic cells and lymphoid tissues [lymphoma]...Most anticancer treatments reduce immunity by causing neutropenia [low white blood cell count - white blood cells protect the body from infection] and mucositis [inflammation of mucous membranes]...Environmental sources of opportunistic pathogens [disease producing organisms] include the surface of fresh fruits and vegetables [bacteria], ...and tap water. " Retrieved from http://www.online.lexi.com/lco/action/doc/retrieve/docid/patch_f/5250 on 5/6/2015. Important Rituxan Safety Information retrieved from http:/www.rituxan.com/hem/hcp/safety on 5/6/2015 included the following additional warnings/precautions: "Laboratory Monitoring: In patients with lymphoid malignancies, during treatment with RITUXAN monotherapy, obtain complete blood counts [red blood cell and white blood cells] (CBC) and platelet counts prior to each RITUXAN course. During treatment with RITUXAN and chemotherapy, obtain CBC and platelet counts at weekly to monthly intervals and more frequently in patients who develop cytopenias [below normal number of blood cells]. The duration of cytopenias caused by RITUXAN can extend months beyond the treatment period."Lexicomp Online also revealed the following: "higher than 10% of patients experience the following adverse reactions when receiving rituxan: Hematologic: Cytopenias ...anemia [low red blood cell count - red blood cells carry oxygen to the tissues in the body] (8%-35%...neutropenia, ... 14%...thrombocytopenia [low platelet count - platelets form blood clots to prevent bleeding] ." Under Warnings/Precautions, Lexicomp listed the following concern related to adverse effects: "Infections...serious and potentially fatal bacterial, fungal, and either new or reactivated viral infections may occur during treatment and after completing rituximab [rituxan]...Special Populations: Elderly Use with caution...higher risk of ...pulmonary adverse events (pneumonia, pneumonitis)." Retrieved on 5/5/2015 from: http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/7634. 2) Resident 1 was treated for thrush (an oral fungal infection) and yet there was a lack of documented evidence of assessment, care, and care planning to include monitoring of the thrush for response to treatment and resolution upon completion of treatment. The DON verified there was no plan of care in the clinical record of Resident 1 which addressed her oral thrush nor an assessment of Resident 1's mouth. Review of the document titled Order Summary Report in the record of Resident 1 disclosed an order dated 7/24/2014 which indicated the following: "Nystatin Suspension [an antifungal medication to treat oral fungal infection]...Give 5 ml by mouth four times a day for oral thrush for 14 Days."Although the order was implemented, review of the Progress Notes of Resident 1 ranging from 7/23/2014 - 8/8/2014, the EMAR (electronic medication administration record), and the facility provided care plan revealed no evidence of any plan of care, physical assessment of the oral cavity, or effectiveness of the treatment.During an interview with the DON on 5/7/2015 at 10:25 a.m., she stated that normally when a resident is on an antibiotic for an infection, daily charting is done related to "effective or not and any side effects." During a subsequent interview with the DON on 5/7/2015 at 1:40 p.m., she verified there was no plan of care in the clinical record of Resident 1 which addressed her oral thrush and she stated there was "no mention of assessment of her mouth in the record that I could find." The DON stated "We must be more vigilant and make sure care plan is done correctly and comprehensively, we missed it."3) Resident 1 was identified to demonstrate signs and symptoms of aspiration of food into her lungs. The clinical document reflected deterioration of her respiratory status and yet there was a lack of assessment, care, and care planning to include prevention, monitoring, and care and treatment of possible aspiration of food into the lungs. The facility inadequately care planned Resident 1's respiratory impairment and failed to assess Resident 1's white blood cell count to determine immune function even after diagnostic evidence of respiratory tract infection. The Speech Language Pathologist stated a care plan should have been initiated to address the Resident 1's respiratory compromise. Aspiration pneumonia contributed to Resident 1's death. Review of the Progress Notes of Resident 1 dated 7/29/2014 at 14:16 (2:16 p.m.) entered by a licensed nurse revealed the following: "during ST [Speech Therapy] eval [evaluation] pt [patient] noted to be coughing thus further assessed pt and noted crackles [clicking, rattling, or crackling noises associated with respiratory disease that are heard with a stethoscope] @ [at] upper bilateral [both sides] lung fields, cxray [chest X-ray] done as of 7/20/2014 w/no [with no] aspiration, atelectasis [deflation of the air sacs in the lungs] and effusion [fluid in the cavity that holds the lungs] noted, downgraded diet, rp [responsible party] DR [MD 1] notified awaits advice and endorsed." The documentation indicated that Resident 1 showed signs and symptoms of possible aspiration.Review of the document titled Speech Therapy Treatment Encounter Note dated 7/29/2014 included the following entry by a Speech Language Pathologist (SLP): "ST [speech therapy] suspects pharyngeal [throat] residue unnoticed by pt and possible delayed aspiration, as cough increased at end of meal...ST consulted nursing who listened to pts [patient's] lungs and recommended downgrade to nectar thick liquids [milkshake consistency to prevent choking]..." During an interview with SLP 1 on 5/21/2015 at 1:35 p.m., she stated that a "care plan should have been initiated" by the SLP for the high risk patient assessment as noted above. According to the SLP documented assessments, Resident 1 continued to show signs and symptoms of possible aspiration. Further Review of the Progress Notes of Resident 1 included an entry by Social Services (SSC) dated 7/30/2014 at 13:32 (1:32 p.m.) which read: "Care Conference: SSC, DCD [Director Care Delivery], Physical Therapy [PT]...Speech downgraded to nectar thick liquids because of hearing sounds while swallowing and to eliminate aspiration."Review of the document titled Physician's Progress dated 8/3/2014 included the following notation: "She is improving...Lungs clear anteriorly and laterally." An additional entry by the Registered Dietician in the Progress Notes dated 8/5/2014 at 11:34 (a.m.) disclosed the following: "S. T. [Speech Therapy] downgraded texture from Mechanical Soft [foods that require less chewing] to Pureed [food prepared at the consistency of a creamy paste]. Diet now reads: CHO [Carbohydrate]- Controlled, Pureed with Nectar Thick Liquids." The record reflected that Resident 1 continued to show signs and symptoms of possible aspiration.An entry in the Progress Notes by Licensed Nurse (LN) 2 dated 8/6/2014 at 17:32 (5:32 p.m.) noted the following: "...resident has crackles. wheezing in lungs, request MD [Medical Doctor] for chest xrays. MD decline..."Review of the licensed nursing Progress Notes dated 8/9/2014 at 13:50 (1:50 p.m.) included the following notation: "spoke to [Nurse Practitioner (NP) 1] on call for [MD 1] complaint of (c/o) frequent use of albuterol neb. [nebulizer - an aerosol machine to deliver medicine for breathing] prn [as needed]...will come to SNF [skilled Nursing Facility] later this afternoon to see pt..."Review of a document titled EMAR (Electronic Medication Administration Record) dated 08/01/2014 - 08/31/2014 in the clinical record of Resident 1 included the following entries: "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML [milliliter - a unit of measure] 0.083% 2.5 mg inhale orally via nebulizer every 6 hours as needed for sob, wheezing." The as needed medication was noted as administered only 4 times from 8/1/2014 to 8/8/2014; however from 8/9/2014 to 8/12/2014 it was noted as administered 2 times daily.Review of the document titled Progress Notes in the clinical record of Resident 1 dated 8/11/2014 at 09:42 (9:42 a.m.) included the following Licensed Nursing notation: "has wheezing sounds, with crackles in upper part of chest. has air hunger. has hard time swallowing food. MD notified. waiting for MD to reply." Further review of the clinical record of Resident 1 included a document titled Order Summary and a physician order dated 8/11/2014 which read: "Chest x-ray on 8/11/2014 for SOB, asthma one time only."Review of the document titled Diagnostic Imaging Report dated 8/11/14 included the following conclusion: "Mild bilateral [both sides] perihilar [area around the main airway enters the lungs] infiltrates [a shadow seen on a chest xray and assumed to represent blood, pus, or other body fluids in the lung] and/or areas of atelectasis [a collapsed or airless condition of the lung]." Although the radiology report demonstrated respiratory tract infection, there was no evidence in the record of an assessment of Resident 1's white blood cell count to determine her immune system response to the infection.Review of the Licensed Nurse Progress Note in the record of Resident 1 dated 8/11/2014 at 23:37 (11:37 p.m.) revealed the following: "02 Sat=[a measurement of peripheral oxygen saturation of the blood] 94% with 02." All other entries in the clinical record of Resident 1 related to her oxygen saturation prior to this date indicated she was on room air and not receiving any oxygen until this entry noted she was on oxygen.Review of a Licensed Nurse Progress Note in the clinical record of Resident 1 dated 8/12/2014 at 12:35 p.m. indicated the following: "Resident has xray results, infiltration of lungs or atelectasis. Family notified. MD aware. faxed to MD received back singed [sic]. but without any new order. called MD twice for clarification. faxed back. waiting for MD response." Further review of Licensed Nurse Progress Notes dated 8/12/2014 at 17:37 (5:37 p.m.) revealed the following: "Received call from [Nurse Practitioner (NP) 1] on call for [MD 1], MD stated that he reviewed results of the chest x-ray that was done on 8/11/2014 and clarified that patient doesn't need antibiotic therapy for this findings, recommended cont [continue-sic] with current orders and monitor for sputum. Family aware of doctor decision. Will cont to monitor." Again there was no evidence in the record of assessment of Resident 1's white blood cell count to determine her immune system function when she demonstrated signs and symptoms and diagnostic evidence of respiratory tract infection. Review of the care plan in the clinical record of Resident 1 revealed the following licensed nursing entries dated 7/24/2014: "Focus: At risk for respiratory impairment related to asthma...Position as upright as possible for meals and afterwards...Elevate the head of the bed..." Further review of the care plan revealed no evidence of a care plan addressing Resident 1's identified problem of possible aspiration or any interventions or precautions to prevent/treat this complication.According to the Clinical Practice Guideline for the Evaluation of Fever and Infection in Older Adult Residents of Long-Term Care Facilities: 2008 Update by the Infectious Disease Society of America: "A Complete Blood Cell count (CBC) including a peripheral WBC [white blood cell count] and differential cell counts...should be performed for all LTCF [long term care facility] residents who are suspected of having infection within 12-24 h [hours] of onset of symptoms (or sooner if the resident is seriously ill).." Retrieved 6/9/2015 from http://cid.oxfordjournals.org/content/48/2/149.full.pdf+html. 4) Resident 1 was diagnosed and treatment prescribed for a urinary tract infection and yet there was a lack of assessments, care, and care planning that included monitoring and treatment of the urinary tract infection. When Resident 1 became unable to take any of her prescribed medications, her physician was not notified nor was her plan of care revised. Resident 1 also had signs and symptoms of a respiratory tract infection, and had a high immunosuppression risk related to her chemotherapy treatment, yet her WBC was not evaluated. The patient's urinary tract infection contributed to her death. Review of the licensed nursing Progress Notes dated 8/9/2014 at 13:50 (1:50 p.m.) included the following notation: "spoke to [NP 1] on call for [MD 1] ...burning upon urination [clinical symptom of infection], as stated will come to SNF [skilled Nursing Facility] later this afternoon to see pt..."Review of the document titled Order Summary revealed a physician order dated 8/10/14 which read: "UA (urinalysis) with C&S (culture and sensitivity - a test to identify bacteria and effectiveness of antibiotics) one time only." MD 1 stated the urinalysis results in the clinical record indicated a "sub-clinical UTI (urinary tract infection)." Further review of the record included a document titled Order Summary with a physician order dated 8/10/2014 that read the following: "Macrobid (an antibiotic medication) 100 MG [milligram - a unit of measure]...Give 100 mg orally two times a day for UTI for 10 days."During an interview with the DON on 5/7/2015 at 10:25 a.m., she stated that normally when a resident is on an antibiotic for an infection, daily charting is done related to "effective or not and any side effects." There was no evidence of daily charting associated with the administration of the Macrobid (antibiotic) being given to Resident 1 for a urinary tract infection.Review of the document titled Progress Notes entered by LN 3 dated 8/12/2014 included the following notation under Macrobid Capsule 100 MG: "difficulty swallowing." During an interview with LN 3 on 4/24/2015 at 1:30 p.m., she stated she had cared for Resident 1 on 8/12/2014 and had done a "test with applesauce" to assess her ability to swallow. LN 3 stated Resident 1 had been unable to swallow and her medications were not given. The medication ordered to treat Resident 1's urinary tract infection was not administered as prescribed and there is no evidence in the clinical record that the physician was notified or consulted concerning Resident 1's inability to swallow her medications.There was no evidence in the record of assessment of Resident 1's white blood cell count to determine her immune system function (which was at risk for being compromised secondary to common adverse effects of chemotherapy) when she demonstrated evidence of urinary tract infection. Review of the care plan in the clinical record of Resident 1 revealed the following licensed nurse entries dated 7/24/2014: "Focus: Urinary incontinence related to impaired Mobility...Goal: Will have no complications due to incontinence...Reports S&S of UTI [such as flank pain, c/o burning/pain, fever, hematuria [blood in the urine], change in mental status, etc..." Further review of the care plan of Resident 1 revealed no evidence of a care plan addressing Resident 1's identified problem of urinary tract infection or any interventions or precautions to prevent/treat this complication.As previously noted, according to the Clinical Practice Guideline for the Evaluation of Fever and Infection in Older Adult Residents of Long-Term Care Facilities: 2008 Update by the Infectious Disease Society of America: "A Complete Blood Cell count (CBC) including a peripheral WBC [white blood cell count] and differential cell counts...should be performed for all LTCF [long term care facility] residents who are suspected of having infection within 12-24 h [hours] of onset of symptoms (or sooner if the resident is seriously ill).." Retrieved 6/9/15 from http://cid.oxfordjournals.org/content/48/2/149.full.pdf+html.Resident 1 was diagnosed with a urinary tract infection, had signs and symptoms of a respiratory tract infection, and had a high immunosuppression risk related to her chemotherapy treatment, yet her WBC was not evaluated.A licensed nurse entry in the clinical record of Resident 1 on 8/12/14 indicated that she "appeared weak and sleepy...appeared to have difficulty swallowing her medications." Subsequent entries on 8/12/2014 indicated Resident 1 was "unable to swallow" her medications. The record reflected Resident 1 was transferred to the hospital after she had become unresponsive on 8/12/2014.Review of the document obtained from the General Acute Care Hospital (GACH) revealed Resident 1 was admitted to the GACH on 8/12/2014. A document in the clinical record titled History and Physical dated 8/12/2014 at 23:45 (11:45 p.m.) disclosed the following entry by the medical doctor: "Physical Examination: Vital Signs: Temperature is 39.4 (102.9 degrees Fahrenheit)...Assessment and Plan...Possible aspiration pneumonia. Chest x-ray shows what appears to be aspirate pneumonia, bilateral pneumonia...Metastatic cancer, otherwise stable..." Further review of the GACH records included the following on the document titled Discharge [upon death] Summary dated 8/13/2014: "Discharge Diagnosis:...Urinary Tract infection... Pneumonia... Pancytopenia [low blood cell counts of white blood cells, red blood cells and platelets]...Febrile neutropenia [fever associated with an extremely low white blood cell count] ...Procedures and Diagnostics:...Chest X-ray shows interval development of bilateral moderately severe disease consistent with pneumonia...CT [Computerized topography - a diagnostic tool] scan of head shows significant interval decrease in size of posterior right frontal lobe mass [cancer]..."An additional document titled Emergency Documentation- MD [medical doctor] dated 8/12/2014 in the GACH clinical record of Resident 1 disclosed the following: "Lab results...WBC 2.1 K/uL [unit of measure] CRIT [critical low value - normal range is 4.5-10 k/uL]...Hgb [hemoglobin - red blood cell count] 7.5 gm/dL L[low - normal range is 12-15]...Plt [platelet - thrombocytes - a blood cell necessary for forming blood clots to prevent bleeding] 83 k/uL L [low - normal range is 150-300k/uL]...urine WBC's 25-50 [normal range is less than 2 to 5] per HPF [high power field microscope]...Ubacteria [urine bacteria] 4 [normal is none]...NIBP [non-invasive blood pressure] systolic [blood pressure] 73 mm Hg L [low - normal is greater than 90]."The document titled Discharge Summary in the GACH clinical record of Resident 1 also revealed the following: "Hospital Course: After the patient presented to the hospital she was noted to be hypoxic [low blood oxygen level], hypotensive [low blood pressure] with spiking temperature. The patient was started on broad-spectrum IV [intravenous - through the vein] antibiotics, IV hydration. The patient continued to be hypotensive and was subsequently started on Levophed [medication to support blood pressure]...the patient passed away around 6:15 p.m. on 8/13/2014."Review of the document titled Sacramento County Department of Health and Human Services Certificate of Death dated 8/13/2014 established the following cause of death of Resident 1: "Immediate Cause (Final disease or condition resulting in death) (A) Severe Sepsis...Sequentially list conditions, if any, leading to cause on line A. Enter UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST...(B) Aspiration Pneumonia...(C) Urinary Tract Infection..." Review of the facility policy titled Requirements and Guidelines for Clinical Record Content under Care Plans included the following statement: A comprehensive care plan is developed within seven (7) days of completion of the comprehensive assessment."The Department determined the facility failed to ensure a comprehensive care plan was developed based on resident assessments and necessary standards of care. Resident 1's assessments revealed evidence of both a urinary tract and respiratory tract infection, neither of which were addressed in her plan of care. Further, services were not provided for Resident 1 to ensure she was monitored and treated appropriately to prevent harm associated with her immune system compromise and multiple infections. These violations, separately or jointly, presented either (1) imminent danger that death or serious harm to the patients or residents of long-term health care facility would result there from or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result there from. |
| 030000028 |
Mission Carmichael Healthcare Center |
030012930 |
A |
2-Feb-17 |
194911 |
16685 |
F314 - 483.25
(c) 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 following citation was written as a result of an unannounced visit for the investigation for Complaint #CA00448211 regarding Quality of Care/Treatment and Resident/Patient/Client Rights.
The Department determined that the facility failed to ensure Resident A did not develop an avoidable pressure ulcer.
This failure lead to the development of a Stage II pressure ulcer on Resident A's left lateral (outer) ankle which progressed to a Stage 4 (Full thickness loss of skin with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).
Resident A was admitted to the facility on XXXXXXX 2015 and diagnosis included cardiovascular disease (refers to a group of conditions that affect the supply of blood to the brain, causing limited or no blood flow to the affected areas), hypertension (high blood pressure), chronic kidney disease (gradual loss of kidney function over time) and congestive heart failure (the heart is unable to pump to sufficiently to meet the body's needs).
Resident A's Admission MDS (Minimum Data Set-an assessment tool), dated 3/17/2015, described him as having clear speech, able to make himself understood and able to understand others. His BIMS (a brief screening that aids in detecting cognitive impairment) score was "12" indicating moderate impairment. The MDS described Resident A as having no signs or symptoms of delirium or behavioral symptoms. The MDS also described Resident A as needing extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, toilet use and personal hygiene. The MDS further described Resident A as having impairment on one side of his upper and lower extremity.
Review of the CAA (Care Area Assessment) Worksheet (part of the MDS), dated 3/17/2015, indicated under section "2. Cognitive Loss/Dementia" that "Res (resident) requires max to total assist w/ADLs (Activities of Daily Living), non-ambulatory and requires staff assist for locomotion." It also indicated, "Res is at risk for pressure ulcer development d/t (due to) above risk factors and also d/t impaired mobility/balance, left hemiplegia (complete paralysis on one side of body), incontinence and meds (medications) (particularly antianxiety, antidepressants, and narcotics)."
Review of the CAA Worksheet, dated 3/17/2015, under section "16. Pressure Ulcer" indicated, "Proceed to care plan to minimize complications r/t (related to) risk factors."
Review of Resident A's clinical record revealed no documentation of a care plan regarding the prevention of skin breakdown nor a care plan regarding Resident A's left sided hemiplegia.
Review of the facility's policy titled, "Skin Management," with a date of 2012, indicated, "A care plan is developed upon admission, identifying the contributing risk for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The care plan should address, but is not limited to: hydration, nutrition, preventive devices, physical activity, pain, positioning requirements and proper body alignment."
Review of the facility's policy titled, "Skin Management," with a date of 2012, indicated, "Appropriate preventive surfaces of beds, wheelchairs, etc. will be implemented on all residents identified as risk (score of 18 or less on the Braden Scale-For Predicting Pressure Sore Risk), and the interventions documented on the care plan."
Review of Resident A's "Braden Scale for Predicting Pressure Sore Risk," dated 3/8/2015, documented his Braden Score Scale Score as "17" with the risk scale category "at risk."
During an interview with the MDS Coordinator, on 8/12/2015 at 11:50 a.m., she stated, "I might of missed it" regarding creating a care plan for preventive skin care.
During an interview with the Director of Nursing (DON), on 8/12/2015 at 12:10 p.m., she confirmed there was no care plan regarding the prevention of skin breakdown. She also confirmed there was no care plan regarding Resident A's left sided hemiplegia.
During an interview with the DON, on 11/13/2015 at 10:10 a.m. she stated "ideally" a care plan would have been developed and the interventions then would have been put on the Kardex (a card-filing system that allows quick reference to the particular needs of each patient for certain aspects of nursing care).
Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "Following admission, the Braden Scale-For Predicting Pressure Sore Risk will be completed weekly for 3 additional weeks (for a total of 4 weeks including admission), quarterly, annually, and with a significant change in status for their risk for development of pressure ulcers."
During an interview with the DON, on 8/27/2015 at 11:10 a.m., she confirmed the Braden Scale-For Predicting Pressure Sore Risk was not completed weekly for 3 additional weeks for Resident A, per the facility's policy.
Resident A's "Skin-Weekly Pressure Ulcer Record," dated 5/14/15, indicated he had developed a "new" "acquired at facility" "Stage II" (Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister) open area on his left outer (lateral) ankle measuring length 1.5 cm x width 1.5 cm x depth 0.1 cm. "Skin-Weekly Pressure Ulcer Record," dated 5/18/15 documented the wound size as 3 cm x 3 cm x UTD (unable to determine) and indicated a "Wound culture done to check for infection. Noted some pus."
On 5/18/2015 Resident A was seen by the wound care specialist. Review of "Wound Care Specialist Initial Evaluation," described Resident A's left lateral ankle as "unstageable DTI (deep tissue injury)" and measured length 3 x depth 3 x width Not Measurable cm."
The facility's, "Skin Management" policy, with a date of August 2012, read "Unstageable" described as "when eschar (slough or dead body tissue that may be tan, brown, black in color) is present, accurate staging is not possible until the eschar has sloughed or the wound has been debrided."
The facility's, "Skin Management" policy, with a date of August 2012, "Suspected Deep Tissue Injury" described as "purple or maroon localized area of discolored intact skin or blood-filled blister due to damage to underlying soft tissue from pressure and/or shear. This area may be preceded by tissue that is firm, mushy, boggy, or warmer or cooler as compared to adjacent tissue. May open and deteriorate rapidly even with optimal treatment."
Wound culture results, dated 5/22/2015, indicated Resident A had MRSA (Methicillin Resistant Staphylococcus Aureus- bacterial infection that is resistant to numerous antibiotics) in his left outer ankle wound and was prescribed an antibiotic.
On 5/25/2015, the "Wound Care Specialist Evaluation," described Resident A's left outer ankle wound as "unstageable necrosis (dead body tissue) " and measured "3.3 x 2.2 x 0.1 cm." Documentation indicated the "wound was debrided via surgical excision and subcutaneous tissue removed along with necrotic tissue."
Resident A's "Skin-Weekly Pressure Ulcer Record," dated, 5/26/15 documented the left outer ankle measured 3.3 cm x 2.2 cm x UTD and described the "wound bed appears with slough and necrotic tissue. [Physician] debrided at bedside ...Pt [Resident A] has MRSA (on that wound and is currently on ATB (antibiotic)."
On 6/1/15, the "Wound Care Specialist Evaluation," indicated Resident A's left lateral ankle was a "Stage 4" (Full thickness loss of skin with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.) and measured "3.5 x 2 x 0.1 cm." Documentation indicated the wound again was "debrided via surgical excision and muscle removed along with necrotic tissue."
Resident A's "Skin-Weekly Pressure Ulcer Record," dated 6/4/2015, documented Resident A's left outer ankle wound measured 3.5 cm x 2 cm x 1.2 cm and described the "wound bed with slough and necrotic tissue."
On 6/8/2015, the "Wound Care Specialist Evaluation," Resident A's left outer ankle wound was described as "Stage 4," measured "2.7 x 1.7 x 0.3 cm" and for a 3rd time the "wound was debrided via surgical excision and subcutaneous tissue removed along with necrotic tissue."
Resident A's "Skin-Weekly Pressure Ulcer Record," dated, 6/9/2015, documented the measurements of the left outer ankle wound as 2.7 cm x 1.7 cm x 0.3 cm and the wound was described as having "slough and necrotic tissue noted to wound bed."
Resident A's "Skin-Weekly Pressure Ulcer Record," dated, 6/15/2015, documented the measurements of Resident A's left outer ankle as 3 cm x 2.5 cm x 0.3 cm and described "wound bed appears with necrotic tissue and slough noted."
On 6/15/2015 the "Wound Care Specialist Evaluation" described Resident A's left lateral ankle as a "Stage 4" and measured "3 x 2.5 x 0.2 cm" and as having "no change." Documentation indicated again the wound was debrided, a fourth time, via (by) surgical excision and muscle removed along with necrotic tissue.
On 6/22/2015 the "Wound Care Specialist Evaluation" described Resident A's left lateral ankle was a "Stage 4" and measuring as "2.3 x 2 x 0.1 cm." Documentation indicated the wound was debrided, a fifth time, via surgical excision and muscle removed along with necrotic tissue.
Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "A Registered Dietician will assess all residents identified with skin impairment for nutritional status in a timely manner."
Review of Resident A's clinical record revealed he was seen by a Registered Dietician (RD) on 6/3/2015, 20 days after the development of the pressure ulcer on his left outer ankle.
During an interview with the DON, on 8/27/2015 at 11:10 a.m., she stated the RD comes into the facility "three times a week."
During an interview with the DON, on 11/13/2015 at 10:10 a.m., she confirmed Resident A should have been seen by the RD "ideally when the wound gets worse." The DON confirmed Resident A should have been seen by the RD the week of 5/18/2015.
During an interview with Treatment Nurse 1, on 11/3/2015 at 10:20 a.m., she stated she verbally notified the RD, by phone, of Resident A's ankle wound as documented on Resident A's "Skin-Weekly Pressure Ulcer Record" dated 5/18, 5/26 and 6/6/2015. Treatment Nurse 1 was asked why Resident A was not seen earlier by the RD but Treatment Nurse 1 did not know why.
During a telephone interview with the RD, on 11/3/2015 at 11:58 a.m., she stated that the treatment nurses never verbally talks to her. The RD stated, "They don't personally call me or email me." The RD also stated the treatment nurses write that they notify her "all the time" but they don't. The RD stated, "They don't call me." The RD could not remember why she did not see Resident A sooner. The RD stated sometimes she'd get a skin sheet with residents' names on who needs to be seen but this skin sheet is "not given all the time." The RD stated she may get it once a week if the Licensed Nurses remember to give it to her.
Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "The Licensed Nurse will document daily monitoring of all pressure ulcers on the Treatment Administration Record (TAR)."
Review of Resident A's May and June 2015 TARs revealed no documentation that Licensed Nurses (LN) conducted daily monitoring of Resident A's pressure ulcer on his left outer ankle.
During an interview with the DON, on 8/27/2015 at 11:10 a.m., she confirmed there was no documentation on Resident A's May and June 2015 TAR that the LNs conducted daily monitoring of Resident A's pressure ulcer on his left outer ankle, per the facility's policy.
Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "A physician's order will be written to monitor each ulcer and documentation on the TAR will reflect the status of the dressing, surrounding skin color and skin and pain associated with the wound. The Licensed Nurse will record: Plus sign (+) if there are no observed abnormalities or changes to the dressing, skin or pain associated with the wound. Minus sign (-) if abnormalities or changes to the dressing, skin or pain associated with the wound are present/observed. If any abnormalities are observed, document a descriptive note of findings and the Licensed Nurses responses in the Nurses notes section of the resident's medical record. The Licensed Nurse will record his/her initials on the TAR to reflect the monitoring of each wound regardless of findings."
Review of Resident A's clinical record revealed no physician's order to monitor Resident A's left outer ankle pressure ulcer. Review of Resident A's May and June 2015 TARs revealed no documentation to reflect the status of the dressing, surrounding skin color and skin and pain associated with Resident A's left outer ankle pressure ulcer.
During an interview with the DON, on 8/27/2015 at 11:10 a.m., she confirmed there was no physician's order written for Resident A's left outer ankle pressure ulcer to be monitored, per the facility's policy. She also confirmed there was no documentation to reflect the status of the dressing, surrounding skin color and skin and pain associated with Resident A's left outer ankle pressure ulcer on the May and June 2015 TARs.
Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "Skin assessment findings will be documented weekly on the Head to Toe Skin Check form."
Review of Resident A's clinical record revealed there was no documentation that a "Skin-Head to Toe Skin Check" form was completed weekly, per the facility's policy.
During an interview with the DON, on 8/27/2015 at 11:10 p.m., she confirmed a "Skin-Head to Toe Skin Check" form was not completed for Resident A on the following weeks: 3/15-3/21/2015, 3/22-3/28/2015, 3/29-4/4/2015, 4/5-4/11/2015, 4/19-4/25/2015, 5/10-5/16/2015 and 5/17-5/23/2015.
Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "Weekly Skin Check" will be transcribed onto the Treatment Record including the day and shift on which the check will be conducted."
Review of Resident A's May and June 2015 TARs revealed no documentation Resident A's "Weekly Skin Check" was transcribed onto the Treatment Record including the day and shift on which the check was conducted.
During an interview with the DON, on 8/27/2015 at 11:10 a.m., she confirmed there was no documentation Resident A's "Weekly Skin Check" was transcribed onto Treatment Record including the day and shift on which the check was conducted, per the facility's policy.
Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "Completion of the weekly skin assessment will be noted on the Treatment Administration Record (TAR) with the Licensed Nurse's initials."
Review of Resident A's May and June 2015 TARs revealed no documentation that the completion of Resident A's weekly skin assessment was noted on the TARs with the LN initials, per the facility's policy.
During an interview with the DON, on 8/27/2015 at 11:10 a.m., she confirmed there was no documentation that the completion of Resident A's weekly skin assessment was noted on the TARs with the LN initials, per the facility's policy.
The Department determined that the facility failed to ensure Resident A did not develop an avoidable pressure ulcer.
The Department determined that the facility failed to ensure Resident A did not develop an avoidable pressure ulcer.
These violations, separately or jointly, presented either;
(1) Imminent danger that death or serious harm to the patients or residents of long-term health care facility would result there from or
(2) Substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result there from. |
| 030000820 |
Manorcare Health Services (Citrus Heights) |
030012933 |
B |
3-Feb-17 |
YS2211 |
4636 |
F205 - CFR 483.12
(b)(1)&(2) Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility, and the nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return.
At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section.
An unannounced visit was made to the facility on 3/16/2016 to investigate two (2) complaints #CA00480931 and #CA00496976.
The Department determined the facility failed to:
Provide a 7 day bed-hold to Resident 1's Responsible Party when Resident 1 was transferred to a General Acute Care Hospital (GACH 2).
These failures had the potential to increase emotional distress for Resident 1 and worry to family members.
According to the record of admission, Resident 1 was an 83 year old admitted to the facility in late February from the GACH 1 with dementia (a general term for a decline in mental ability severe enough to interfere with daily life) and Alzheimer's (a type of dementia that causes problems with memory, thinking and behavior).
During a telephone interview on 3/15/2016 at 9:20 a.m., Resident 1's family member stated "...on 3/11/2016 we received a Three Day Notice of transfer/discharge to another facility to occur on 3/14/2016. We are not happy with the decision and would like more time to find a more appropriate home for [Resident 1]."
During an interview on 3/15/2016 at 1:15 p.m., the Social Services Assistant (SSA) stated they [the facility] "have exhausted options for the resident... We have sent requests all over Sacramento and Roseville... Either there are no beds or they are not a locked facility... Resident 1 has a bed at [named skilled nursing home] and [named locked assisted living facility]...the family would have to pay for the [assisted living facility] until Medi-Cal kicked in and they could then apply for a waiver... Family said they cannot afford."
During an interview on 3/15/2016 at 1:30 p.m., the Administrator (ADM) stated "... I have rescinded the Three Day Notice to allow the family more time to find a place for [Resident 1]."
During a telephone interview on 3/16/2016 at 11:15 a.m. with Resident 1's family member, they stated Resident 1's Responsible Party received a new Three Day Notice of transfer/discharge to occur on XXXXXXX2016 to the same alternate facility in the prior notice.
Review of Resident 1's clinical record document titled Progress Notes, dated 3/25/2016 at 12:27 p.m., indicated Resident 1 was transferred to the GACH 2 for medical management to "stabilize acute behaviors."
On 3/28/2016 at 2:10 p.m. during a telephone interview with the facility ADM, the ADM stated "I did not issue a bed hold for the resident because we were not going to take him back."
Review of facility document titled Bed Hold Agreement revised 9/2011 indicated "If I am away from the Center for more than 24 hours, I will be offered the option to pay for a bed hold to hold my bed and retain my belongings in the Center".
Review of California Code of Regulations, Title 22, Chapter 3 Skilled Nursing Facilities, Article 5 Administration, 72520 Bed Hold, "(a) If a patient in a skilled nursing facility is transferred to a general acute care hospital... the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or the patient's representative... (b) Upon admission of the patient to the skilled nursing facility and upon transfer of the patient of a skilled nursing facility to a general acute care hospital, the skilled nursing facility shall inform the patient, or the patient's representative, in writing of the right to exercise this bed hold provision."
Therefore, the Department determined the facility failed to provide a 7 day bed hold to Resident 1's Responsible Party when Resident 1 was transferred to a General Acute Care Hospital (GACH 2).
This violation had a direct or immediate relationship to the health, safety, or security of the long-term care facility patients or residents. |
| 030001168 |
Mid-Town Oaks Post-Acute |
030013121 |
B |
14-Apr-17 |
4H6V11 |
2611 |
F206 - Policy To Permit Readmission Beyond BedHold
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 following citation is written as a result of complaint #CA00499785. Unannounced visits were made to the facility on 8/25/16, 8/26/16, and 8/30/16, to investigate failure to readmit.
The Department determined the facility failed to readmit Resident 1 to the first available bed in when the facility had available beds on 13 days.
Resident 1 was admitted to the facility with diagnoses that included; end stage renal disease (kidney failure) and osteomyelitis (infection of the bone).
Review of the Resident Face Sheet for Resident 1 indicated he/she had insurance coverage with both Medicaid and Medi-Cal.
Review of Resident 1's clinical record documented:
Resident Progress Notes dated 7/25/16 at 1:14 a.m., indicated, "Patient [resident] c/o [complained of] pain radiating to right arm noted with weakness on the right arm. ...NP [Nurse Practitioner] aware with an order...send [Resident 1] to the ER [emergency room] for further evaluation and treatment. ...Patient [resident] transferred to [acute care facility] by [ambulance] around 1:05 a.m. via [by way of] gurney."
General Order dated 7/25/16 at 12:45 a.m., indicated an order, "Ok to send patient [resident] to ER for further evaluation and treatment may hold bed x [times] 7 days if applicable."
General Order dated 8/1/16 at 10:50 a.m., indicated an order, "Discharged".
In a telephone interview with the Acute Care Case Manager (ACCM) on 8/25/16 at 8:45 a.m., she said her associate contacted the skilled nursing facility (SNF) on 8/4/16 and was told there were no available beds for Resident 1. The ACCM said she called the SNF on 8/5/16 and the Social Services Assistant (SSA) told her there were no available beds. The ACCM related as of this date (8/25/16), the SNF continued to say there were no available beds.
Review of the acute care Clinical Management Progress Note for Resident 1, dated 8/1/16 at 1:35 p.m. indicated, "Per clinical care team patient [Resident 1] ready for transfer back to [SNF]." It further stated that when the SSA at the SNF was contacted, "She said his 7 day bed hold was up and [she] has no bed available to take this patient [Resident 1] today." |
| 100000107 |
Modesto Post Acute Center |
040010229 |
B |
22-Oct-13 |
Q2LP11 |
5950 |
CLASS B CITATION-QUALITY OF CARE CFR 483.25(h) Accidents (1) AND (2) ACCIDENTS AND SUPERVISION The facility failed to ensure Resident (Res) 1 was provided an environment that was free from accident hazards and provided supervision and assistive devices to prevent avoidable accidents when Resident 1 fell from a mechanical lift and was injured. On 3/14/13 an initial investigation was conducted of Entity Reported Incident #CA00345578, regarding an accident involving a mechanical lift. The facility failed to: Ensure Resident 1 received and was provided adequate care and equipment to ensure a safe environment when Certified Nursing Assistant (CNA) 1 and CNA 2 failed to ensure the total body lift used to transfer Resident 1 from the bed to the chair was used according to manufacturer instructions.Resident 1 was admitted to the facility on 3/9/04 with diagnoses that included Right Hemiplegia (inability to move a group of muscles in one side of the body), Cerebral Vascular Accident (stroke,) and Dementia (loss of cognitive ability).Res 1's Quarterly Minimum Data Set (MDS) assessment (a tool used to perform a basic total assessment) dated 12/21/12, indicated he had been totally dependent on facility staff for all transfers. Res 1 had been unable to communicate, had contractures (muscle wasting and inability to move) of both legs, and had uncontrolled movement of his arms. Res 1 had required the transfer assistance of two staff using the mechanical body lift (equipment that assisted with body transfer).On 3/15/13 at 8:45 a.m., during an interview, Certified Nurse's Assistant (CNA) 1 stated on 3/2/13 at 6:40 a.m., she and CNA 2 had lifted Res 1 out of bed and transferred him to the Geri chair (special chair with high back for supporting residents) with the mechanical body lift. CNA 1 stated the sling "broke" while Res 1 had been suspended in the air. CNA 1 stated after the sling had broken, Res 1 immediately fell to the floor and hit his head on the ground.On 3/15/13 at 9 a.m., during a telephone interview, CNA 2 stated she had assisted CNA 1 with Res 1's transfer from the resident's bed to the Geri chair on 3/2/13 at 6:40 a.m. CNA 2 stated Res 1's transfer had been assisted by use of the total body lift. CNA 2 stated while Res 1 had been suspended in the air the sling had broken and Res 1 had fallen to the floor and hit his head.On 3/15/13 at 9:15 a.m., during an interview, Licensed Nurse 1 (LN 1) stated she had been the charge nurse on duty responsible for Resident 1 on 3/2/13. LN 1 stated she had observed Res 1 on the floor soon after the fall. She notified the physician and Res 1 had been taken by ambulance to the emergency room at the acute care hospital where he had been evaluated for neurological and other possible injuries and admitted for care. On 3/15/13 at 9:55 a.m., during an observation and concurrent interview in the Administrator's office, the Administrator retained and identified the sling which had been used on the mechanical body lift on 3/2/13. The sling had a broken strap at the shoulder level on one side. The Administrator identified the sling as the same sling which had been used on the total body lift to transfer Res 1 when he fell on 3/2/13. When the sling was viewed, the Administrator stated the sling was visibly frayed. The strap on the sling was observed as visibly frayed on both sides. During the interview the Administrator stated the Director of Nurses (DON) had previously shared the results of her investigation into Res 1's fall with him. The Administrator stated the DON had specifically told him the CNAs involved in the transfer of the resident told her they had noticed the sling was frayed before they used it on the lift, but the staff had decided to use it anyway as they thought " it would hold."Review of Res 1's clinical record, Emergency Department " Provider Notes" dated 3/2/13, indicated [Resident 1] S/P [status post] fall/dropped by SNF [skilled nursing facility] staff...Subdural hematoma (a collection of blood in the lining of the brain) on CT [computerized tomography]...will admit to hospitalist [medical doctor assigned to care for patients in the hospital] for further evaluation and observations monitoring and treatment...". On 3/15/13 at 3 p.m., during an interview, the Central Supply Supervisor (CSS) stated at the Safety Committee meeting in January 2013, she and the Administrator had discussed the need to buy more slings for the total body lifts because there were not enough slings available for staff to use. The CSS stated there had been a shortage of slings and she was to check the slings to determine how many needed to be replaced. The CSS stated she had not examined all of the slings to determine how worn the slings were.On 3/15/13 at 12:05 p.m., during an interview, the Administrator stated the facility was using the "Maxi Twin" (mechanical body lift) "Instructions for use" as the facility's policy and procedure for use of the lift. The Manufacturer's "Instructions for use" indicated on page 8, "Pre-inspect the sling prior to use. If any part is missing or damaged - do NOT use the product!" Also on page 40, "Visually check the slings. Check for fraying, holes, cuts, loose stitching and damaged plastic clips. If the sling is found damaged in any way, take out of use immediately and replace the sling."The facility failed to ensure the "Max Twin" which had visible frayed straps on both sides was taken out of use immediately and replaced prior to transferring Resident 1. As a result, Resident 1 had fallen approximately three feet from the total body lift to the ground. Resident 1 had been transported by ambulance to the emergency room at the hospital, and admitted for tests, observation and monitoring. Resident 1 sustained a subdural hematoma brain injury. The above violation had a direct or immediate relationship to the client's health, safety, or security, and therefore constitutes a Class 'B' Citation. |
| 040000034 |
MADERA REHABILITATION & NURSING CENTER |
040010905 |
B |
04-Aug-14 |
E50111 |
6456 |
The facility must ensure that resident environment remains free of accidents as possible, and each resident receives adequate supervision and assistance devices to prevent accidents. These practices include, but are not limited to, the following: (h) (2) SupervisionThe Entity Reported Incident CA00386649 was investigated during an on-site visit on 2/14/14. The following reflects the findings of California Department of Public Health during the investigation of Entity Reported Incident: CA00386649. Representing the Department of Public Health by Federal I.D. 28502.The facility failed to provide the supervision necessary to prevent an avoidable accident, when Resident 1 had been left unsupervised standing alone without assistance. This resulted in a fall that caused a fracture of Resident 1's left wrist.Resident 1 was a 67 year old female who was admitted to the facility on 12/18/13. Resident 1 had diagnoses that included: a history of multiple falls, osteoporosis (brittle bones), osteoarthritis, hypertension (high blood pressure), and dizziness. Resident 1's "Nursing Admission Assessment" dated 12/18/13, indicated Resident 1 had poor safety judgment, impaired balance, unsteady gait, was at risks for falls, and required extensive assistance for toileting. Resident 1's Minimum Data Set assessment (MDS) (a federally mandated assessment of residents in a nursing home to identify functional abilities and health problems) ... "Functional Status" dated 1/1/14, indicated, "Balance during transition and walking...only able to stabilize with staff assistance." Resident 1's "Care Plan....Impaired physical functioning," dated 12/26/13, indicated that ambulation, transferring, and locomotion required the assistance of one to two Certified Nursing Assistants (CNA).On 2/14/14 at 10 a.m., during an interview, in the conference room (with an interpreter), Resident 1 stated she remembered the night she fell. Resident 1 stated CNA 1 had been assigned to her. Resident 1 stated CNA 1 had not worked with her before. Resident 1 stated she had gone to the bathroom with the assistance of CNA 1. Resident 1 stated when she was done in the bathroom CNA 1 started to assist her back to her bed. CNA 1 had been holding on to Resident 1's arm. Resident 1 stated she was unsteady on her feet and needed someone to keep her from losing her balance. Resident 1 stated outside the bathroom CNA 1 had let go of her and instead of helping her back into bed, had turned to close the bathroom door. Resident 1 stated she fell forward and put her hands out to try and stop the fall. Resident 1 stated she fell with her full weight on her hands. Resident 1 stated she believed that CNA 1 had been careless and if CNA 1 had held on to her she would not have fallen.On 4/28/14 at 3 p.m., during a telephone interview, CNA 1 stated on the evening of 2/1/14 she had been assigned to work with Resident 1. CNA 1 stated she knew a little about Resident 1 but was not usually assigned to this resident. CNA 1 stated she had put a "Gait Belt" (a large strap wrapped around the waist of a resident in order to maintain balance) on Resident 1 to walk her to the bathroom. CNA 1 stated after Resident 1 had finished in the bathroom she got Resident 1 up and walked Resident 1 to the sink outside the bathroom and told the resident to "Hold on to the sink." CNA 1 stated she had let go of the gait belt when she turned her back away from Resident 1 to close the bathroom door. CNA 1 stated when she turned back around Resident 1 had been on the floor. On 7/1/14 at 10:30 a.m., during a telephone interview, Resident 1 stated CNA 1 had not used a gait belt while walking her to the bathroom. Resident 1 stated when CNA 1 had begun to walk her back to the bed, CNA 1 stopped in the middle of the room. Resident 1 stated CNA 1 did not say why she stopped... CNA 1 did not ask Resident 1 to hold on to a sink, or the walker and did not ask her to "Wait." Resident 1 stated she put her arm behind herself to try and feel for CNA 1. Resident 1 stated she was standing alone in her room between the bathroom and her bed. Resident 1 stated she was not close enough to the bed to touch it, lean on it, or sit on it. Resident 1 stated she was unsteady standing alone and started to fall forward. To keep from hitting her head on the floor Resident 1 put out both her hands in front of her. Resident 1's left wrist was fractured when she hit the floor. Resident 1's MDS assessment dated 1/1/14, indicated, "Balance During Transitions and Walking...not steady, only able to stabilize with staff assistance...transfers." Facility document titled, "Physical Therapy Note" dated 1/21/14, indicated, "Treatment Diagnosis: Difficulty Walking...Muscle Weakness." Resident 1 required tactile cues for proper form...ambulation...with "Contact Guard Assistance" (routinely requires contact with resident due to unsteadiness during transfer)...with jerky starts and stops with shuffling feet." The facility document titled, "Interdisciplinary Team Notes" dated 2/5/14, indicated on 2/1/14 Resident 1 had been taken to the bathroom by CNA 1. Resident 1 called for CNA1 when she had finished in the bathroom. CNA 1started to assist Resident 1 back to bed (approximately 10 feet from bathroom door to end of Resident 1's bed). Before Resident 1 and CNA1 had reached Resident 1's bed, CNA 1 turned around to go close the bathroom door. After CNA 1closed the door she turned back around to Resident 1 when she had saw Resident 1 had fallen. The document indicated Resident 1 had put out her hands to try to stop the fall, and Resident 1's wrist had been fractured in the fall. The facility administrative document titled, "Fall Prevention and Incident Management" dated 4/1/01, indicated, "It is the policy of this facility to identify residents at risk for fall and or accidents which the facility has control over by planning interventions and implementing procedures to prevent fall and or accident...to protect the safety of our residents." Therefore the facility failed to provide the supervision necessary (as indicated in Resident 1's risk assessments) to prevent injury to Resident 1, when Resident 1 was left unsupervised resulting in a fall causing a fracture of Resident 1's left wrist. The above violation either jointly, separately or in any combination had a or immediate direct relationship to the clients health, safety and well- being and therefore constitutes a Class "B" Citation. |
| 040000036 |
Manning Gardens Care Center, Inc. |
040010976 |
B |
03-Sep-14 |
8V8E11 |
10689 |
F325:483.25(i) MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE Based on a resident's comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem.The facility violated the aforementioned regulation by failing to provide Resident 1 with adequate calories to maintain normal body weight or sustain life. Resident 1 experienced dysphagia (difficulty swallowing) and was unable to take any food or fluids orally. Resident 1 was totally dependent upon the facility to provide nutrition through a gastrostomy (stomach) tube. The facility provided a total of 720 calories per day through the tube; an inadequate amount to maintain a normal body weight. As a result, Resident 1 suffered a severe weight loss (greater than 10 percent of body weight over a six month period of time). The severe weight loss of 14.6 pounds and 12.8 percent of her body weight over six months exposed Resident 1 to potential harm from potential development of pressure sores, further decline and death. Review of Resident 1's clinical record indicated Resident 1 had been admitted to the facility on 7/12/12. Resident 1 was 59 years old with diagnoses that included dementia (a cognitive disorder), anxiety, depressive disorder, Alzheimer's Disease (a cognitive disorder marked by confusion), pseudobulbar affect (disorder characterized by involuntary episodes of crying or laughing), dysphagia, gastrostomy status, and altered mental status. Resident 1 had been receiving hospice care for "terminal Alzheimer's Disease" beginning 6/13/13. On 6/30/14 at 1:10 p.m., during an observation in Resident 1's room, a 1000 milliliter (ml) plastic bottle labeled, "Jevity 1.2" (a formula feeding that supplies 1.2 calories per ml and is used for people with feeding tubes inserted into the stomach) hung on a pole and was attached to a pump to deliver the feeding at a specific rate. The feeding pump was set to deliver 30 ml per hour. The pump had been delivering the feeding into Resident 1's gastrostomy tube (G-tube, a tube inserted into the stomach). Resident 1 was lying in bed with eyes open, was thin and did not respond to questions. Review of Resident 1's physician orders dated 12/29/13 indicated, "Glucerna 1.2 [tube feeding that provides 1.2 calories per ml] 55 cc [cc equals ml] /hr X 20 HRS [hours] enteral [stomach] tube to provide 1320 calories [per day]." Review of Resident 1's physician orders dated 2/18/14 indicated a change from Glucerna 1.2 at 55 cc per hour for 20 hours to Glucerna 1.2 at 40 cc per hour for 20 hours per day by enteral tube to provide 960 calories per day.Review of Resident 1's physician orders dated 6/18/14 indicated a change from Glucerna 1.2 at 40 cc per hour for 20 hours to Jevity 1.2 (tube feeding that supplies 1.2 calories per ml) at 30 cc per hour for 20 hours per day by enteral tube to provide 720 calories per day.Review of Resident 1's physician orders for 6/1/14 through 6/30/14 indicated Resident 1 had no orders for food by mouth and had received nutrition through the G-tube only. On 7/1/14 at 2:10 p.m., during an interview, the facility consultant Registered Dietician (RD) stated he did not know why the tube feeding had been decreased to 30 ml/hr for Resident 1. The RD stated the hospice nurse had not communicated with him regarding decreasing the rate of the feeding. The RD stated 30 ml/hr for 20 hours of Jevity 1.2 would only provide Resident 1 with 720 calories per day and it would not be enough calories to maintain a normal weight for Resident 1. The RD stated, "It is starvation really." The RD stated Resident 1 had a significant weight loss of 12.8% of body weight over the past six months due to the low calorie feeding regimen. The RD stated, "I made a recommendation to increase calories on 6/8/14 [23 days earlier] when I saw the weight loss. Even 960 calories was not adequate. Today I found out hospice decreased the feeding even more, down to 30 ml/hr [720 calories per day]. They did not notify me or consult me or take my recommendations. She [Resident 1] will continue to decline just from inadequate calories." The RD stated Resident 1 was 50 inches tall and should have weighed between 104 and 114 pounds for ideal body weight. The RD stated Resident 1 needed 25 calories per kilogram (1 kilogram equals 2.2 pounds) of ideal body weight daily to prevent weight loss. The RD stated Resident 1 needed a minimum of 1181 calories daily based on a minimum ideal body weight of 104 pounds (47.2 kilograms). The RD stated Resident 1 had been receiving only 720 calories per day (15 calories per kilogram of ideal body weight).Review of Resident 1's clinical record, "Progress Note" written by the RD dated 6/8/14 indicated, "Wt. 99.2# [pounds] on 6/3/14; -[lost]4.8# in one month and -[lost]14.6# (12.8%) over 6 mos [months] noted as she continues to decline on Hospice low Calorie feeding regimen. Tolerates feeding well....Skin is at risk. Nutritional status is gradually declining due to low level feeding...Recommend feeding rate increase to 50 ml/hr..." Review of Resident 1's "monthly weight report" indicated Resident 1's weight as follows:1/2/14 - 114.2 pounds (lbs.) 2/3/14 - 113.6 lbs. 3/4/14 - 106.2 lbs. 4/1/14 - 104.2 lbs. 5/1/14 - 104.0 lbs. 6/1/14 - 99.2 lbs. On 7/1/14 at 3:15 p.m., during an interview, the hospice medical director (MD) 1 stated he was not sure why the tube feeding had been decreased to 720 calories per day. MD 1 stated tube feedings were sometimes decreased if a resident was unable to tolerate the amount of the feeding. MD 1 stated the decrease in feeding would have been done on the recommendation of the hospice nurse. On 7/1/14 at 3 p.m. during an interview, the Director of Nursing ( DON) stated review of Resident's 1's nursing notes over the past 6 months from January 2014 through June 2014 indicated the resident had tolerated tube feedings without difficulty. The DON stated the nurse's notes indicated Resident 1 had not had any complications from the tube feeding such as vomiting, diarrhea or difficulty absorbing the feeding. The DON stated resident weight loss was usually reviewed by the facility's Quality Assessment and Assurance committee (QAA), (a committee to identify problems and create solutions) but Resident 1's weight loss had not been reviewed because she was on hospice care. The DON stated, "Hospice writes the orders and we carry them out. They are responsible for writing orders."On 7/2/14 at 12:15 p.m., during an interview in the DON's office, Hospice Nurse (HN) 1 stated Resident 1 had not had trouble tolerating the tube feeding. HN 1 stated the tube feeding was decreased to 720 calories per day without consulting the facility RD or the hospice staff RD who was available to advise regarding nutritional requirements. HN 1 stated there was no hospice policy regarding reducing tube feedings to a low level and had no knowledge of any research that indicated it was beneficial to the resident. HN 1 stated the reason the feeding was decreased was Resident 1's family had difficulty deciding to discontinue feedings completely so the decision was made by hospice and the facility to decrease the amount of the feeding. HN 1 stated the effect of the low calorie feeding would be the resident would decline (physical condition would worsen). HN 1 stated, "She will decline overall. I expect all my clients to decline." HN 1 stated she had not reviewed the facility consultant RD's progress note of 6/8/14. On 7/3/14 at 10:15 a.m. during a phone interview, hospice nurse (HN) 2 stated there was no policy or procedure that indicated a low calorie feeding of 720 calories per day was beneficial for Resident 1. HN 2 stated the low calories could place Resident 1 at risk for skin breakdown and the development of pressure ulcers.On 7/7/14 at 9:40 a.m., during a phone interview, the facility Medical Director (MD) 2 stated family conflict was not a medical reason to lower a tube feeding to a level inconsistent with maintaining normal weight. MD 2 stated she did not see how lowering the tube feeding to 720 calories per day would have had any benefit for the resident. MD 2 stated she expected the Registered Dietician and the Resident's personal physician to be consulted before the feeding was lowered. MD 2 stated the facility should have notified her of Resident 1's significant weight loss and it should have been reviewed in the QAA committee.Review of professional reference, "Weight Loss in the Elderly: What's Normal and What's Not", Michael Lewko, M.D. P&T (Pharmacy and Therapeutics), November 2003, Vol. 28, No.11, indicated, "A weight loss greater than 5% over six months should be investigated...The first steps in managing patients with weight loss are to identify and treat any specific causative or contributing conditions and to provide nutritional support when indicated...Some of the consequences of IWL [involuntary weight loss] include: anemia, decreased cognition, edema, falls, hip fractures, immune dysfunction, infections, muscle loss, osteoporosis and pressure sores." Review of professional reference, "Older Adult Health Facts" http://www.health.gov.dietary guidelines/dga2005/toolkit/older adults/OAnutrition.htm, "Estimated Calories Needed by Gender, Age, and Activity Level" indicated the daily caloric needs for a sedentary female age 51 or older was 1,600 calories daily.Review of Resident 1's "Physician Orders for Life Sustaining Treatment" (a legal document that indicates the Resident or their legally responsible party's (RP) directions for care in the event the Resident cannot speak for themselves) dated 12/12/2013 and signed by Resident 1's RP indicated, "C- Artificially Administered Nutrition: Long-term artificial nutrition, including feeding tubes." On 7/1/14 at 4:05 p.m. during a phone interview, Resident 1's RP stated, "They [hospice] told me it was comfort care and I just want her comfortable. I don't want to stop treatment. I just want her comfortable. I never told them to stop care. They told me she has lost weight because her stomach doesn't work anymore." The facility failed to provide Resident 1 with adequate calories to supply needed nutritional requirements. Resident 1 had a severe weight loss of 12.8% of her body weight over 6 months. This weight loss placed Resident 1 at risk for skin breakdown, pressure sores, decline and death. These violations had a direct relationship to the health of Resident 1 and thereby constitute a Class B Citation. |
| 040000036 |
Manning Gardens Care Center, Inc. |
040013358 |
B |
26-Jul-17 |
0PDX11 |
20211 |
Class B CITATION -
F 201 CFR 483.15(c)(1)(i)(ii) Transfer & Discharge
(1) Facility requirements
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) 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;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) 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. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.
F 203 483.15(c)(3) Notice Before Transfer
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer of discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.
483.15(c)(4) Timing of the notice
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered, under paragraph (c)(1)(ii)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c) (1)(ii)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(ii)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (C)(1)(ii)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.
483.15(c)(5) Contents of the notice.
The written notice specified in paragraph (C)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone of the Office of the State Long Term Care Ombudsman;
483.15(c)(6) Changes to the notice
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.
F 204 CFR 483.15(c)(7) Orientation for Transfer or Discharge
A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.
Title 22, Section 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 of discharge. Such actions shall be documented in the patient's health record.
On 4/28/17 an unannounced visit was made to the Skilled Nursing Facility (SNF) to investigate Complaint CA 00534476 regarding an allegation of resident discharge rights.
The facility failed to ensure Resident 2 or his Responsible Party (RP) received a 30 day notice of discharge that included Resident 2's right to appeal the discharge to the State and failed to ensure sufficient preparation and orientation for a safe and orderly discharge from the facility. Resident 2, who had cognitive (pertaining to memory, reasoning and judgement) impairment, was discharged from the SNF without providing a 30 day notice of discharge to his RP. Resident 2 was discharged from the SNF to a room and board (R&B, an unlicensed home that provides food and lodging, and requires residents to be independent). The SNF assessed Resident 2 at the time of discharge to require 24 hour nursing care and insulin (hormone that lowers blood sugar levels) injections four times a day to treat his medical condition and the R&B did not have staff on duty 24 hours a day or staff who could administer injections. Resident 2 was discharged from the SNF into the care of the owner of R&B 1 who soon determined Resident 2 needed a higher level of care than R&B 1 could provide. The owner of R&B 1 transferred Resident 2 to R&B 2 (also a home which only provides meals and a room). The facility failed to verify the level of care provided by an R&B upon discharge and incorrectly identified the R&B as a Board and Care (B&C, licensed homes staffed with caregivers 24 hours a day/seven days a week) and as an Assisted Living home (housing for elderly or disabled that provides nursing care, housekeeping, and prepares meals).
As a result of these failures Resident 2 was discharged from the SNF to a lower level of care, (R&B), without verification that Resident 2's needs could be met or the care and services that Resident 2 needed was available. Resident 2 fell in the less supervised setting of the R&B, was transferred to the acute care hospital (ACH), and underwent major surgery to repair a fractured hip sustained in the fall. Resident 2's RP was denied the right to advocate for Resident 2 and to appeal the discharge. Resident 2's RP was not notified of Resident 2's new residence until three days after the discharge occurred.
Resident 2's face sheet indicated Resident 2 was 82 years old at the time of discharge from the SNF. Resident 2 was admitted to the facility on XXXXXXX15 and resided in the facility a total of 761 days. Resident 2's diagnoses while a resident at the SNF included dementia (disorder characterized by gradual loss of memory, judgement and reasoning), fracture of the right hip, diabetes mellitus (disorder which causes high blood sugar due to insufficient production of the hormone insulin), and psychosis (a mental disorder characterized by behaviors indicating loss of reality). The face sheet indicated Resident 2's family member, (FM), was the RP to be contacted for notifications regarding Resident 2's care.
Resident 2's Minimum Data Set (MDS) (a resident assessment tool used to plan care) assessment dated 11/5/16, indicated Resident 2 had moderately impaired cognitive function and was totally dependent on staff for toilet use and bathing.
Resident 2's SNF care plan, dated 1/5/15, indicated, "Residents condition requires long-term care. Resident requires 24/7 nursing care ..." The care plan, dated 1/29/15, indicated, "Resident is at risk for elopement [leaving the facility without permission or supervision] ...wandering with poor safety awareness ..." The care plan, dated 1/15/15, indicated, "The resident uses physical restraints WanderGuard (alarmed device to alert staff when resident wandered near an exit door) ..." The care plan, dated 1/12/15, indicated the resident was Spanish speaking.
Resident 2's Physician's order, dated 1/5/15, indicated Resident 2 was to wear a WanderGuard alarm at all times due to Resident 2's high risk for elopement and a bed alarm was required due to poor safety awareness.
Resident 2's physician's orders, dated 7/29/16, indicated insulin injections four times a day were required to manage his diabetes.
Resident 2's physician discharge order, dated 2/2/17, indicated, "May discharge to [R&B 1] on 2/3/17 with medications, home health R.N. [registered nurse] evaluation, wheelchair, and P.T [physical therapy]. The physician order for discharge did not include the level of care Resident 2 would require upon discharge.
Resident 2's face sheet indicated Resident 2 was discharged on XXXXXXX17 (to R&B 1).
On 4/28/17 at 9 a.m., a telephone interview with a Social Worker for the [name of county] Department of Social Services (SWFDSS) was conducted. The SWFDSS stated Resident 2 was discharged from the SNF to the care of R&B 1 on XXXXXXX 17. The SWFDSS stated the owner of R&B 1 transferred Resident 2 to the care of R&B 2 (owned and operated by different people at another location). The owner of R&B 2 applied for In-Home Supportive Services (IHSS, subsidized in-home care) for Resident 2. The SWFDSS stated she was involved in screening residents for IHSS care. The SWFDSS stated she was contacting APS regarding concern of appropriate placement of Resident 2 in a room and board facility.
On 4/28/17 at 1:45 p.m., during an interview, the Director of Nursing (DON) stated she was aware the Assistant Administrator (AA) of the SNF made the decision to discharge Resident 2 to a place the AA called an Assisted Living. The DON stated she was not aware of the difference in the level of services provided by an Assisted Living as opposed to an R&B. The DON stated she did not have any input on deciding resident discharge. The DON stated, "If I said no [to a discharge] because the resident is not medically safe or with wounds, the AA will over-ride my decision."
On 4/28/17 at 1:50 p.m., during an interview, the AA referred to R&B 1 as "an Assisted Living facility." The AA stated she was not aware of the care and services provided at R&B 1. The AA stated Resident 2 was discharged from the facility because he was functioning well and able to ambulate (walk).
On 4/28/17 at 2 p.m., during an interview, the Social Services Designee (SSD) referred to R&B 1 as "an Assisted Living Facility." The SSD stated she had never been there and did not know the level of care R&B 1 provided.
On 5/1/17 at 9:20 a.m., during a telephone interview, the SWFDSS stated Resident 2 had fallen at R&B 2 and was at the ACH for treatment.
On 5/1/17 at 11:15 a.m., R&B 2, where Resident 2 resided, was visited. A woman that identified herself as a resident in R&B 2 allowed surveyors to enter the home. There were no care givers present. Resident 2 was not at R&B 2 on 5/1/17.
Resident 2's ACH Emergency Department (ED) record dated 4/28/17, indicated Resident 2 arrived to the ACH on 4/28/17 at 11:18 a.m. The ACH record indicated, "Chief Complaint - Patient presents with Pain - Leg...brought in by ambulance, presents to ED with s/p [status post] unwitnessed fall this morning. Per EMS [emergency medical services] report staff noticed patient on the floor in his bedroom [at R&B 2]. Unknown down time." The ACH ED record dated 4/28/17 at 1:09 p.m., indicated, "Imaging [X-ray] XR [X-ray] bilateral [both] hip...Lt [left] hip fx [fracture]." The ACH record indicated Resident 2 had undergone surgery 4/29/17, to repair the left hip fracture.
On 5/1/17 at 3:10 p.m., during an observation and concurrent interview, Resident 2 was observed in a room at the ACH. The ACH Interpreter services were engaged to attempt to communicate (in Spanish) with the Resident. Resident 2 did not make eye contact and did not make any recognizable verbal or nonverbal effort to communicate.
On 5/2/17 at 11:12 a.m., during an interview and concurrent record review, the SSD stated she had met the owner of R&B 1. The SSD provided the flier that R&B 1's owner handed out when he visited the SNF. The flier indicated, "...Our guests are independent and are people who wish to live in a "clean and sober" environment. Our house provides 3 meals per day, laundry, phone and other services..." The SSD stated she had not visited or otherwise validated the services provided at R&B 1. The SSD stated Resident 2 did not have good safety awareness, was not independent and would not be safe without supervision at the time of discharge. The SSD stated Resident 2's condition had not significantly improved during his stay in the SNF. The SSD stated there were no resident assessments to verify Resident 2's physical or medical condition drove the need for discharge, nor had the IDT (Interdisciplinary team, a team of healthcare providers who plan resident care) met and determined it was safe to discharge Resident 2 to a lower level of care. The SSD stated the decision to discharge Resident 2 was made by the facility Administrator (Adm) and the AA. The SSD stated the Adm and AA asked her to contact the owner of R&B 1 to inquire if Resident 2 could be placed in his care; it was her (the SSD) responsibility to make the arrangements. The SSD stated, in her opinion, the discharge was unsafe. The SSD stated she did not voice her opinion because she believed the decision to discharge had already been made, and her opinion would not matter. The SSD stated the owner of R&B 1 visited Resident 2 in the SNF, prior to discharge, conducted record review, and accepted Resident 2 for discharge to R&B1. The SSD stated the facility left the determination of appropriate placement to the owner of R&B 1. The SSD stated, "I trusted him [the owner of R&B 1] to set up the home health services...No 30 day notices [notice of transfer/discharge and the right to appeal the discharge] were given...a letter was sent to Resident 2's son, but after the fact [ on 2/6/17, three days after the discharge had occurred]."
On 5/2/17 at 1 p.m., during an interview, the DON stated there was no discharge plan documented in Resident 2's clinical record which indicated the Interdisciplinary Team (IDT, team of health care providers that plan resident care) met or that resident assessments drove the decision to discharge. The DON stated she was told in a morning meeting Resident 2 was being discharged. The DON stated the IDT did not work as a team on Resident 2's discharge, but they usually would. The DON stated Resident 2 was a long term care resident at the SNF and it was unusual to discharge long term care residents. The DON stated it was the AA's decision to discharge the resident. The DON stated Resident 2 needed supervision and nursing care at the time of his discharge.
On 5/2/17 at 1:45 p.m., during an interview, the AA stated, "[Adm] decided to discharge [Resident 2]. Discharge takes about a month. It took a long time to get [Resident 2's] funds coming here. We had to get [his] money coming here before we could discharge." The AA stated Resident 2 needed 24 hour care. The AA stated she did not know the level of care R&B 1 offered and she had not been to the R&B homes. The AA stated she thought because Resident 2 could ambulate, it was a safe placement.
On 5/2/17 at 2 p.m., the Adm stated Resident 2's name was brought up in a morning meeting and there was no objection to the discharge from the SNF. The Adm stated the SSD was responsible to find placement for residents upon discharge and the IDT had an opportunity to object to the discharge. The Adm stated the IDT was made up of the Adm, the AA, the SSD, and the DON. The Adm stated he was not aware Resident 2 required insulin which would have made him ineligible for discharge to R&B, but B&C would have been appropriate.
On 5/2/17 at 4:45 p.m., an interview and concurrent record review with the DON was conducted. The DON stated Resident 2's condition had not significantly improved during his stay in the SNF, and he was not ready for discharge on XXXXXXX 17.
On 5/11/17 at 8:10 a.m., a telephone interview with Resident 2's RP was conducted. The RP stated he understood his father was supposed to be in a skilled nursing facility, but they [the facility] put his father in a group home without his knowledge. The RP asked, "Why would they move him without talking to me?" The RP stated when he learned his father was no longer at the facility; he waited three days to learn his father's location. Resident 2's RP stated when he was finally able to locate and visit his father; he realized his father was not getting the care he needed and deserved, and that there were no Spanish speaking individuals to communicate with his father. The RP started to sob, and stated, "I had never in my life seen my father with a beard. I did not know what to do. Then, I heard he fell and hurt himself..."
On 5/16/17 at 9:50 a.m., during a telephone interview, the owner of R&B 1 stated he accepted Resident 2 at R&B 1 on 2/4/17 but later transferred Resident 2 to R&B 2. The owner of R&B 1 stated Resident 2 "fell too much" and needed a higher level of care than he could provide at R&B 1. The owner of R&B 1 stated, "I kept an eye on [him] for half a month."
On 5/16/17 at 1:55 p.m., a telephone interview with Resident 2's physician, MD 1, was conducted. MD 1 stated, "I understood [Resident 2] was discharged to an Assisted Living facility. This patient has dementia, severe dementia. Not able to go to an R&B. R&B residents must be independent. This resident was not independent. The social worker should arrange a safe discharge. Physicians depend on that. We just sign the paperwork."
On 5/16/17 at 3:35 p.m., an interview and concurrent record review with the Adm was conducted. The Adm stated Resident 2's discharge to a B&C probably would have been fine; but not an R&B. The Adm stated he was not aware Resident 2 required insulin injections. The Adm stated insulin injections would have made Resident 2 unsuitable for B&C placement as well. The Adm stated, "We didn't do everything right. We didn't do our homework." The Adm stated the facility did not validate the type of services or the level of care provided at any of the R&B's.
Therefore, as a result of these failures, Resident 2, who suffered from dementia, was deprived of the right to appeal his discharge when his RP was not provided with a 30 day notice prior to the discharge to R&B 1, a lower level of care. Resident 2 was discharged to a lower level of care without the provision of 24 care and supervision and subsequently fell and suffered a fractured hip requiring an ACH stay and surgical intervention.
These violations had a direct or immediate relationship to Resident 2's health, safety and security and thus constitute a Class "B" Citation. |
| 040000036 |
Manning Gardens Care Center, Inc. |
040013361 |
B |
26-Jul-17 |
0PDX11 |
18792 |
Class B CITATION -
F 201 CFR 483.15(c)(1)(i)(ii) Transfer & Discharge-
(1) Facility requirements
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) 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;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) 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. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.
F 203 483.15(c)(3) Notice Before Transfer
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer of discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.
483.15(c)(4) Timing of the notice
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered, under paragraph (c)(1)(ii)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c) (1)(ii)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(ii)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (C)(1)(ii)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.
483.15(c)(5) Contents of the notice.
The written notice specified in paragraph (C)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone of the Office of the State Long Term Care Ombudsman;
483.15(c)(6) Changes to the notice
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.
CFR 483.15(c)(7) Orientation for Transfer or Discharge
A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.
Title 22, Section 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 of discharge. Such actions shall be documented in the patient's health record.
On 4/28/17 an unannounced visit was made to the Skilled Nursing Facility (SNF) to investigate Complaint CA 00531944 regarding an allegation of violation of resident discharge rights.
The facility failed to protect Resident 3's right to appeal his discharge from the facility when a 30 day notice of discharge was not provided to him or an advocate to act on his behalf. The facility failed to ensure sufficient preparation and orientation for a safe and orderly discharge from the facility. Resident 3, was discharged from the SNF, where he was assessed to require 24 hour care and extensive staff assistance for activities of daily living, to a room and board (R&B, an unlicensed home that provides food and lodging and requires residents to be independent) which did not have staff on duty 24 hours a day to provide care or supervision. Resident 3 was discharged from the SNF into the care of the owner of R&B 1 who soon determined Resident 3 needed a higher level of care than R&B 1 could provide. The owner of R&B 1 transferred the care of Resident 3 to R&B 2 (also a home which only provides meals and a room). The facility failed to verify the level of care provided by an R&B upon discharge and incorrectly identified the R&B as a Board and Care (B&C, licensed homes staffed with caregivers 24 hours a day, seven days a week) and as an Assisted Living home (housing for elderly or disabled that provides nursing care, housekeeping and meal preparation).
As a result of these failures, Resident 3 was discharged to a lower level of care, R&B 1, without verification that Resident 3's needs could be met or what services were available. Resident 3 who required 24 hour care and extensive staff assistance was discharged to R&B 1 where those services were not provided, placing Resident 3 at risk for harm, injury, and inadequate care.
Resident 3, who had cognitive (pertaining to memory, reasoning and judgement) impairment, could not make reasonable independent decisions and had no family to advocate on his behalf. The facility was aware of Resident 3's mental status and did not question the decision to discharge to a lower level of care and failed to advocate for his right to appeal the discharge.
Resident 3's face sheet indicated Resident 3 was XXXXXXX years old at the time of discharge from the SNF. Resident 3 was admitted to the SNF on XXXXXXX13 and resided in the facility a total of 1458 days. Resident 3's diagnoses included, prostate cancer (the prostate is a male sexual gland located behind the bladder), depression (altered mood with feelings of worthlessness and despair), and dysphagia (difficulty swallowing).
Resident 3's Minimum Data Set (MDS) (an assessment tool used to plan resident care) assessment, dated 1/15/17, indicated Resident 3's cognitive skills for daily decision making were "moderately impaired - decisions poor; cues/supervision required." The same MDS indicated Resident 3 required extensive staff assistance for dressing, toilet use, personal hygiene and bathing.
Resident 3's care plan, last revision dated 1/16/17, indicated, "Resident's condition requires long-term care. Discharge to community not feasible, Resident requires 24/7 [24 hours per day, seven days a week] nursing care..." Resident 3's care plan, last revised 3/13/13, indicated he had an activity of daily living self-care performance deficit and required staff assistance with personal hygiene, dressing, eating and transfer. Resident 3's care plan dated 11/4/13, indicated a WanderGuard (alarmed device to alert staff when resident wandered near an exit door) to be worn at all times for wandering and high risk of elopement (leaving the facility without permission or supervision).
Resident 3's physician's "Order Summary Report" dated 2/1/17, indicated a WanderGuard to be worn at all times for wandering and high risk of elopement.
Resident 3's physician order, dated 1/14/15, indicated a pureed diet (diet consisting of foods that have been strained or blended and require no chewing), due to the diagnosis of dysphagia.
Resident 3's physician discharge order, dated 2/2/17, indicated, "May discharge to [R&B 1] on 2/3/17 with medications, home health R.N. [registered nurse] evaluation, and P.T [physical therapy]. The physician order did not indicate the level of care Resident 3 would require upon discharge.
Resident 3's face sheet indicated Resident 3 was discharged from the SNF on XXXXXXX 17 (to R&B 1).
On 4/28/17 at 9 a.m., a telephone interview with a Social Worker for the [name of county] Department of Social Services (SWFDSS) was conducted. The SWFDSS stated before Resident 3 was admitted to the SNF, he was receiving In Home Supportive Services (IHSS, subsidized in- home care). The SWFDSS stated prior to placement at the SNF, Adult Protective Services (APS) was involved with Resident 3's care because Resident 3 had memory issues and no family or support system available. The SWFDSS stated Resident 3 was discharged from the SNF to the care of R&B 1 on XXXXXXX17. The SWFDSS stated the owner of R&B 1 transferred Resident 3 to the care of R&B 2 (owned and operated by different people at another location). The owner of R&B 2 applied for IHSS for Resident 3. The SWFDSS stated she was involved in reviewing cases to determine whether IHSS was appropriate for residents. The SWFDSS stated she was contacting APS regarding concern over the previous APS case for Resident 3 and the questionable appropriateness of current placement in an R&B, as Resident 3 was determined to be unsafe at that level of care prior to placement at the SNF. The SWFDSS stated the previous APS case was related to Resident 3's need for a public guardian because he didn't have family, but the application was not pursued because he was safely placed at the SNF.
On 4/28/17 at 1:45 p.m., during an interview, the Director of Nursing (DON) stated she was aware the Assistant Administrator (AA) made the decision to discharge Resident 3 to a place the AA called an Assisted Living. The DON stated she was not aware of the difference in the level of services provided by an Assisted Living as opposed to an R&B. The DON stated she did not have any input on deciding resident discharge. The DON stated, "If I said no [to a discharge] because the resident is not medically safe or with wounds, the AA will over-ride my decision."
On 4/28/17 at 1:50 p.m., during an interview, the AA referred to R&B 1 as "an Assisted Living facility." The AA stated she was not aware of the care and services provided at R&B 1. The AA stated Resident 3 was discharged from the facility because he was functioning well and able to ambulate (walk).
On 4/28/17 at 2 p.m., during an interview, the Social Services Designee (SSD) referred to R&B 1 as "an Assisted Living Facility." The SSD stated she had never been there and did not know the level of care R&B 1 provided.
On 5/1/17 at 11:15 a.m., R&B 2, where Resident 3 resided, was visited. A woman that identified herself as a resident in R&B 2 allowed surveyors to enter. There were no caregivers present. Resident 3 was observed in the back bedroom, sitting on the side of the bed eating breakfast cereal (Cheerios in milk) and a banana. Resident 3 had milk puddled around his mouth, in his full, bushy beard, and there was a distinct smell of urine about him. Resident 3 did not make eye contact, or make any recognizable verbal or nonverbal attempts to communicate.
On 5/2/17 at 11:12 a.m., during an interview and concurrent record review, the SSD stated she had met the owner of R&B 1. The SSD provided the flier that R&B 1's owner handed out when he visited the SNF. The flier indicated, "...Our guests are independent and are people who wish to live in a "clean and sober" environment. Our house provides 3 meals per day, laundry, phone and other services..." The SSD stated she had not visited or otherwise validated the services provided at R&B 1. The SSD stated Resident 3 did not have good safety awareness, was not independent and would not be safe without supervision at the time of discharge. The SSD stated Resident 3's condition had not significantly improved during his stay in the SNF. The SSD stated there were no resident assessments to verify Resident 3's physical or medical condition drove the need for discharge, nor had the Interdisciplinary Team (IDT, a team of healthcare providers in the facility who meet to assess resident needs and plan care) met and determined it was safe to discharge Resident 3 to a lower level of care. The SSD stated the decision to discharge Resident 3 was made by the Administrator (Adm) and the AA. The SSD stated the Adm and AA asked her to contact the owner of R&B 1 to inquire if Resident 3 could be placed in his care; it was her responsibility to make the arrangements. The SSD stated, in her opinion, the discharge was unsafe. The SSD stated she did not voice her opinion because she believed the decision to discharge had already been made, and her opinion would not matter. The SSD stated the owner of R&B 1 visited Resident 3 while in the SNF, prior to discharge, conducted record review, and accepted Resident 3 for discharge to R&B 1. The SSD stated the facility left the determination of appropriate placement to the owner of R&B 1. The SSD stated, "I trusted him [the owner of R&B 1] to set up the home health services... No 30 day notices [30 day advance notice of discharge and the right to appeal the discharge] were given..."
On 5/2/17 at 1 p.m., during an interview, the DON stated there was no discharge plan documented in Resident 3's clinical record which indicated the IDT met or that resident assessments drove the decision to discharge. The DON stated she was told in a morning meeting Resident 3 was being discharged. The DON stated the IDT did not work as a team on the discharge of Resident 3, but they usually would. The DON stated Resident 3 was a long term care resident at the SNF and it was unusual to discharge long term care residents. The DON stated it was the AA's decision to discharge Resident 3. The DON stated Resident 3 needed supervision and nursing care at the time of his discharge on XXXXXXX17.
On 5/2/17 at 1:45 p.m., during an interview, the AA stated, "[Adm] decided to discharge [Resident 3]. Discharge takes about a month. It took a long time to get [Resident 3's] funds coming here. We had to get [Resident 3's] money coming here before we could discharge." The AA stated, "Only partial payment [for Resident 3] was coming here. We had to get Social Security to send money here." The AA stated Resident 3 needed 24 hour care. The AA stated she did not know the level of care R&B 1 offered and she had not been to the R&B homes. The AA stated she thought because Resident 3 could ambulate, it was a safe placement.
On 5/2/17 at 2 p.m., the Adm stated Resident 3's name was brought up in a morning meeting and there was no objection to the discharge of Resident 3 from the SNF to a lower level of care. The Adm stated the SSD was responsible to find placement for residents upon discharge and the IDT had an opportunity to object. The Adm stated no one objected to Resident 3's discharge to R&B 1. The Adm stated he was not aware of the previous APS referral, or that Resident 3 had no family. The Adm stated, "I doubt he [Resident 3] ever needed skilled nursing. He has dementia ...We sent him to Assisted Living ... I really don't know the level of care..."
On 5/2/17 at 4:45 p.m., an interview and concurrent record review with the DON was conducted. The DON stated Resident 3's condition had not significantly improved during his stay in the SNF, and he was not ready for discharge on XXXXXXX 17.
On 5/16/17 at 9:50 a.m., during a telephone interview, the owner of R&B 1 stated he accepted Resident 3 at R&B 1 on 2/4/17 but later transferred Resident 3 to R&B 2. The owner of R&B 1 stated Resident 3 "started hitting people" and needed a higher level of care than he could provide at R&B 1. The owner of R&B 1 stated, "I kept an eye on [him] for half a month."
On 5/16/17 at 2:30 p.m., a telephone interview with Resident 3's physician, MD 2, was conducted. MD 2 stated, "I am not sure what drove the discharge." MD 2 stated Resident 3 required the same level of care (after discharge) that was provided in the SNF. MD 2 stated she went with the recommendation of the staff (to discharge to R&B 1).
On 5/16/17 at 3:35 p.m., an interview and concurrent record review was conducted with the Adm. The Adm stated Resident 3's discharge to a B&C probably would have been fine; but not an R&B. The Adm stated, "We didn't do everything right. We didn't do our homework." The Adm stated the facility did not validate the type of services or the level of care provided at any of the R&B's.
Therefore, as a result of these failures, Resident 3 was deprived of his right to appeal the discharge or have someone advocate on his behalf. Resident 3 was discharged to a lower level of care without provision of 24 hour care and supervision, placing Resident 3 at risk of harm and inadequate care and subsequent referral to APS.
These violations had a direct or immediate relationship to Resident 3's health, safety and security and thus constitute a Class "B" Citation. |
| 040000036 |
Manning Gardens Care Center, Inc. |
040013363 |
A |
26-Jul-17 |
0PDX11 |
28836 |
F 203 483.15(c)(3) Notice Before Transfer
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer of discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.
483.15(c)(4) Timing of the notice
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered, under paragraph (c)(1)(ii)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c) (1)(ii)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(ii)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (C)(1)(ii)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.
483.15(c)(5) Contents of the notice.
The written notice specified in paragraph (C)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone of the Office of the State Long Term Care Ombudsman;
F 204 483.15 (c)(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. This orientation must be provided in a form and manner that the resident can understand.
On 11/10/16 an unannounced visit was made to the Skilled Nursing Facility (SNF) to investigate Complaint CA00506068 regarding an allegation of violation of resident discharge rights.
The facility failed to ensure Resident 1 received a 30 day notice of discharge that included Resident 1's right to appeal the discharge to the State and failed to ensure sufficient preparation and orientation for a safe and orderly discharge from the facility. Resident 1 was discharged without physician ordered services, including 24 hour companion care, necessary medical equipment, therapeutic diet instructions and a home safety evaluation in place prior to discharge.
Resident 1 was discharged without an assessment of family support and into a situation that previously required Adult Protective Services (APS) intervention.
As a result of these failures, Resident 1 was not discharged home as planned. Instead, the facility staff called 911 from the sidewalk in front of the home and left Resident 1 at this location once the local police and fire departments arrived. Resident 1 experienced emotional and physical distress as a result. Local police and fire departments subsequently transferred Resident 1 to the acute care hospital by ambulance.
Resident 1's face sheet (a document containing resident personal information) indicated Resident 1 was 73 years old and was admitted to the facility on XXXXXXX 16. Resident 1's diagnoses included, diabetes (disorder which causes high blood sugar due to insufficient production of the hormone insulin which regulates blood sugar), heart failure, and an open wound to the right foot. Resident 1's Minimum Data Set (MDS) (a resident assessment tool) assessment, dated 8/24/16, indicated Resident 1 had no cognitive (memory) impairment. The MDS assessment indicated Resident 1 did not ambulate (walk) and required total staff support in bed mobility, transfers from bed to wheelchair, locomotion while in wheelchair, dressing, toilet use, personal hygiene and bathing.
Administrative document review, untitled and dated 10/6/16, indicated a typed written 30 day notice of discharge addressed to Resident 1. The letter indicated, "Hand delivered to [Resident 1] at [the facility] ...Copy to [Resident 1's Family Member (FM) 1] ...You are hereby given a 30 day notice of discharge from [facility]...because you have not been paying your share of cost. Your Medi-Cal determined share-of-cost is $2,269 per month. Your current bill is $11,649.63. You will be discharged on XXXXXXX 2016 unless your bill is paid in full and/or a satisfactory repayment plan is established prior to that time. Your bill will increase by $2,269 plus interest by that date. You will be discharged to your home with [FM 1]. We will assist you in setting up in-home care if you desire. You have all your mental capacities and even with certain physical limitations you should be able to function at home with some in-home supportive services..."
On 11/10/16 at 9:40 a.m., during an interview and concurrent clinical record and administrative document review, the Assistant Administrator (AA) stated Resident 1 was discharged from the facility on XXXXXXX 16. The AA stated, "We provided transportation to her [Resident 1's] home. Her [FM 1] refused to open the gate to let her come in." The AA stated she and the facility Administrator (ADM) drove to Resident 1's house after Resident 1's transport driver informed them FM 1 would not let Resident 1 inside the home. The AA stated FM 1 yelled and cursed at them, and refused to open the gate. The AA stated, "We offered to let him pay the bill." Then Resident 1 complained she didn't feel well so she (the AA) called 911 [the emergency response phone number]. The AA stated two policemen and three or four firemen responded to the 911 call and the AA and the ADM then left Resident 1 at her house. The AA stated, "We were told we were free to go. We left. [FM 1] was in the house. The resident [Resident 1] was at the gate with officers, and the paramedics were taking her [Resident 1] to the hospital...She [Resident 1] said she knew the law. She didn't believe she would be kicked out." The AA stated FM 1 had not answered phone calls from the facility prior to Resident 1's discharge and had not participated in Resident 1's discharge planning.
Resident 1's acute care hospital (ACH) clinical record titled, "ED [emergency department] Provider Notes dated 11/7/16, indicated, "Chief Complaint...patient was kicked out of SNF, PD [police department] states home is unfit for patient to live in...73 year old was left in front of her house and FPD [local PD] stated her house is unfit to live in, therefore was transported to the hospital..."
Resident 1's ACH clinical record titled, "Acute Care Physical Therapy Initial Assessment and Discharge" dated 11/8/16, indicated, "...Summary/Analysis of examination: The patient ...who presents for placement due to unsafe living conditions at her home. She [Resident 1] demonstrates weakness about all extremities with right hemiplegia [paralysis of one side of the body] consistent with previous stroke 15 years ago. She required maxA [maximum assistance] to complete bed mobility and transfer tasks...She exhibits excessive extensor tone [muscle tightness] about BLE [both lower extremities] which made stand pivot transfers difficult to complete...Recommend disposition to long term SNF when medically cleared...Nursing staff to assist patient with bed mobility...Most appropriate from 2 person stand pivot transfer versus lift transfer [mechanical device to lift patient out of bed and transfer to chair] for patient and caregiver safety..."
Resident 1's ACH clinical record titled, "Case Manager Addendum" dated 11/7/16, indicated, "...Per medical record review - she was an APS case 05/10/16 - APS report filed by PD [police department] due to unsanitary living conditions and suspicion of abuse/neglect. Pt [patient] with a past medical history of CVA [cerebral vascular accident - stroke] x 2 [twice], residual right side weakness, and diabetes... In [identity of facility] ED [emergency department] pt was noted to have hair soiled with feces, small cockroaches on her, and multiple wounds. Wound on right foot found to have maggots. Report received by APS from PD that pts home is uninhabitable and that [FM 1] appears to have his own medical conditions and cannot care for pt..."
Resident 1's ACH clinical record titled "... EMS [emergency medical services]" dated 5/8/16, indicated, "...72 year old female...found laying on the floor by [FM 1], c/o [complaint of] possible fall unknown how long pt has been on floor...firemen on scene stated, "The inside of the house is not livable, I (captain) called ...PD to come out and start an APS case, the pt cannot take care of herself and when you see her inside [home] you'll see what I mean. [FM 1] was on scene in the house, [FM 1] stated "I have been at the hospital; for the past 4 days ...I don't know how long she has been on the floor." Pt ...completely soiled head to toe, coffee ground emesis [vomit] inside the pt mouth/on arms/shirt, diaper full leaking out, cockroaches crawling all over the pt ..."
On 11/15/16 at 1 p.m., during an interview and concurrent clinical record review, the Social Services Designee (SSD) stated there were allegations of abuse at Resident 1's home prior to her admission to the facility. The SSD stated Resident 1 did not have a "safe discharge" (referencing the discharge to home on XXXXXXX16). The SSD stated there were issues surrounding APS. The SSD stated, "When we talked to her, she wanted to go home...she hadn't seen [FM 1] in six months." The SSD stated FM 1 did not participate in any discharge planning. The SSD stated medical equipment was required for home care, which needed to be arranged prior to Resident 1's discharge. The SSD stated Resident 1 was bed and wheel chair bound, and Resident 1 had not walked during her stay at the facility. The SSD stated Resident 1's physician ordered a hospital bed, a wheelchair, a mechanical lift, a bedside commode [portable bedside toilet] and a shower chair for the home. The SSD stated there was no validation the items had been delivered to the house or would be able to be acquired with Resident 1's insurance. The SSD stated, "There was no reason to expect [FM 1] would cooperate. I knew it was an unsafe discharge. I didn't have access to her house. I didn't know if she had medical equipment." The SSD stated, "A 30 day notice was given for failure to pay [her facility bill]." The SSD stated Resident 1's discharge, "Was up to the Administrator."
Resident 1's Progress Note entered by the SSD, dated 6/7/16 at 2:13 p.m., indicated, "This writer contacted the Adult Protective Services to confirm if there is an open case. Spoke with [worker's name] and he said yes the case is still open..." An additional Progress Note, entered by the SSD, dated 8/23/16 at 11:31 a.m., indicated, "It is uncertain if returning to her home would be a safe discharge. Adult Protective Services were involved. This writer has left many messages for her FM [FM 1] and he does not return the calls..."
On 4/13/17 at 9 a.m., during an interview, Licensed Nurse (LN) 1 stated Resident 1 was discharged home on XXXXXXX16 at 2 p.m. LN 1 stated Resident 1 did not want to sign for her discharge. LN 1 stated, "She [Resident 1] didn't want to sign the discharge papers. She was angry and then she began crying." LN 1 stated the ADM and the AA spoke to Resident 1 about her discharge taking place on 11/7/16 and told her, she needed to sign the discharge papers. LN 1 stated Resident 1 had wounds on her right foot. LN 1 could not explain what type of wound affected Resident 1. LN 1 stated Resident 1 required daily wound care to her right foot toes. LN 1 stated she did not think Resident 1 could perform her own wound care. LN 1 stated she did not know what date the home health agency would follow up with Resident 1 for the wound care. LN 1 stated she did not think Resident 1 had a safe discharge home.
Resident 1's clinical record titled "Surgical Consent" dated 10/27/16, indicated, "Consultation for wound on right medial [inner side] foot ...Subcutaneous [under the skin] tissue debridement [removal] performed by surgical excision [cutting out] of devitalized [dead] subcutaneous tissue ...The pre-op [before procedure] wound area was 1.5 centimeters [cm- unit of measurement where 2.4 cm is equivalent to 1 inch] X [by] 1.5 cm X .3 cm ...The post op [after procedure] was 1.5 cm X 1.5 cm X .3 cm ...DRESSING USED: Santyl [topical medication used to remove dead tissue]/ Calcium alginate [absorbent dressing] The patient has a wound located at the right medial foot ...wound debrided today was at the right medial foot. For this wound there was evidence of tissue breakdown requiring aggressive management and may require future debridement ...No guarantee for wound healing can be made given the patient risk factors and diagnoses that contributes to the condition of this wound."
Resident 1's clinical record titled "Pressure and Vascular Ulcer Log" dated 11/2/16, indicated, "R [right] medial foot wound 2 cm X 1.9 cm X .2 ..."
Resident 1's physician orders dated 11/2/16, indicated, "CLEANSE [RIGHT] MEDIAL FOOT WITH [NORMAL SALINE] PAT DRY, APPLY SANTYL, THEN CALCIUM ALGINATE COVER WITH DRY DRESSING, MONITOR FOR [SIGNS AND SYMPTOMS] OF COMPLICATIONS UNTIL RESOLVED."
Resident 1's Clinical records titled "Video Swallow Evaluation" dated 9/28/16, indicated "History of Silent aspiration [food or fluids enter the lungs] and dysphagia [difficulty swallowing] ...With thin liquids, premature spillage [food or liquid swallowed escapes from the mouth and reaches the pharynx (throat) before the swallow starts] is seen into the piriforms [located in the pharynx are narrow hollowed areas] ...Premature spillage is seen which may predispose to future episodes of aspiration ...No aspiration or penetration with nectar or dry solids ..."
Resident 1's clinical record titled "Order Summary Report" dated 11/7/16, indicated Resident 1 had a physician order for "Mechanical Soft Diet [diet consisting of easy to swallow foods including ground meats and soft cooked diced vegetables and fruits], Nectar consistency [thick liquids]."
On 4/13/17 at 10:40 a.m., during an interview and a concurrent record review, the Director of Nursing (DON) stated Resident 1 was on a mechanical soft diet and required thickened liquids (liquids with an added unflavored powder used to thicken the consistency for those with swallowing problems) due to her dysphagia. The DON stated Resident 1 was seen by the speech therapist (ST) who determined Resident 1 needed to remain on nectar thick liquids to prevent aspiration of liquids into the lungs. The DON stated she did not know if Resident 1 could cook. The DON stated she did not know who would prepare Resident 1's meals at home or if Resident 1 knew how to thicken her liquids. The DON stated she did not know if Resident 1 was discharged with thickener because it was not reflected in Resident 1's clinical notes. The DON stated the SSD made all of the arrangements for the discharge and determined what support system existed for the residents being discharged. The DON stated she did know FM 1 was not involved in the care of Resident 1. The DON stated she was unsure if Resident 1 demonstrated the ability to perform her wound treatment. The DON stated, "I didn't know APS was involved. I don't think it was a safe discharge."
On 4/13/17 at 11:30 a.m., during an interview, the AA stated she believed Resident 1 received a safe discharge. The AA stated Resident 1 wanted to be discharged from the facility. The AA stated Resident 1 was left on her [Resident 1's] property. The AA stated FM 1 was in Resident 1's house and the police officers were present. The AA stated, "We had already lost a lot of money from her [Resident 1] nonpayment." The AA stated she was aware of APS involvement and she couldn't say whether or not it was appropriate for Resident 1 to return to the same previous living arrangements. The AA stated she was not aware of any regulation requiring facilities to ensure a safe discharge.
Review of Resident 1's Physician Orders dated, 11/1/16, indicated, "[Resident 1] May be discharged home with [Home Health Agency] for complete evaluation for home safety, medication training, wound care, around the clock companion care, physical therapy, hospital bed, wheelchair, [brand name mechanical] lift [a mechanical device used to transfer disabled residents out of bed and onto a chair or commode], bedside commode, and shower chair."
On 11/15/16 at 9:40 a.m., during a telephone interview with the Staffing Supervisor (SS) of (Company that provides companion care services and activities of daily living assistance), the SS stated he visited Resident 1 on 10/25/16 at the skilled nursing facility to discuss services that his company could provide to Resident 1 after discharge from the facility. The SS stated the around the clock companion care ordered by Resident 1's physician was not covered by Resident 1's insurance. Resident 1 would have to pay privately for the 24 hour companion services and activities of daily living assistance. The SS stated Resident 1 informed him on 10/25/16 that private pay was an issue for her; she did not have the money to pay for the services. The SS stated Resident 1 did not have 24 hour companion services or activities of daily living assistance arranged for her discharge home due to her refusal of services related to inability to pay.
On 11/15/16 at 1 p.m., during an interview, the SSD stated she was aware the 24 hour companion care services and activities of daily living were not covered by Resident 1's insurance and required Resident 1 to pay with private funds. The SSD stated she was not aware Resident 1 had declined the services due to inability to pay for around the clock companion care.
On 4/13/17 at 2:45 p.m., during a telephone interview, the home health agency ADM (HHAADM) stated the agency received orders for physical therapy and a home safety evaluation only. The HHAADM stated, "When we reviewed it [the orders], It looked like we would require more assistance and a nurse to follow. The nurse was scheduled for visit on 11/9/16. [Two days after the discharge occurred.]"
Resident 1's clinical record from the home health agency titled, "Patient Communication" dated 11/6/16, indicated, "Patient referral from [facility] for discharge on 11/7 to home, includes medication training and wound care. Should RN (registered nurse) open to Home health? This patient is scheduled for PT [physical therapy home safety evaluation] on 11/9/16 ..."
On 4/13/17 at 9:55 a.m., during an interview and concurrent record review, the SSD stated home health services were offered to Resident 1 on 10/6/16. The SSD stated home health would complete an evaluation for home safety, medication training, and wound care. The SSD stated she did not contact the home health agency to coordinate or assist Resident 1 in arranging the first visit to ensure Resident 1 was safe. The SSD stated she did not know when the home health agency would follow up with Resident 1. The SSD stated Resident 1 did not have a supportive family unit working towards Resident 1's discharge. The SSD stated she made no attempts to contact APS prior to Resident 1's discharge and she did not review the discharge instructions prior to Resident 1's discharge home. The SSD stated Resident 1 should not have been discharged to the same living conditions that existed prior to her admission to the facility. The SSD stated, "...It was not safe. She [Resident 1] should not have been discharged to those living conditions."
On 4/19/17 at 10:40 a.m., during a telephone interview, the durable medical equipment assistant (DMEA) stated the facility notified the equipment company via facsimile on 11/4/16 of the durable medical equipment (DME) needed for Resident 1 at home. The DMEA stated, "It looks like they ordered a manual wheelchair, oxygen, commode, hospital bed, a mechanical lift and a shower chair. The wheelchair was not going to be covered [by Resident 1's insurance]. We needed additional documentation, more supporting notes and oxygen levels. The facility never responded, and they didn't call to make any arrangements." The DMEA stated the additional documentation was requested from the facility on 11/14/16 seven days after Resident 1 was discharged from the facility and ten days after the initial durable medical equipment was ordered.
On 4/19/17 at 11:05 a.m., during a telephone interview, the DME supervisor (DMES) stated, "It [the DME order] shows that we needed additional documentation to be able to determine if the DME ordered would be delivered. There are strict guidelines and the need [requires] to be supported with documentation. We did not receive it. It also looks like the form was left incomplete. We need patient height, patient weight, length of need and prognosis."
Resident 1's clinical record titled, "MULTI-DISCIPLINARY DISCHARGE SUMMARY [document that contains resident discharge assessment and plan]" dated 11/7/16, contained an incomplete discharge summary. The document did not list a discharge diagnosis; under "Nutritional Status Special Needs [including Preferences and Restrictions]" did not list Resident 1's mechanical soft diet orders or need for nectar thick liquids. The document indicated an incomplete "Nutritional Intake and Eating Habits." The document lists "weakness" under "Joint Motions Disorders." The document listed "Rt foot open wound" and "Dressing changed q [every] day "under "TREATMENTS AND OR PROCEDURES." The document had incomplete entries under "Procedures, Rehabilitation Potential, Discharge Potential, Activity Interest, Activity Potential and Activity Participation." The document had incomplete signatures and persons completing the forms. The document was not signed by Resident 1 in the space that indicated, "Resident Signature."
On 4/18/17 at 10:20 a.m., during an observation and concurrent interview, Resident 1 was alert and sitting up in bed in SNF 2. Resident 1's fingers of her right hand were stiff and drawn in toward her palm. Resident 1 demonstrated difficulty moving her fingers. When asked about her discharge from SNF 1, Resident 1 stated she had been upset by the discharge. Resident 1 stated she had not been shown how to take care of her right foot wound. Resident 1 stated she would not have been able to care for her foot wound due to her limited mobility with her right hand and fingers. Resident 1 stated, "[FM 1] is unable to care for me at home. He has been in and out of the hospital...My house has no electricity and no running water or heat...The manager [Administrator] at the facility accused me of being a thief because I didn't give them my pension...I wanted to explain that [FM 1] was using my money to pay for my taxes and my bills plus the utilities. I was not stealing from them. "Resident 1 stated, "I was sad by the entire thing, I was stuck between a rock and a hard place. They were calling me a thief and accusing [FM 1] of stealing from me, but what would they have done. I felt horrible that I was kicked out of the facility and not let into my house, but [FM 1] is also ill himself. I wanted to be taken away [by the paramedics]."
On 4/18//17 at 10:55 a.m., during an interview, Resident 1 stated the facility did not offer her a right to appeal the discharge. Resident 1 stated, "They wanted me out of there."
On 4/18/17 at 12:05 p.m. during an interview and concurrent administrative document review, the ADM stated the facility gave Resident 1 a 30 day discharge notice on 10/16/16. The ADM stated the discharge notice did not indicate Resident 1's right for an appeal. The ADM stated the discharge notice did not have information on how to request an appeal. The ADM stated, "All I can say is that I'm sure we told her, but we don't have to show that in the letter [30 day discharge notice]." The ADM stated, "I feel it was a safe discharge because [Resident 1] was never left in an unsafe situation. The cops were present...she [Resident 1] was on her property and [FM 1] was not letting her in her home. He refused to open the gate." The ADM stated, "You can talk to [SSD] but [FM 1] and [Resident 1] were both in agreement to discharge home. The ADM stated Resident 1, "Complained about being on a mechanical soft diet. I told her that she could go home and eat whatever she wanted." The ADM stated he assumed Resident 1 had a blender to prepare the mechanical soft diet because Resident 1 said she, "had everything at home." The ADM stated he believed Resident 1 could prepare her own meals. The ADM stated he didn't think he called Resident 1 a thief. The ADM stated, "Putting it into perspective, I told her the money belonged in the facility and she was stealing from the facility." The ADM stated he knew APS had a closed case on Resident 1 involving [FM 1].
On 4/19/17 at 3:10 p.m., during a telephone interview, with APS supervisor (APSS) 1 and APSS 2, APSS 1 stated he was familiar with Resident 1's APS case of 5/10/16. APSS 1 stated Resident 1 should have never been discharged back to "those conditions." APSS 2 concurred with APSS 1's discharge assessment.
Administrative document review of type written letter untitled dated 3/30/17, indicated, "We reviewed the regulation; there is no place where it says "Safe Discharge." Please provide us the regulation that requires the policy for safe discharge. Notwithstanding the above we contend that this was a safe discharge in as much as we completed all the requirements for a discharge but when [FM 1] refused to allow her back into her own home a medical transport was summoned to take to the hospital so [Resident 1] was never in an unsafe situation ..." The letter was signed by the ADM.
Administrative document review type written letter untitled dated 4/14/17, indicated, " ...[Resident 1] postponed the inevitable numerous times as should be apparent by how high we allowed her bill had become. She broke down crying when the time of her discharge became a reality as probably anyone would. The fact that she ultimately had to be issued a 30 day notice naturally brought into play a conflictual situation which came to a head at the moment of her discharge. Staff also reported ...about a safe discharge. Naturally a safe discharge is always in everyone's best interest however we have been unable to find a regulation which requires a "safe" discharge. My comment is if you are aware of a "safe" discharge regulation...please share it with us...In addition we would like an explanation of how this could be considered an unsafe discharge. For all practical purposes [Resident 1] was actually discharged to the hospital with a visit in between to see her home and her [FM 1], [Resident 1] was never not "safe"..." The letter was signed by the ADM.
Review of facility policy and procedure titled, "Discharge Summary and Plan" dated revised 2010, indicated, "...When the facility anticipates a resident's discharge to a private residence...a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment."
As a result of these failures, Resident 1 received an unsafe discharge from the facility into a home that was deemed uninhabitable and unsafe. Resident 1 was denied entrance into the home by the only known family member who was incapable of being the care giver due to a recent hospitalization and who refused to provide care. Resident 1 experienced emotional and physical distress that required intervention by local police and fire departments and ultimately required the transfer of Resident 1 to an acute care hospital by ambulance.
These violations placed Resident 1 in imminent danger that death or serious harm would have resulted or a substantial probability that death or serious physical harm would result and therefore constitutes a class "A" citation. |
| 050000140 |
Marian Regional Medical Center DP/SNF |
050009380 |
A |
08-Aug-12 |
4W7U11 |
2314 |
CFR 483.25 (h) Accidents- The facility must ensure that (2) Each resident receives adequate supervision and assistance devices to prevent accidents.During a recertification survey, the Department determined the facility failed to provide adequate supervision and the assistance of a side rail to prevent an accident to Resident A. The facility failed to implement interventions including two person assist for bed mobility. These failures resulted in Resident A falling from bed and sustaining a hip fracture requiring surgery and hospitalization.Resident A was admitted to the facility on July 1, 2010 with diagnoses including brain tumor, history of seizures, and altered mental status. Physician orders, on admission, and repeated on August 11, 2010 included: "side rails when in bed."A comprehensive assessment dated October 12, 2011 revealed Resident A was non-ambulatory, unable to provide assistance in positioning, and required two person assistance for bed mobility and transfers. Resident A was severely impaired in decision making and was assessed at risk for falls. Resident A's fall care plan did not include the intervention of two person assistance for bed mobility and transfers as identified in the comprehensive assessment.Review of the facility's investigative report dated October 28, 2011 revealed on October 19, 2011, Resident A fell from bed after being turned by a CNA onto her left side, the side rail lowered, and the CNA left Resident A unattended. The investigative report found the factors that contributed to the fall were there should have been two persons to complete the care, the CNA did not raise the side rail prior to turning Resident A to her side, and the CNA did not gather all the equipment needed prior to providing care.During an interview on June 21, 2012 at 3:30 p.m., the administrator confirmed Resident A was left unattended lying on her side with the side rail down that resulted in a fall and hip fracture.The facility's failure to leave the side rail up or provide adequate supervision when Resident A was unattended resulted in Resident A's transfer to the hospital and repair of a fractured hip.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. |
| 050000055 |
MARY HEALTH OF THE SICK CONVALESCENT & NURSING HOSPITAL |
050011175 |
A |
03-Nov-15 |
B2FE11 |
1862 |
CFR 483.25(m) Medication Errors. The facility must ensure that? (2) Residents are free of any significant medication errors. The Department determined the facility failed to ensure Resident A was free from significant medication error. The facility administered 100 units of Lispro, a rapid?acting insulin (a hormone to control high blood sugar level, starts to work approximately 15 minutes after injection) to Resident A, instead of 2 units as ordered by the primary physician.Resident A was a 67 year old male, admitted to the facility with diagnosis including diabetes (blood sugar level rises higher than normal). Resident A?s physician?s order dated 11/25/14, included the insulin Lispro injection, forblood sugar level 101-150 milligram per deciliter (mg/dl), give 2 units of Lispro; for blood sugar level 151-200 mg/dl, give 4 units of Lispro; and for blood sugar level 201-300 mg/dl, give 6 units of Lispro. Review of record revealed, on 11/27/14, at 7:30 am, a licensed nurse (LN 1) administered 100 units of Lispro to Resident A, instead of 2 units as ordered by the physician for a blood sugar level of 101-150 mg/dl. Resident B was transferred to the hospital, was admitted due to insulin overdose, and treated for hypoglycemia (low blood sugar level).During an interview on 12/3/14 at 9:20 a.m., and 12/3/14 at 9:30 a.m., after this medication error, the Director of Staff Development (DSD) and the Director of Nurses (DON) both indicated the facility had not provided in services to all of the facility's licensed nurses regarding safe administration of insulin. The licensed nurses continued to administer insulin to residents without being cross checked by another qualified nurse.This failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 050000056 |
MAYWOOD ACRES HEALTHCARE |
050011521 |
B |
24-Nov-15 |
SKJM11 |
1937 |
California Health and Safety Code 1418.91(a)(b) Failure to Report (a) A long-term care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class ?B? violation.The Department determined the facility was in violation of the above statute by the failure to report to the Department, local Police Department or Ombudsman, allegations of suspected sexual abuse involving Patient A to Patient B, C, and D immediately or within 24 hours.Patient A was admitted to the facility with diagnoses including dementia (mental process marked by memory disorders, personality changes and impaired reasoning).The nursing notes dated August 24, 2014 by a licensed nurse indicated, "A male (Patient A) was in the room (Patients B and C) playing with his private parts."During an interview on April 29, 2015 at 3:45 p.m., licensed nurse (LN 1) verified the incident and did not report the incident to the director of nursing (DON). During an interview on 4/30/15 at 2 p.m., social service designee (SSD) verified the incident and she did not report the incident to the DON.The nursing notes dated November 18, 2014 indicated, "Resident (Patient D) was checked after staff informing that she (Patient D) was on patio with another male resident (Patient A) who apparently showed his private parts to her."The facility?s Progress Note dated November 18, 2014 by a licensed nurse indicated, Patient A had "Inappropriate behavior showing his privates area to female resident." An Annual Note dated December 12, 2014 written by the social service designee, indicated Patient A, "Has episodes of showing his private parts to female residents and approaches two females in particular." The violation of this regulation had a direct relationship to the health, safety, or security of residents. |
| 050000629 |
MITCHELL HOME |
050011629 |
B |
19-Oct-15 |
I58X11 |
2347 |
Health and Safety Code 1419.9l(a)(b)(c)(d) (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. (c) For purposes of this section, "abuse shall mean any of the conduct described in subdivision (a) and (b) of section 15610.07 of the Welfare and Institutions Code. (d) This section shall not change any reporting requirements under Section 15630 of the Welfare and Institutions Code, or as otherwise specified in the elder Abuse and dependent Adult Civil Protection Act, Chapter 11 (commencing with Section 15600) or Part 3 of Division 9 of the Welfare and Institutions Code.The Department determined the facility is in violation of the above statute by its failure to report allegations of abuse of a client(s) to the Department immediately or within 24 hours. On April 29, 2015, Client A hit Clients B, C, and D during shower time at the facility. On May 13, 2015, Client A hit Client D three times on the back. On May 21, 2015, Client A hit Clients B, C, and D on their backs, arms, and head. Client A was admitted to the facility with diagnoses including bipolar mood disorder, cerebral palsy, and a seizure disorder. Human Rights Committee Meeting minutes dated April 27, 2015 indicated Client A to have "Aggression, kick/hit/bite others, objects." Facility notes written by the qualified intellectual disability professional (Q) dated April 29, 2015, May 13, 2015, and May 21, 2015 described the physical altercations inflicted by Client A onto Clients B, C, and D. The May 21, 2015 note indicated, "Client A continues to abuse her peers (Clients B, C, and D). The Q confirmed on July 6, 2015 at 10:51 a.m. the incidents of abuse by Client A to Clients B, C, and D. The executive director (ED) and the Q could not provide evidence the incidents had been faxed, mailed, e-mailed, or communicated to the Department within the required time frames. During interviews on July 6, 2015 at 10:39 a.m. and 10:51 a.m. the ED and Q confirmed not reporting the incidents of abuse by Client A to Clients B, C, or D to the Department. The violation of this regulation had a direct relationship to the health, safety, or security of residents. |
| 050000051 |
MISSION VIEW HEALTH CENTER |
050011735 |
B |
26-Jan-16 |
ITZ711 |
4126 |
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.The Department determined, the facility failed to protect Resident A from verbal abuse. Resident A repeatedly received obscene gestures and words related to his disability by a certified nursing assistant (CNA 1). As a result, Resident A suffered repeatedly feelings of an unsafe environment and anger. Resident A was a 56 year old male, admitted to the facility with diagnoses including epilepsy (seizure disorder) and history of stroke. The comprehensive assessment dated 6/10/15 revealed, Resident A was able to report correct year and month, able to repeat three words after first attempt, and able to recall two words without cueing. Resident A's ability to hear and see was adequate and needed extensive assistance with bed mobility and transfers. Resident A's legs were impaired and used a wheelchair for mobility.During an interview on 8/11/15 at 1:30 p.m., licensed nurse (LN 4) explained, Resident A had difficulty communicating and sometimes, became frustrated when unable to communicate. Resident A, when frustrated, became loud and yelled. Resident A understood everything well but could not speak clearly.During an interview on 8/12/15 at 10:30 a.m., Resident A's sister indicated, Resident A became frustrated and loud when he could not communicate the words. Resident A can make his needs known through words, gestures, and writing.During an interview on 8/11/15 at 11 a.m., the ombudsman (residents' advocate) explained, Resident A had tried to tell her something during her visit on 7/25/15 at 2:15 p.m. Resident A was angry and had given her a drawing to explain himself. He was angry at one of the male nursing staff. The ombudsman notified LN 7. The ombudsman explained to LN 7, Resident A was angry at one of the male nursing staff indicating that staff was "giving Resident A hard time." During a concurrent observation and interview on 8/11/15 at 11:30 a.m., Resident A, in the presence of the ombudsman, revealed, a nursing employee, he verbally described as a "big, strong, bald man", had been making a hand gesture to Resident A, with his middle finger and saying "Screw you" and "Stroke", repeatedly, in a sarcastic and taunting tone. This interview was accomplished by both surveyor and ombudsman asking Resident A questions, to repeat statements, spell out words, and explain a drawing of a large and a small person-shaped figures he had drawn for the ombudsman in an earlier attempt to communicate his complaint.In the drawing, Resident A identified the large figure as the "Big bald, strong man" and himself, as the smaller figure by pointing at himself. When asked if the big figure hurt the small figure he said, "yes". During this interview process, a male employee (CNA 1) walked by Resident A's door to the hallway. Resident A's facial expression changed. Resident A, with widened eyes, pointing at CNA 1 said adamantly, "Yes, yes! Him! (CNA 1)."When asked again what that person did to Resident A, Resident A picked up his call button, pushed it and pointed to the doorway (as if to indicate whenever he asked for help, CNA 1 would respond). Resident A said CNA 1 would say to Resident A "Screw you!" He gestured with his middle finger raised and said again, "Stroke? Stroke?" in a sarcastic tone of voice. He added, "All the time!" indicating this was a common practice of CNA 1 to Resident A.During an interview on 8/11/15 at 5 p.m. with the administrator present, Resident A repeated this complaint without variation. Resident A confirmed, CNA 1 made him feel angry and he did not feel safe with CNA 1 still working at the facility. During an interview on 8/13/15 at 12 p.m. revealed, CNA 1 found it difficult to work with Resident A because he became loud when frustrated and sometimes yelled at him. CNA 1 stated, "The shouting really gets to me." The violation of the regulation has caused or occurred under circumstances likely to cause, significant humiliation, indignity, anxiety, or other emotional trauma to the resident. |
| 630012459 |
Mark Lane One |
060009604 |
B |
15-Oct-15 |
M3F611 |
8155 |
Welfare and Institutions Code, Section 4502 (d). Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following: (d) A right to prompt medical care and treatment. The above statute was NOT MET as evidenced by: On 8/28/12, an unannounced visit was made to the facility to investigate an entity reported event (ERI) regarding Client 1 falling while in the facility van and fracturing her femur. Based on interview and record review, the facility failed to: Ensure the registered nurse (RN) assessed Client 1 after falling in the van, which resulted in the client not receiving immediate medical care and experienced continued pain due to the undetected fracture of the femur. Review of the facility's documentation of the incident showed on 8/19/12 at approximately 1530 hours, Client 1 was taken via facility van on an outing to Target. There were two DCS and four clients making the trip. Documentation showed Client 1 was placed in the van using her wheelchair, but the wheelchair was not taken with her to the store.Per interview with DCS 1, Client 1 was going to use an electric wheelchair provided by the store. The DCS stated when they arrived at the store, one of the DCS went into the store to get the wheelchair. The wheelchair ramp on the van was then raised so the client could step out on the ramp and ride it down without a wheelchair while the two DCS were standing outside of the van waiting for the client. The client got up from the van seat by herself, took a step to the ramp and then fell. The DCS continued to state the client said her leg had given out. DCS 1 also stated the client immediately complained of pain; therefore, the trip was cancelled and the DCS drove back to the facility. DCS 1 also stated Client 1 was unable to be moved back to the van seat and rode home sitting on the van floor after being pushed back away from the mechanical wheelchair ramp by the DCS. Upon arriving at the home, a male staff member from a sister facility was called upon to help move Client 1 from the van into her wheelchair so she could be transported back into the house.On 8/28/12, an interview was conducted with DCS 2, who worked at Client 1's home. She stated she helped to bring the client into the facility when the group arrived back at the facility on the day of the incident.DCS 2 also stated she did a body check on Client 1 and only noted a "scrape on her left ankle when she fell with ____ and _____ "(two DCS names). DCS 2 stated Client 1 was complaining of left leg pain so at approximately 1630 hours, DCS 2 called the RN who was on call (this RN worked for the company that owned this facility and several other sister facilities, but this facility was not one that the RN on call worked at).DCS 2 stated the RN told the DCS she could give the client the Tylenol she had ordered for pain. The Tylenol was given to the client at 1648 hours. Client 1 told the DCS she could not move; however, the DCS said the client was able to move her left foot. DCS 2 stated Client 1 refused to eat her dinner due to the pain and at 1720 hours, DCS 2 called the RN back to tell her the client still had pain and was refusing to eat. The DCS stated the RN told her it was too soon to give any more pain medication and did not tell her to do anything else. DCS 2 stated she tried to get the client to eat and was able to get her to take only a few bites of food. The client kept refusing because she said she could not move her leg and that it hurt. DCS 3 was present while DCS 2 was being interviewed. DCS 3 stated she had worked the night of 8/19/12 and she arrived at the facility between 1800 hours and 1900 hours. She stated Client 1 was crying and complaining of pain. DCS 2 stated on 8/19/12 at approximately 2045 hours, she called the RN back and told the RN the client was still having pain. DCS 2 then gave Client 1 two more Tylenol. DCS 2 had recorded on the medication administration record (MAR) that Client 1 described her pain as 10 of 10 (zero [no pain] to 10 [severe pain]). DCS 2 also stated the client did not even ask to go outside to smoke as her usual routine due to the pain.DCS 2 was asked how the client was toileted. She stated the client was able to wheel herself to the bathroom and transfer herself to the toilet. When asked if the client was toileted from the time she arrived back at the facility until the DCS went home on the night of 8/19/12 at 2200 hours, DCS 2 stated, no, the client did not want to move the wheelchair at all due to the pain.DCS 2 stated Client 1 was still up in the wheelchair when she left the facility on 8/19/12 at 2200 hours as she was refusing to move from the chair to go to bed. DCS 2 stated she called the facility at 2300 hours to check on Client 1 and was told the night DCS had finally been able to get Client 1 into bed and that she was asleep.Per clinical record review, there was documentation from the facility RN as follows: "8/21/12 0945 @ 0645 8/20/12 msg rec ' d that _____ (client name) was refusing to get up. C/o leg pain. Informed by staff that pain started Sunday night. Instructed to transport to ER for eval. "Documentation showed on 8/20/12, the client was transported to the local hospital and was admitted at 0920 hours. She was found to have a fractured femur.The client required surgery for the fracture. An open reduction internal fixation of the fracture was done on 8/21/12.On 8/28/12, the RN who was on call when the client fell was called for a telephone interview. She stated she was called on 8/19/12 between 1630 hours and 1700 hours and was asked if it was okay to give Client 1 pain medication. The RN said she told the DCS if she had pain medication ordered it could be given without calling her. She did however ask why the client needed pain medication. The RN stated she was told Client 1 had gone on an outing and was upset she did not have an electric wheelchair. So the client had a behavior and threw herself out of the wheelchair and she fell on her knee. The RN stated she assumed the client had "fallen" from a sitting position. The RN stated she asked the DCS if there was any swelling, bruising or cuts. She was told, no, and that the client only complained of pain if asked to move.The RN stated she called the facility back to check on the client and was told the client would not roll her wheelchair by herself to the table to eat her dinner. She stated she was told the pain medication had helped and the DCS was able to do the 2000 hours treatments the client had ordered for her feet. The RN then stated she received a call on 8/19/12, from the night shift DCS, stating the client would not get out of the wheelchair to go to bed. The RN stated she spoke to the client on the phone and told her she could not stay in the wheelchair all night and she had to get into bed. She stated she did not hear from the facility again. The QMRP was interviewed on 8/28/12. He stated he received five calls from the facility about the incident and one call from the RN. The first call was from DCS 1 to inform him of the fall. The second call was from DCS 2 but he was unable to remember what the call was about. He then received the call from the RN "informing him of the situation." The next two calls were just "updating him on the situation" with the last call from the night shift DCS informing him Client 1 did not want to go to bed. The failure of the RN to assess Client 1 when she continued to have pain, refused to move from the wheelchair for more than six hours and refused to eat due to the pain, had a direct or immediate relationship to the health, safety, or security of the client. |
| 060000055 |
MISSION PALMS HEALTHCARE CENTER |
060009916 |
A |
23-May-13 |
QYQ411 |
8955 |
F323, 485.23(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.Investigation of Complaint No: CA00352356 resulted in the following findings: The facility failed to provide adequate supervision for one of three sampled residents (Resident 1). Resident had a known history of falls and was a high fall risk and injuries. On 3/8/13, Resident 1 fell when she was left unattended in the bathroom. Resident 1 sustained a laceration to her right periorbital (eye area), a subarachnoid hemorrhage (bleeding into the brain), right side facial fractures with a hematoma (blood clot). Resident 1 died on 3/17/13. The death certificate showed the cause of death was cardiopulmonary arrest secondary to traumatic brain injury from a mechanical fall. Findings:Closed clinical record review for Resident 1 was initiated on 4/30/13. Documentation showed Resident 1 was an elderly woman admitted to the facility on 8/24/11. Her diagnoses included dementia, anemia and history of DVT (blood clot in a blood vessel). Resident 1 was prescribed Coumadin (anticoagulant) 5 mg everyday for DVT. Review of Resident 1's Minimum Data Set (an assessment tool) dated 2/21/13, showed Resident 1 had severe cognitive impairment, required extensive assistance for transfers, including transfers on and off the toilet and to cleansing self after elimination. In addition, the resident was identified to have a poor balance without human assistance. Review of Fall Risk Assessments dated 2/21, 3/2 and 3/8/13, showed Resident 1's fall risk score was 18. A score of 10 or higher identifies the resident as being a "HIGH RISK" for falls. Resident 1 sustained falls on 11/2/12, 3/4/13 and on 3/8/13.Review of the "Nurse's Notes" showed the following: * On 2/17/13, licensed staff documented the resident at risk for falls. The interventions included having the bed in a low position, floor mats on both sides of the bed, sheep skin padding on the 1/2 side rails. In addition, the resident's wheelchair was equipped with anti-tippers (to prevent tipping backwards), a lap tray (prevent the resident getting up unassisted), and she wore a helmet.* On 3/2/13, Resident 1's personal alarm (to alert staff if the resident attempted to get up unassisted) was sounding. The licensed nurse found Resident 1 kneeling on the floor mat beside her bed. The resident was assessed to have a left posterior head abrasion. The abrasion measured 0.5 cm x 1.2 cm with a bump and minimal bleeding noted. The resident was not able to recall what happened. The physician and family were notified. The physician ordered a CT scan (Computed Tomography, a detailed x-ray), which was negative for hemorrhage. * On 3/4/13, Resident 1 remained at high risk for falls and injury due to "unpredictable behavior, poor safety awareness and due to multiple falls." A discussion with the resident's family and IDT was conducted to remove the bed frame and place the mattress on the floor to decrease the risk for falls and injury.Review of the plan of care showed the following: * A care plan problem dated 3/2/13, addressed a "Recent Fall." The approach plan included frequent visual checks, neurochecks, assist with all transfers, assist to the bathroom or toilet as necessary, helmet to be used at all times.* A care plan problem dated 6/8/11 and last updated on 3/4/13, addressed the resident's Risk for Injury/Fall, related to lack of awareness, cognitive deficit, unsteady gait and history of falls. The approach plan included to remind the resident to use the call light, anticipate resident's needs, and to wear a helmet at all times except during showers. Additional review of the Nurse's Notes showed an entry dated 3/8/13 at 1245 hours. Staff documented Resident 1's bed alarm was sounding and the resident was found sitting on the side of the bed. The resident asked to go to the bathroom. The resident's CNA was summoned to assist the resident to the bathroom. While in the bathroom; Resident 1 fell off the toilet and sustained a head injury. The licensed nurse documented she asked the resident's CNA what happened. The CNA reported the resident was sitting on the toilet and she (the CNA) turned away to reach for the wheelchair, and the resident suddenly leaned forward and fell on to the floor, hitting the right side of her face. Staff documented the resident was assisted back to bed and assessed to be alert and had no change in her cognition. At 1255 hours, the physician was notified and ordered the resident transferred to the emergency department.Review of the emergency room physician's documentation dated 3/8/13, showed Resident 1 remained unresponsive, did not open her eyes and was nonverbal. Laboratory blood tests and a CT scan of the head were ordered.Review of the CT scan results dated 3/8/13 at 0330 hours, showed progressive hemorrhage to the head with an increase in subarachnoid hemorrhage, acute fractures of the right orbit lateral wall, the medial wall and the right zygomatic arch (upper cheek).Review of the acute hospital "Discharge Summary" dated 3/11/13, showed, due to the resident's overall poor prognosis, hospice was discussed with the resident's family. The resident was transferred back to the skilled nursing facility under hospice care.Resident 1 was readmitted to the facility on 3/11/13, her admitting diagnosis was acute left subarachnoid hemorrhage. An IDT note dated 3/12/13, showed the resident's family declined any aggressive treatment and opted for comfort measures and hospice care. The resident died on 3/17/13.Review of the "Certificate of Death" dated 3/17/13, listed Resident 1's cause of death as "cardiopulmonary arrest secondary to traumatic brain injury from a mechanical fall." Other conditions contributing to Resident 1's death were dementia, deep vein thrombosis with anticoagulant therapy. Observation of Resident 1's room and bathroom was conducted on 4/30/13. The bathroom toilet is located between two walls; on each wall is a vertical safety grab bar. Directly in front of the toilet, approximately 8 feet away, is the sink. Staff identified Resident 1's wheelchair was just outside the bathroom door, inside the resident's room.On 4/30/13 at 0945 hours, an interview was conducted with CNA 2. CNA 2 stated, Resident 1 had unpredictable behavior and was impulsive. She stated, when she assisted the resident to the bathroom, she would stay with her to prevent her getting up or falling.During an interview with CNA 3 conducted on 4/30/13 at 1000 hours, the CNA stated Resident 1 was able to walk slowly with assistance. She stated, when a resident requires extensive assistance, it is the facility's policy to stay with the resident while they are in the bathroom. She stated, when she would assist Resident 1 to the bathroom, she would stay with her. She stated all equipment and hygiene products should be placed within reach, prior to sitting the resident on the toilet, so they would not leave the resident unattended. Review of the facility's P&P titled Falls Prevention Program (undated) showed staff are not to leave residents unattended while they are on the commode, if the resident requires help with transfers. On 4/30/13 at 1100 hours, an interview with the DON was conducted. The DON was asked about Resident 1's fall incident on 3/8/13, and her level of care. The DON stated CNA staff are given report about their assigned residents during change of shift. She stated CNA 1 knew the plan of care for Resident 1. She stated residents who require extensive assistance with toileting or transfers, are not to be left unattended while on the commode.On 5/1/13 at 1630 hours, an interview with CNA 1 was conducted. CNA 1 stated she had walked Resident 1 to the bathroom on 3/8/13. She said the resident was sitting on the toilet, when she stepped just outside the bathroom to get the resident's wheelchair; it was during this time the resident fell from the toilet onto the bathroom floor. The CNA stated "I should have walked her back to her bed." Review of the facility's investigation summary dated 4/12/13, showed CNA 1 had assisted Resident 1 to the bathroom. While Resident 1 was sitting on the toilet, the CNA left the resident to reach for her wheelchair. The CNA reported the wheelchair was located just outside the bathroom, which adjoins the resident's room. While in the process of getting the wheelchair, the CNA had to remove the lap-tray and leg rests from the wheelchair to prepare the chair for the resident to sit on. The CNA stated, while preparing the wheelchair, she saw movement from the corner of her eye and found the resident had fallen to the floor. The CNA immediately summoned her supervisor. These facility failures presented either imminent danger that death or serious physical harm would result to the resident of the long-term health care facility |
| 060000122 |
Mesa Verde Post Acute Care Center |
060011127 |
B |
14-Nov-14 |
KHLZ11 |
18420 |
Abbreviated Survey converted to Class B citation F204: Preparation for safe/orderly transfer/discharge: A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. The facility failed to ensure a safe and orderly discharge for one of two sampled residents (Resident 1) who was discharged home. Resident 1 had multiple medical conditions requiring medical management and monitoring. Resident 1 was dependent on a wheelchair for mobility and dependent on staff for all ADLs and was discharged to his family's home. There was no documented evidence the resident's family was provided an advanced notice, education or sufficient preparation and orientation to ensure this was an appropriate and safe discharge.* Resident 1 required extensive assistance for all ADLs. There was no documented evidence the facility had provided any education and/or training to the resident's family prior to or upon discharge. * Resident 1 had been receiving multiple medications for various medical conditions, including insulin injections (manage blood sugar levels). However, there was no documented evidence the facility provided the caregiver instructions on how to test the resident's blood sugars, administer insulin injections, or any information on dietary restrictions. * The discharge instructions provided to the family were incomplete and written in medical terminology.These failures placed Resident 1 at risk for decline in his overall health condition. Resident 1's family brought him to an acute care hospital ED a few days after being discharged from the facility due to their inability to manage his care. Resident 1 was admitted to the hospital.Findings:Review of the facility's P&P titled Discharge and Transfer of Residents dated 1/21/12, showed the attending physician will order the transfer or discharge of a resident if the resident's welfare and needs cannot be met by the facility. Nursing staff will coordinate with Social Services to ensure the resident or their representative will have instructions and information about their post-discharge plan.Review of the facility's P&P titled Disposition of Resident's Drugs Upon Discharge showed medications for resident's use will be furnished to the resident by the licensed nurse upon discharge according to the orders of the resident's physician.Closed clinical record review was initiated on 8/21/14 for Resident 1. Resident 1 was admitted to the facility on 5/20/14, and re-admitted after being evaluated at an acute care hospital ED visit on 8/12/14.Review of the physician's orders on 5/20/14, showed Resident 1 had at least 17 different medications ordered, including two types of insulin to be administered up to four times a day. He also had an order for two types of eye drops to be administered daily for glaucoma.Review of an H&P dated 5/23/14, showed Resident 1 had fluctuating capacity to understand and make decisions. He had limited mobility of his upper and lower extremities. He was dependent on a wheelchair for mobility. In addition, some of his medical conditions included hypertension (high blood pressure), diabetes requiring insulin injections, glaucoma, and was legally blind.According to the MDS (standardized assessment tool) dated 5/27/14, Resident 1 was assessed to be cognitively impaired, required extensive assistance from two staff for bed mobility, transfers, toileting, and bathing. He required assistance from one staff member to dress and eat his meals. The discharge MDS dated 8/12/14, showed Resident 1 continued to require extensive assistance for bed mobility, transfer, dressing, toileting, and bathing.On 5/27/14, the MDS showed Resident 1 required "skilled nursing care on a continuing basis..." There was no other documentation to show the resident no longer required skilled nursing care at the time of discharge.On 6/6/14, the physician ordered staff to monitor the resident every shift for inappropriately touching females residents and staff.Review of Resident 1's nurses' notes showed the following: * On 8/1/14 at 2200 hours, Resident 1 did not display any behaviors involving touching other residents. * On 8/2/14 during the 3-11 PM shift (Nursing Daily Skilled Summary), there were no episodes of inappropriately touching other residents. * On 8/3/14 at 2100 hours, there were no episodes of inappropriate touching noted. * On 8/4/14 at 0500 hours, there were no inappropriate touching behaviors noted. * On 8/4/14 at 1500 hours, there were no inappropriate behaviors noted. * On 8/9/14 at 2130 hours, there were no abnormal behaviors noted. * On 8/10/14 at 2230 hours, there were no behaviors noted. * On 8/11/14 at 1330 hours, staff contacted psychiatric services regarding observation of resident's inappropriate touching behaviors, and the psychiatric provider would follow up with the resident. * On 8/11/14 at 1330 hours, the PA ordered for the resident to transfer out of facility to a psychiatric facility because of inappropriate touching behaviors. * On 8/11/14 at 1645 hours and 1730 hours, a psychiatric bed was not available for the resident, and an order was given to send the resident to an ED for evaluation. On 8/11/14, the physician ordered Resident 1 be transferred to the acute care hospital ED for evaluation.On 8/11/14 at 1930 hours, the nurse documented Resident 1 transferred to the ED. Review of acute hospital ED record dated 8/11/14, showed the facility transferred Resident 1 due to a behavior of inappropriately touching others. Resident 1 was identified to have a UTI, treated with antibiotics, and transferred back to the facility on 8/12/14.On 8/12/14 at 1500 hours, the nurse documented Resident 1 was in bed (unknown time when he returned to the facility), alert and responsive. There was no documentation regarding any behaviors. On 8/12/14 at 1624 hours, staff obtained a physician's order to discharge Resident 1 to his family member's home. The ordered included to discharge the resident with his mediations, home health nurse, and follow-up with a psychiatrist. This order was a telephone order written by RN 1.Review of the Post Discharge Plan of Care form dated 8/12/14, showed the name of the home health agency; however, there was no contact information provided or information about what service/treatment to expect. Staff identified the resident needed a wheelchair; however, there was no documentation to show the resident was provided one or if one was ordered. The form also listed 16 different medications, including an oral antibiotic, eye drops, two types of insulin, and a transdermal patch. There was no documented evidence as to how much of each medication was provided to the family, if any instructions were provided or if the family understood what the medications were and how to administer them. In addition, staff used medical terminology. For example, for the frequency of insulin, staff wrote "S/Q 3x daily" (subcutaneously 3 times daily). There was no evidence the family understood what "S/Q 3x daily" meant, knew how to administer Resident 1's insulin, or whether the insulin should be held if the resident did not eat. In addition, the resident was to be given Lisinopril (used to treat high blood pressure). Staff used medical terminology when writing to hold if "SBP<110" (systolic blood pressure is less than 110 mmHg). However, there was no evidence the family knew how to take the resident's blood pressure or if they understood what "SBP <110" meant.
On 8/21/14 at 1110 hours, an interview was conducted with the SSD regarding Resident 1. The SSD stated when she came out of a meeting on 8/12/14, she was told arrangements were made for Resident 1 to be discharged to home. She stated she knew the resident was discharged to home with a family member, but she did not know any details about the discharge. The SSD stated the Admissions Director and DON were involved in arranging Resident 1's discharge. The SSD confirmed Resident 1's family did contact her a few days after the resident was discharged. She stated the family member called her to ask for paperwork to help get the resident admitted to another facility.
On 8/21/14 at 1130 hours, an interview was conducted with the Admissions Director. She was asked to describe what she did to assist with the resident's discharge. She stated the DON asked her to call Resident 1's family member because the resident was inappropriate and could not stay at the facility. The Admissions Director stated the resident had been in the ED and needed to be transferred to a psychiatric facility; however, "there were no hospital beds available, so the resident was sent back to the facility." The Admissions Director stated she was directed by the DON to call Resident's family and ask that Resident 1 be taken home "because it was unsafe for him to be around other residents." She added, "The resident had to go because of his behaviors."On 8/21/14 at 1205 hours, a concurrent interview and closed clinical record review was conducted with RN 1. RN 1 reviewed the Post Discharge Plan of Care form for Resident 1. She confirmed she was the nurse who completed and signed the form. She stated she discharged the resident home with his family member on 8/12/14 at around 1730 hours. RN 1 confirmed a home health agency's name was listed; however the telephone number, address, and contact information sections were not provided. RN 1 stated Social Services arranged for home health services for Resident 1.
RN 1 was asked about the discharge medications listed on the Post Discharge Plan of Care. RN 1 initially stated she gave all the medications listed to Resident 1's family along with the instructions. However, a few minutes later, RN 1 stated some of the medications had to be delivered from the pharmacy; therefore, not all of his medications were given to the family upon discharge. RN 1 could not recall what mediations were sent with the family.RN 1 was also asked to locate any documentation showing the caregiver's education and/or instructions were provided to Resident 1's family. RN 1 was unable to locate any evidence the family member was trained on how to lift or transfer the resident, how to address his diabetic nutrition, how to administer his insulin and other medications, or what symptoms to look for if the resident's blood sugars went too low or too high. RN 1 stated the family member knew how to care for the resident, including monitoring his blood sugars. When asked to show documented evidence the family did not need or had refused caregiver training, RN 1 was unable to do so.
On 8/21/14 at 1250 hours, an interview and concurrent closed clinical record review was conducted with the DON. She stated Resident 1 had been wandering into other residents' rooms. The DON stated she was unable to locate an available bed in a behavioral psychiatric facility, so she contacted the resident's psychiatric PA (PA 1) and obtained an order to send Resident 1 to the ED for an evaluation of his behaviors. The DON stated Resident 1 was sent to the ED for psychiatric evaluation on 8/11/14, but because the resident did not have a clinical need to be admitted, he was transferred back to the facility on 8/12/14. The DON was asked since Resident 1 was dependent on others for all ADLs, including medication administration and monitoring, whether it was appropriate to discharge the resident to home with his family member on 8/12/14. The DON stated the resident's physician gave the discharge order.On 8/21/14 at 1430 hours, an interview was conducted with the DON. She confirmed there was no documentation to show the caregiver's education or instruction regarding Resident 1's medication administration and discharge care needs were provided. She also confirmed there was no documentation showing the resident received a Proposed Notice of Discharge form or contact information provided regarding home health services, and the resident was discharged without his own personal wheelchair. On 8/22/14 at 0930 hours, a telephone interview was conducted with Resident 1's family member. The family member stated Resident 1 had lived at another skilled facility before being admitted to this facility. The family member stated he received a call on 8/12/14, from the facility stating, "Your father is back from the emergency room and he is misbehaving. He's wandering around and we can't have this in the facility. You have to come and get him...because we no longer want him here."
The family member stated he felt he had no choice but to pick up Resident 1.
The family member stated he tried to explain to the facility he was not able to provide care for Resident 1 as the resident required long-term care. He stated he told the facility he would need assistance with finding another place for Resident 1 to reside. He said the facility insisted he had to take the resident out of the facility as there were no other options available. He said when he arrived at the facility on 8/12/14 at approximately 1730 hours, the Administrator was not in the facility. He stated, "I had nowhere to turn and I had to take the resident home with me."
The family member was asked if he was provided any instructions, education, or training as to the resident's daily needs (how much assistance he required, how to transfer the resident, incontinence care, medication administration, dietary needs, etc). He said, "No." He was asked if he received any instructions or training regarding how to manage the resident's diabetes or insulin administration. He said, "No."
The family member was asked if he was in a hurry or unable to wait for the facility to provide any education, medications, or supplies. He said, "No."
The family member was asked if Resident 1 was discharged with a wheelchair. He stated the resident was admitted to the facility with his own wheelchair, but the facility was unable to locate it. He stated the facility allowed him to "borrow" a wheelchair for the discharge but instructed him to return it the next day.
When asked about 16 medications listed on the discharge paperwork, the family member stated he was only given three packages of one medication (a blood pressure medication). He stated he knew the resident was taking several medications and had repeatedly asked staff for the medications but was only provided one bottle of eye drops. The family member stated staff told him once he got the resident relocated, contact the facility, provide them the name of the pharmacy, and they would arrange for the medications to be transferred. The family member denied receiving any insulin. When asked if he received a medication called Ceftin (antibiotic prescribed in the ED for a UTI on 8/11/14). He stated, "No, I was only given Lisinopril and the eye drops."
When asked if he had spoken to someone from Social Services about the discharge, the family member stated, "No, not until after the resident was discharged." He stated he contacted Social Services to help him get the necessary paperwork to have the resident admitted to a different facility.
The family member stated he had to take Resident 1 to another family member's home because he was not able to care for the resident. He stated the other family member was also not able to care for Resident 1 and had to take the resident to the nearest acute hospital ED, and the resident was admitted to the hospital again.Review of the acute care hospital ED documentation showed Resident 1's family members brought him to the ED on 8/16/14. The ED physician's documentation showed Resident 1 had been residing in skilled nursing facilities for 8 years. However, on 8/12/14, he was "discharged abruptly from the facility and told that the family needed to come pick him up." The resident was admitted for further evaluation of a cough, fever and urinary tract infection.On 8/26/14 at 1505 hours, a telephone interview was conducted with RN 3. RN 3 worked with Resident 1's physician and said she was contacted by the facility's DON. RN 3 said the DON contacted her directly and told her "the family decided to take him home." RN 3 stated Resident 1 was being followed by a psychiatric provider while at the facility, and the psychiatric provider wanted the resident to be transferred to a psychiatric behavioral facility. When asked to clarify if the DON had asked whether the family could take the resident home, RN 3 stated, "No." She said the DON said, "The family decided to take him home." RN 3 stated she communicated the family's request to take the resident home to the physician; therefore, the physician had given the discharge order.
During an interview and concurrent closed record review with the DON on 9/2/14 at 1330 hours, the DON was asked to locate documentation showing the resident had been seen or evaluated by a psychiatric provider. She was unable to do so.
On 9/2/14 at 1530 hours, a telephone interview and concurrent closed clinical record review was conducted with the DON. She confirmed there were no psychiatric progress notes found in the resident's record. On 9/16/14 at 1534 hours, a follow-up telephone interview and concurrent closed record review was conducted with the DON. The DON stated she contacted the psychiatric provider who then faxed a copy of the record of his visit with Resident 1 to the facility.The DON offered to fax the record of this visit.On 9/17/14, the faxed documents were received. Review of the Psychiatric Evaluation dated 7/27/14, showed the resident had a history of dementia with behavioral disturbances; however, the mental status evaluation showed the resident was in a good mood, and he had no apparent delusional thoughts, or suicidal or homicidal ideation. The note showed, "There were no disturbances expressed during the encounter." The mental status evaluation also showed the resident did not seem to have any prominent signs of major cognitive decline. Resident 1's assessment showed he had "behaviors of wandering into other resident's room and touching them." The plan included increasing Depakene (manage behaviors) to 250 mg two times a day and continuing to monitor his behaviors in response to the medications.
The facility's failure to permit Resident 1 to return to the facility presented likely had a direct or immediate relationship to the health, safety, or welfare of the resident. |
| 630012459 |
Mark Lane One |
060011249 |
B |
15-Oct-15 |
M3F611 |
9054 |
Welfare and Institutions Code, Section 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 above statute was NOT MET as evidenced by: On 8/28/12, an unannounced visit was made to the facility to investigate an entity reported event (ERI) regarding Client 1 falling while in the facility van and fracturing her femur. Based on interview and record review, the facility failed to: Ensure direct care staff (DCS) were properly trained on transporting clients in wheelchairs using the facility van; and ensure the DCS assisted Client 1, who was unable to walk without assistance, to exit the van. As a result, Client 1 fell in the facility van and fractured her femur. Review of the facility's documentation of the incident showed on 8/19/12 at approximately 1530 hours, Client 1 was taken via facility van on an outing to Target. There were two DCS and four clients making the trip. Documentation showed Client 1 was placed in the van using her wheelchair, but the wheelchair was not taken with her to the store.Per interview with DCS 1, Client 1 was going to use an electric wheelchair provided by the store. The DCS stated when they arrived at the store one of the DCS went into the store to get the wheelchair. The wheelchair ramp on the van was then raised so the client could step out on the ramp and ride it down without a wheelchair while the two DCS were standing outside of the van waiting for the client. The client got up from the van seat by herself, took a step to the ramp and then fell. The DCS continued to state the client said her leg had given out. DCS 1 also stated the client immediately complained of pain; therefore, the trip was cancelled and the DCS drove back to the facility. DCS 1 also stated Client 1 was unable to be moved back to the van seat and rode home sitting on the van floor after being pushed back away from the mechanical wheelchair ramp by the DCS. Upon arriving at the home, a male staff member from a sister facility was called upon to help move Client 1 from the van into her wheelchair so she could be transported back into the house.On 8/28/12, an interview was conducted with DCS 2. She stated she helped to bring the client into the facility when the group arrived back at the facility on the day of the incident.DCS 2 also stated she did a body check on Client 1 and only noted a "scrape on her left ankle when she fell with ____ and _____ "(two DCS names). DCS 2 stated Client 1 was complaining of left leg pain so at approximately 1630 hours, DCS 2 called the RN who was on call (this RN worked for the company that owned this facility and several other sister facilities, but this facility was not one that the RN on call worked at).DCS 2 stated the RN told the DCS she could give the client the Tylenol she had ordered for pain. The Tylenol was given to the client at 1648 hours. Client 1 told the DCS she could not move; however, the DCS said the client was able to move her left foot. DCS 2 stated Client 1 refused to eat her dinner due to the pain and at 1720 hours, DCS 2 called the RN back to tell her the client still had pain and was refusing to eat. The DCS stated the RN told her it was too soon to give any more pain medication but did not tell her to do anything else. DCS 2 stated she tried to get the client to eat and was able to get her to take only a few bites of food. The client kept refusing because she said she could not move her leg and that it hurt. DCS 3 was present while DCS 2 was being interviewed. DCS 3 stated she had worked the night of 8/19/12 and she arrived at the facility between 1800 hours and 1900 hours. She stated Client 1 was crying and complaining of pain. DCS 2 stated on 8/19/12 at approximately 2045 hours, she called the RN back and told the RN the client was still having pain. DCS 2 then gave Client 1 two more Tylenol. DCS 2 had recorded on the medication administration record (MAR) that Client 1 described her pain as 10 of 10 (zero [no pain] to 10 [severe pain]). DCS 2 also stated the client did not even ask to go outside to smoke as her usual routine due to the pain.DCS 2 was asked how the client was toileted. She stated the client was able to wheel herself to the bathroom and transfer herself to the toilet. When asked if the client was toileted from the time she arrived back at the facility until the DCS went home on the night of 8/19/12 at 2200 hours, DCS 2 stated, no, the client did not want to move the wheelchair at all due to the pain.DCS 2 stated Client 1 was still up in the wheelchair when she left the facility on 8/19/12 at 2200 hours as she was refusing to move from the chair to go to bed. DCS 2 stated she called the facility at 2300 hours to check on Client 1 and was told the night DCS had finally been able to get Client 1 into bed and that she was asleep.Documentation showed on 8/20/12, the client was transported to the local hospital and was admitted at 0920 hours. She was found to have a fractured femur. The client required surgery for the fracture. An open reduction internal fixation of the fracture was done on 8/21/12.A review of the clinical record of Client 1 was done. Client 1 was 63 years old with a diagnosis of arthritis and a history of left hip arthoplasty (surgery to relieve pain and restore range of motion by realigning or reconstructing a joint). There was documentation the client had been having left leg pain described as a dull ache after walking downstairs. No swelling or discoloration was ever noted by the RN. The client was sent for a left knee x-ray on 8/6/12. The x-ray noted "moderate/advanced degenerative joint disease." Per interview with DCS 2, Client 1 had been using a walker for ambulation, but since she had been complaining of pain, she had been using a wheelchair when leaving the facility. She was still using the front wheel walker in the facility prior to the accident. Documentation showed the physical therapist last evaluated the client on 3/14/12. She stated the client had an objective to walk in the community using her walker for 20 minutes; however that "may be deferred if she has pain due to her osteoarthritis. _____ (client name) should use her w/c only when needed, but should be encouraged to stay as mobile (walking) as possible." The therapist also stated the "client favors her left leg when walking and needs balance support of walker." Also documented was the client was able to walk using a rolling walker in the home and community. The facility's policy for transporting clients in the van was reviewed. The policy stated passengers are never to be left unattended for any reason or amount of time. There was nothing in the policy about a non-wheelchair bound client using a wheelchair lift to enter or exit the van.Even the directions on the lift itself always referred to the use of a wheelchair when using the ramp. On 8/28/12, the QMRP was asked about staff training for the use of the van and transporting clients. The QMRP stated training was done in June 2012. It was determined the person (Staff 1) who transported many of the clients to physician appointments and other sites was responsible for the in-service done in June. Staff 1 was interviewed by telephone on 8/29/12. He stated he had done the in-service and covered the following: 1. Van wheelchair lift operation. 2. Tie down of wheelchairs. 3. Use of seat belts. Staff 1 was asked if using the wheelchair lift for someone not in a wheelchair was ever discussed. He stated, no, he had never been told to allow a client on the lift if not in a wheelchair. As far as he knew it had never been an issue.DCS 1 was interviewed about the use of the wheelchair lift. She was asked if she normally transferred a client on the lift who was ambulatory. She stated it "depended on the client's capabilities .... That she does transfer on feet if the client is ok to walk." DCS 1 had not attended the June in-service noted above per interview with Staff 1 and by documentation on his attendance sheet. The failure of the DCS to follow instructions for the use of the wheelchair lift by trying to have a client who was not in a wheelchair use the lift to be lowered to the ground; and to allow Client 1 to transfer by herself from the van seat out of the van without her walker for balance or the assistance of a DCS had a direct or immediate relationship to the health, safety, or security of Client 1. |
| 060000122 |
Mesa Verde Post Acute Care Center |
060011742 |
B |
13-Oct-15 |
KZFV11 |
28179 |
The citation narrative for this penalty will not fully display due to narrative length limitations. Please send a request toÿCHCQdata@cdph.ca.govÿto obtain a full copy of this citation narrative.ÿ
Glossary of Abbreviations:
CDPHCalifornia Department of Public Health (also referred to as "Department.")
CNACertified Nursing Assistant
Dementialoss of mental function such as thinking, memory, and reasoning skills
DONDirector of Nursing
DSDDirector of Staff Development
IDTInterdisciplinary Team
LVNLicensed Vocational Nurse
MyoclonicInvoluntary jerking or twitching motion of a muscle or group of muscles
Obliquebroken at an angle across the bone
Osteopeniareduced bone mass.
Phalanxbone of the finger or toe
Proximalnearer the center of the body
P&PPolicy & Procedure
RNRegistered Nurse
SBARSituation Background Assessment Recommendation
F226: The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
Findings:
Based on interview, clinical record review and facility document review, the facility failed to thoroughly implement their abuse P&P and to fully investigate reported allegations of resident to resident abuse for 13 of 16 sampled residents (Residents 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 14, 15, and 16).
On 7/15/15, the facility reported allegations of resident to resident abuse which occurred in July and August 2014 for Residents 2, 3, 4, and 5.
On 8/3/15, the facility reported an allegation of resident to resident abuse between Residents 9 and 16.
On 8/4/15, the facility reported an allegation of resident to resident abuse between Residents 8 and 16.
On 8/21/15, the facility reported three separate allegations of resident to resident abuse between Residents 10 and 16, between Residents 5 and 11, and between Residents 8 and 16.
* On 8/10/15, the facility reported an injury of unknown origin for Resident 7. The facility failed to thoroughly implement their abuse P&P to fully investigate the resident's injury of unknown origin.
* The facility failed to thoroughly implement their abuse P&P for four of 16 sampled residents (Residents 8, 9, 5, and 16). The residents were identified by the facility to have been involved in resident to resident abuse allegations during the past year.
* The facility failed to ensure a thorough investigation was conducted and reported to the appropriate authorities when the facility became aware Resident 1 had been involved in four resident to resident allegations of abuse where he was identified to be the alleged abuser.
* Resident 2 reported she awoke and found Resident 1's hand near her vaginal area. A CNA witnessed Resident 1's hand under Resident 2's covers. The facility failed to conduct an investigation and failed to report the allegation of abuse to the appropriate authorities.
* Resident 3 reported she awoke and found Resident 1's hand on her thigh, moving his hand up her leg. The facility failed to conduct a thorough investigation and failed to report any investigative findings to the Department.
* Resident 4 reported he awoke and found Resident 1 placing his finger in his (Resident 4's) anus. The facility failed to ensure a thorough investigation was conducted, failed to report the allegation of abuse to the appropriate authorities, and failed to provide investigative findings to the Department within 5 days.
* Resident 5 reported Resident 1 touched her inappropriately. The facility failed to ensure a thorough investigation was conducted for the allegation of resident to resident abuse for Resident 5 and failed to report the allegation of abuse to the appropriate regulatory agencies.
* Resident 7 reported someone squeezed her hand. The resident's right hand was assessed to be swollen and bruised. An x ray showed Resident 7 sustained a fracture of the second finger on her right hand. The facility failed to ensure a thorough investigation was conducted for Resident 7's injury and failed to report the investigation findings to the Department within 5 days.
* Resident 8 reported she was sitting in her wheelchair with her right elbow on the arm of the wheelchair, lower arm and hand flexed upwards when Resident 16 came from behind her and hit her between the thumb and first finger of her right hand. The facility failed to ensure a thorough investigation was conducted and failed to report a written investigative summary to the Department within 5 days.
* On 8/21/15, the facility reported another resident to resident abuse allegation between Residents 8 and 16. The facility reported Resident 16 used her fist to strike Resident 8 from behind and hit Resident 8's left shoulder blade. The facility failed to conduct a thorough investigation and failed to report the investigation findings to the Department within 5 days.
* Resident 9 reported Resident 16 slapped her on the face when she attempted to pass Resident 16 in the hallway. The facility failed to ensure a thorough investigation was conducted and failed to ensure Resident 9 had been clinically assessed when the allegation of abuse was reported.
* Resident 10 reported a nurse had struck her with papers on 3/9/15, and caused an injury to her eye. Resident 10 was sent to the acute hospital on 3/12/15, after a fall and reported to the hospital staff that a facility nurse had struck her in the eye with papers. The facility failed to ensure a thorough investigation was conducted to address the allegation of abuse.
* Resident 11 reported on 4/26/15, her roommate stated, "maybe I should just kill you and your boyfriend." The facility failed to ensure a thorough investigation was conducted.
* Resident 14 was reported to have struck Resident 15 on her right arm. The facility failed to ensure a thorough investigation was conducted and reported timely to the Department.
* Resident 15 reported Resident 14 struck her on the right arm. The facility failed to ensure a thorough investigation was conducted and failed to report the investigation findings to the Department within 5 days.
* The facility reported Resident 16 had been involved in several alleged physical resident to resident abuse allegations where Resident 16 had been identified as the aggressor. The facility failed to ensure thorough investigations were conducted and failed to ensure a safe environment for other residents.
Failure to follow the facility's P&P and thoroughly investigate allegations of abuse and injuries of unknown origin placed residents at risk for further abuse and a negative impact on their physical, emotional, and/or mental health status condition.
Findings:
Review of the facility's P&P titled Abuse Prevention/Suspicious Criminal Activity Program dated 3/2013 showed the following:
If an alleged abuse/suspicious criminal activity occurs between one resident and another resident and the resident who perpetrated the alleged abuse/suspicious criminal activity has demonstrated behaviors that place others at risk, other measures will be put in place to protect all other residents.
Employees or others who have information about an alleged or suspected abuse/suspicious criminal activity and who do not come forward with this information, either before or during an investigation, are considered as culpable as the person(s) committing the alleged or suspected abuse/suspicious criminal activity.
The role of the Abuse/Suspicious Criminal Activity Coordinator includes monitoring and coordinating the program, investigating alleged or suspected abuse/suspicious criminal activity, and reporting alleged, suspected or substantiated abuse/suspicious criminal activity to the appropriate regulatory or law enforcement agency within the timeframes stipulated by law or regulation.
Verbal reports/statements by residents, families or staff that allege abuse/suspicious criminal activity will be considered an allegation of abuse/suspicious criminal activity until an investigation substantiates or fails to substantiate the allegation. Allegations will be immediately reported (24 hours a day, 7 days a week) to the RN Supervisor or any Department Manager in the facility and/or the Abuse/Suspicious Criminal Activity Coordinator.
The facility will complete a thorough and extensive investigation. Injuries of unknown origin will be reported to the DON for further investigation. Incidents of unknown origin that involve suspicious injury will be treated as possible abuse/suspicious criminal activity and investigated as such.
The facility investigation will include a description of the initial allegation, a summary of findings, notes on facts utilized to substantiate or unsubstantiate the allegation, a list of people interviewed and a conclusion.
A licensed nurse will conduct a physical exam for any resident who reports alleged physical abuse/suspicious criminal activity.
The facility will report all alleged and substantiated abuse/suspicious criminal activity to the appropriate enforcement agencies as required and take appropriate actions to minimize further occurrences. Mandated reporters will send a written report within 24 hours (2 hours for suspected abuse resulting in serious bodily injury) to the local Ombudsman, local law enforcement agency (if required), and CDPH. The form titled "SOC 341" will be used for initial reporting to appropriate agencies.
According to the facility's P&P titled Unexplained Injuries Investigations dated 8/1/14, unexplained injuries are promptly and thoroughly investigated by the DON, Services and/or other staff person appointed by the Administrator. Documentation must include information relevant to risk factors and conditions that cause or predispose someone to similar signs and symptoms. Any descriptions in the clinical record must be sufficiently detailed and should not speculate about cause.
Review of the facility's Recertification Survey completed on 4/1/15, showed the facility was cited at F226 for failure to conduct an investigation into an allegation of resident to resident abuse. The facility's plan of correction showed "The Abuse Coordinator will monitor for compliance by reviewing all reports of alleged abuse and confirming that a written investigation of the incident was completed according to the facility's Abuse Prevention P&P.
1. Resident 1 was alleged to have been involved in resident to resident abuse with Residents 2, 3, 4, and 5 during July and August of 2014.
Clinical record review was initiated for Resident 1 on 7/29/15 at 0910 hours. Resident 1 was admitted on 5/20/14, and discharged on 8/11/14. According to the H&P dated 5/23/14, Resident 1 had fluctuating capacity to understand and make decisions. Review of physician's orders showed Resident 1 was being treated for dementia and mood problems.
On 7/29/15 beginning at 0910 hours, an interview and concurrent facility document review was conducted with the Administrator. The Administrator confirmed he was the facility's Abuse Coordinator. When asked to provide documentation regarding the investigations for alleged abuse regarding Residents 1, 2, 3, 4, and 5, he stated everything was handled through the IDT and anything they had would be in the DON and IDT's notes.
The Administrator was asked if he conducted an investigation for the allegation of abuse between Residents 1 and 4. He stated he sent a letter to CDPH, but no other investigation had been done. When asked if he conducted an investigation for the allegation of abuse between Residents 1 and 5, and for the allegation of abuse between Residents 1 and 3, he deferred to the DON.
On 7/29/15 at 1015 hours, the DON joined the interview and concurrent facility document and clinical record review with the Administrator. The Administrator informed the DON of the documents needed and the DON left the room to obtain them. Upon her return, she provided an internal document showing the allegation made by Resident 5.
The Administrator stated all of the allegations were handled through the IDT process and he did not do his own investigations. The Administrator stated the investigations between Resident s 2, 3, and 4 were all handled the same way.
The facility's Abuse P&P was reviewed with the Administrator, which showed the Abuse Coordinator will coordinate/conduct an investigation and listed steps to take with an investigation. The Administrator verified the P&P outlined his role and responsibilities.
Review of a Nurse's Record dated 7/8/14 at 0600 hours, showed Resident 1 was "found in a female resident's room and was touching her leg while she was sleeping." The note showed "will monitor behavior closely."
Review of an IDT note dated 7/18/14 at 1000 hours, showed Resident 1 was observed/reported to have "caressed/touched" another resident (Resident 2) on the upper extremity and thigh and had also gone into another resident's room. The IDT's recommendations included continued observation of Resident 1's behaviors.
According to a physician's evaluation dated 7/27/14, Resident 1 had been wandering into other residents' rooms and had "touched these residents on the arms and legs."
Review of a Physician's Progress Note dated 8/11/14, showed Resident 1 touched another resident "in her vaginal area." The note also showed Resident 1 had a history of punching other residents, "but this was the first time with him touching somebody sexually."
Review of another facility internal document dated 8/22/14, showed Resident 1 allegedly touched another resident's anus (Resident 4) while Resident 4 was in bed asleep.
During an interview with the Administrator on 7/29/15 at 1430 hours, the Administrator stated he had not done an investigation for Resident 1's involvement with allegations of abuse. He stated Resident 1's behaviors were addressed by the IDT and the IDT would have documented their findings.
On 8/25/15 at 0825 hours, a telephone interview was conducted with the Ombudsman assigned to the facility. The Ombudsman stated their office did a thorough search and did not find any documentation to show the facility notified them about the allegations of abuse involving Resident 1. The Ombudsman stated she did not receive any reports from the facility regarding the allegations of abuse during July and August 2014 or any reports for resident to resident abuse allegations between Resident 1 and Residents 2, 3, or 4.
a. On 7/29/15 at 0910 hours, a concurrent interview and facility document review was conducted with the Administrator. He was asked to provide all documents showing the facility conducted an investigation into Resident 2's allegation of abuse.
The Administrator provided an internal document dated 8/1/14, showing Resident 2 reported she woke up and found Resident 1's hand touching her vaginal area. The document showed a CNA observed Resident 1's hand under Resident 2's covers at 0630 hours; however, there was no documentation to show the CNA was interviewed. The Administrator confirmed he did not notify the appropriate authorities of Resident 2's allegation of abuse. He stated he did not complete an SOC 341 or conduct other interviews.The Administrator stated he did not conduct an investigation.
On 7/29/15 at 1430 hours, an interview was conducted with the DON. She was asked to locate an IDT note to show Resident 2's allegation of abuse was addressed. The DON provided a xeroxed copy of her note, showing the IDT met on 8/12/14, regarding the alleged abuse. It did not show the resident's physician was notified of the incident.
Review of the facility's internal document dated 8/1/14 at 0630 hours, showed a CNA witnessed the alleged abuse and a medication nurse saw Resident 1 in Resident 2's room at 0630 hours and told him to go back to his room. When the DON was asked if she interviewed these staff members, she stated, "I don't know. I'll need to check my notes."
The DON located a nurse's note (undated) at 0720 hours, which showed Resident 1 was observed to have his hand under Resident 2's covers by a CNA. There was no documentation to show Resident 2's physician had been contacted about the incident.
b. Clinical record review was initiated for Resident 3 on 7/29/15. Resident 3 was admitted to the facility on 7/7/14, and re admitted on 10/7/14.
Resident 3 reported on 7/8/14, she woke up and found a male resident (Resident 1) in a wheelchair at her bedside. He was touching her thigh and moving his hand up her leg. Resident 3 shouted at him and told him to get out.
On 7/29/15 at 1130 hours, an interview was conducted with the Administrator. The Administrator confirmed he had not taken the steps outlined under "Investigation," and handled it through the IDT.
Review of the Social Work Progress Notes showed a late entry dated 8/21/14 (untimed) thatResident 3 alleged she woke up at approximately 0530 hours on 7/8/14, and found a man (Resident 1) in a wheelchair at her bedside, touching her thigh, and progressively working his hand up her leg. Resident 3 yelled at Resident 1 to get out and Resident 1 started to wheel himself toward the door of the room. Resident 3 called the nurse and Resident 1 was escorted away from the door. The note did not show if a staff member reported the allegation of abuse (as recalled by the resident to have happened on 7/8/14) to the administrative staff.
On 7/29/15 at 1530 hours, an interview was conducted with the Administrator. He confirmed he did not conduct an investigation regarding Resident 3's allegation of abuse. He stated it was handled through the IDT.
On 8/11/15 at 0950 hours, an interview was conducted with Resident 3. Resident 3 stated she recalled the incident and stated she suddenly awoke and was startled to find a male resident in her room, touching her thigh.
On 7/29/15 at 1445 hours, a concurrent interview and clinical record review was conducted with the DON. She was asked to locate any documentation showing the IDT addressed the allegation of abuse and evaluated Resident 3; however, she was unable to do so. The DON was asked to locate documentation to show Resident 3 had a nursing assessment conducted when she reported the allegation of abuse. The DON located nursing documentation which described the incident; however, the documentation did not show a clinical assessment of Resident 3 had been conducted. In addition, there was no documentation to show the physician and responsible party had been notified.
The Administrator was asked to provide all documentation to show an investigation was conducted for Resident 3's allegation of resident to resident abuse. The Administrator provided an internal facility document dated 8/22/14. The section for date of incident and time of incident was left blank. The sections to document information about witnesses and staff observations were marked "N/A." There was no documentation to show the nurse who escorted the resident out of Resident 3's room was interviewed for this investigation.
The Administrator was asked to provide documents to show the abuse allegation had been investigated. The Administrator stated the allegation of abuse was handled through the IDT process and he did not conduct his own investigation.
The Administrator stated he reported the resident to resident abuse to the Ombudsman. When the Administrator was asked if the Ombudsman responded to his report, he stated he did not know. The Administrator stated the police never responded and he thought it was odd the Department never came out about this. The Administrator was informed the Department did not receive his report.
c. Review of an SOC 341 form Report of Suspected Dependent Adult/Elder Abuse dated 8/22/15, provided by the Administrator on 7/29/15, showed the facility was notified on 8/21/14, by another resident that Resident 4 stated Resident 1 placed his finger in Resident 4's anus while he was sleeping. The report showed Resident 4 was interviewed and stated the other resident did not poke him in the anus, rather, the other resident had his finger in the crack of his (Resident 4's) buttock while he was sleeping.
On 7/29/15 at 0910 hours, a concurrent interview, clinical record review for Resident 4, and facility document review was conducted with the Administrator. He was asked to provide documentation to show he investigated Resident 4's allegation of abuse. The Administrator stated he dealt with this issue through the IDT and there was no other formal investigation.
The Administrator also provided a copy of a letter addressed to the Department dated 8/29/14, which showed a copy of the above Confidential Report was also faxed to the Ombudsman and Police Department. However, the letter showed neither agency had responded. The Administrator stated he sent a letter to the Department; however, he was advised the letter was not received by the Department.
On 7/29/15 at 1015 hours, the DON joined the interview and concurrent facility document review was conducted.The DON was asked to locate documentation in Resident 4's clinical record to show a clinical assessment had been conducted when the abuse allegation was reported to the facility, but she was unable to do so. The DON referred to a brief note, written on a Post Fall Assessment form dated 8/22/14. The note did not show the physician or responsible party had been notified and did not address the allegation of abuse.
d. Clinical record review was initiated for Resident 5 on 7/29/15. Resident 5 was admitted to the facility on 12/31/12, and readmitted on 5/8/14.
Resident 5 reported on 8/21/14, she was sitting in her wheelchair when Resident 1 rolled up next to her in his wheelchair and touched the inside of her thigh and tried to move his hand upward toward her groin.
The facility failed to ensure a thorough investigation was conducted for the allegation of resident to resident abuse for Resident 5 and failed to report the allegation of abuse to the appropriate regulatory agencies.
Review of the clinical record for Resident 5 showed a Social Work Progress Note dated 8/21/14, as a late entry for 8/5/14, which showed Resident 5 had confided in her friend regarding the allegation of abuse. The SSD documented she interviewed Resident 5 and Resident 5 repeated the same allegation as above.
Further review of Resident 5's clinical record showed no documented evidence of a clinical assessment and no documentation by the IDT to show the allegation of abuse was addressed and investigated.
An interview was conducted with the Administrator on 7/29/15 at 0910 hours. The Administrator was asked if an investigation had been completed for Resident 5. The Administrator deferred to the DON.
During an interview with the Administrator on 7/29/14 at 1125 hours, the Administrator stated everything was handled through the IDT and anything they had would be in the DON and IDT's notes.
Review of Resident 5's Incident Report showed the date of the allegation of abuse was 8/21/14, and the time of the alleged incident was mid morning. The Incident Report had a section titled Review Findings which showed Resident 5 had a psychological consult completed on 7/23/14.
On 7/29/15 at 1220 hours, an interview and concurrent clinical record review for Resident 5 was conducted with the DON. The DON was asked to locate the IDT notes which addressed Resident 5's allegation of abuse and the IDT's recommendations. The DON was asked if a clinical assessment had been conducted by nursing and if the physician and responsible party had been notified. The DON was unable to find the requested documentation in Resident 5's clinical record.
e. The facility reported a resident to resident allegation of abuse for Resident 5 on 4/27/15. The Investigation Summary dated 5/1/15, showed the facility was unable to substantiate the allegation. The allegation showed Resident 5 verbally threatened Resident 11 by saying "I should just kill you and your boyfriend." The Administrator was unable to provide any other documented evidence to show the allegation was thoroughly investigated.
Review of Resident 5's clinical record did not show the IDT addressed the allegation of abuse or show any interventions or recommendations.
An interview was conducted with the DON on 8/11/15 at 1400 hours. The DON was asked to locate the information regarding the resident to resident allegation of abuse. The DON was unable to provide any other information. The DON stated the Administrator had conducted the investigation.
2.a. Review of an SOC 341 dated 8/2/15, showed a resident to resident allegation of abuse between Resident 16 and Resident 9, which occurred on 8/1/15. The facility reported Resident 9 alleged she was slapped in the face by Resident 16 when she asked to pass by her in the hallway.
Review of the facility's investigation summary regarding the incident with Resident 9 on 8/1/15, dated 8/9/15, showed it was not completed timely.
Review of a Post Fall Assessment dated 8/3/15, did not show the details of the incident and what steps were taken on the resident's behalf.
b. Review of an SOC 341 dated 8/4/15, showed on 8/3/15, Resident 8 was hit by Resident 16 on her right arm/hand.
Review of the facility's Investigation Summary dated 8/10/15, showed Resident 8 was visiting with another resident in the doorway of the other resident's room when she felt a slap on her right hand.
Review of a Post Fall Assessment form dated 8/4/15, showed the IDT addressed the incident and recommended Resident 16 be monitored as a 1:1 (one to one) until the resident was assisted to bed at bedtime.
The Administrator confirmed he did not conduct any interviews regarding the allegation of abuse between Resident 16 and 8 on 8/4/15. The Administrator stated that was the second time in two days Resident 16 had struck another resident.
On 8/21/15 at 1214 hours, the facility reported a second resident to resident abuse allegation between Residents 16 and 8 and the resident to resident abuse allegations between Residents 16 and 10 and between Residents 16 and 13.
c. The facility reported Resident 16 was being wheeled by a caregiver in the hallway on 8/20/15. When Resident 16 was being wheeled past Resident 8, Resident 16 struck Resident 8 on the left shoulder with her fist. Review of the investigation documents provided by the facility showed page two of a two page document dated 8/21/15. The document contained information to show the authorities were notified of the resident to resident abuse allegation on 8/20/15. A short term care plan problem dated 8/21/15, showed there were "two incidents of resident to resident abuse from the previous week reported to the facility on 8/21/15."
The facility reported a resident to resident abuse allegation between Residents 8 and 16 on 8/21/15 at 1214 hours. The facility reported Resident 8 was walking in the hallway when a caretaker was pushing Resident 16 in her wheelchair from behind. Resident 8 reported Resident 16 struck Resident 8's left shoulder blade with her fist as she approached her. Review of an internal facility document dated 8/21/15, showed Resident 16's caregiver witnessed the allegation of abuse.
On 8/27/15, the facility provided the second page of a two page document which showed the authorities were to be notified of the incident on 8/21/15. Contents of the missing first page were unknown. The narrative report showed Resident 16 was coming up the hallway behind Resident 8, being pushed by a caregiver. As the caregiver started to push Resident 16's wheelchair around Resident 8, Resident 16 struck Resident 8's left upper shoulder blade with her left fist.
As of 9/1/15 (11 days after the facility reported the allegation of abuse to the Department), the Department had not received an investigation summary of findings as required by the regulatory requirement and facility's P&P. |
| 630012459 |
Mark Lane One |
060012730 |
B |
8-Nov-16 |
XZW811 |
8689 |
W331 - The facility must provide clients with nursing services in accordance with their needs. On 8/26/16, an anonymous complaint was sent to CDPH (California Department of Public Health) regarding an ambulatory client who developed a pressure ulcer (a localized injury to the skin and/or underlying tissue usually on a bony prominence, as a result of pressure or pressure in combination with shear) at the facility. The client's legs were swollen and required assistance with walking. There was a physician's order to transfer the client to a skilled nursing, however; the client was still at the facility. On 9/7/16 at 0900 hours, an unannounced visit was conducted at the facility to investigate the above complaint. According to the National Pressure Ulcer Advisory Panel, the pressure ulcer should be assessed initially and reassessed weekly. Weekly assessment provides an opportunity for the healthcare professional to detect any complications and the need for changes in treatment plan. Assess and accurately document the physical characteristics such as the location, category/stage, size, tissue type, wound bed and condition of the areas around the wound (periwound), wound edges, sinus tract, undermining, tunneling, exudate, necrotic tissue, odor, presence or absence of granulation tissue, and epithelialization. Closed clinical record review for Client 1 was initiated on 9/22/16. Client 1 was admitted to the facility on 3/7/13, with diagnoses including profound intellectual disability (an individual with an Intelligence Quotient of less than 25), blindness, and epilepsy. Review of the Nurse's Notes dated 5/20/16, showed Client 1 was seen at the urgent care center for a left upper thigh wound. Documentation showed the wound measured 3 centimeters (cm), was red, and had no drainage. The documentation also showed Client 1 was on antibiotic for one week. However, there was no documentation to identify the kind of wound Client 1 had; and whether the length, width, or depth was "three cm." Also, there was no documentation as to whether a wound treatment was ordered. The Nurse's Notes dated 5/27/16, showed Client 1's wound status had not changed since the urgent care center visit. However, review of the physician's progress note dated 5/27/16, showed the wound had black eschar (dead tissue) and a referral for the wound specialist was ordered. Review of the Quarterly Nursing Audit dated 6/1/16, showed no documented evidence the RN had assessed Client 1's left upper thigh wound. The Nurse's Notes dated 6/8/16, showed Client 1 was seen by his PCP (Primary Care Physician) for a wound care follow up. The documentation showed the wound measured 2 cm by 3 cm with redness and had purulent (yellowish-white fluid formed in infected tissue) discharge; however, there was no documentation on what type of wound Client 1 had. There was no documented evidence the PCP was notified of the wound deterioration. There was no documentation to show a wound treatment was ordered. The documentation also showed the wound specialist referral was still pending. Review of the wound care clinic visit record dated 6/16/16, showed Client 1 had a pressure ulcer to the left hip. However, there was no documented evidence the RN had notified the PCP and attempted to find an appropriate placement for the client who had a pressure ulcer. The Nurse's Notes dated 6/16/16, showed Client 1 was seen at the wound care clinic and received orders to cleanse the wound with normal saline solution, apply silver alginate pad (antimicrobial dressing), and cover with a dry sterile dressing. However, there was no documented evidence the RN had assessed and measured the wound. In addition, there was no documented evidence the RN had provided instructions to the DCS (Direct Care Staff) on how to care for the wound and provide the wound treatment. The Nurse's Notes dated 6/20 and 6/23/16, showed Client 1's left hip wound continued to be the same size. Further review of the clinical record showed no documented evidence the RN had assessed and measured Client 1's wound after 6/23/16. There was no documentation on the status of the wound after 6/23/16. In addition, there was no documented evidence to show Client 1 was seen at the wound care clinic weekly. Review of the Monthly Nursing Summary for July 2016 showed Client 1 had a change of condition/illness on 5/20/16, and was seen at the urgent care center for a left upper leg wound. There was no documentation on the size and status of the wound during the month of July 2016. The Qualified Intellectual Disabilities Professional's (QIDP) note dated 7/19/16, showed Client 1 did not go the Day Program. The documentation showed Client 1 was in "some kind of pain." The documentation also showed the RN at the Day Program "thinks it may have to do with the wound." There was no documented evidence the facility's RN had assessed Client 1's pain and wound status. The wound care clinic visit form dated 7/20/16, showed Client 1's pressure ulcer on the left hip measured 2 cm by 2 cm. The documentation also showed the treatment plan was to continue using the silver alginate pad. The QIDP's note dated 7/23/16, showed Client 1 "still seems in some pain and walking as little as possible." There was no documented evidence the RN had assessed Client 1's pressure ulcer and notified the PCP about Client 1's pain and wound status. In addition, there was no documented evidence to show Client 1 continued to be seen at the wound care clinic weekly. The Nurse's Note dated 8/18/16, showed the left hip wound had increased drainage and odor. The documentation showed an appointment at the wound care clinic was arranged and scheduled for 8/24/16. However, there was no documentation to show the RN had assessed the wound. The Nurse's Note also showed Client 1 was transferred to an acute care hospital on 8/18/16, for an evaluation of the left hip pressure ulcer. Review of the documentation from the acute care hospital visit dated 8/18/16, showed Client 1's right hip wound had "gotten worse". There was no documented evidence the RN had assessed Client 1 after the client returned from the acute care hospital on the same day, 8/18/16. The physician's order from the wound care clinic dated 8/24/16, showed Client 1's pressure ulcer was larger and ordered to transfer to a Skilled Nursing Facility for wound care. Further review of the Nurse's Note showed no documented evidence the RN had assessed and measured Client 1's wound consistently every week. There was no documentation from the RN regarding the size of the wound from 6/23/16 to 8/31/16. The Nurse's Note dated 8/31/16, showed Client 1 was transferred to an ICF-DD/N (Intermediate Care Facility for Developmentally Disabled/Nursing is a facility that provides 24-hour personal care, developmental services, and nursing supervision for developmentally disabled persons who have intermittent recurring needs for skilled nursing care) for wound care. During an interview and concurrent clinical record review with RN 1 on 9/22/16 at 1550 hours, RN 1 stated she started working at the facility on 8/15/16, and was in training with RN 2 until 8/18/16. RN 1 further stated on 8/17/16 at around 1700 to 1800 hours, she and RN 2 received a call from a DCS that Client 1's wound had increased in size, drainage, and odor. When asked if she had assessed the wound, RN 1 replied she did not see the wound. RN 1 further stated Client 1 was seen by the wound specialist on 8/24/16. The wound specialist informed RN 1 Client 1's wound had deteriorated and the client was no longer appropriate to stay in the facility. During a telephone interview with the QIDP on 10/5/16 at 1120 hours, the QIDP was asked if Client 1 had been seen at the wound care clinic weekly. The QIDP verified Client 1 was seen at the wound care clinic on 6/16, 7/20, and 8/24/16, only. The facility failed to ensure the necessary services and treatments to promote the healing of a pressure ulcer were provided. The facility RN failed to appropriately assess Client 1's pressure ulcer on the left hip. The facility RN failed to consistently measure and monitor weekly the status of Client 1's pressure ulcer on the left hip. The facility RN failed to consult with the physician when Client 1 continued to have pain from the left hip pressure ulcer. These failures resulted to the RN not promptly detecting changes in the wound status and the need to change treatment plan to promote healing. Consequently, Client 1's pressure ulcer on the left hip deteriorated. The above violations, either jointly, separately, or any combination had a direct or immediate relation to the patient's health, safety, or security. |
| 070000047 |
MILPITAS CARE CENTER |
070011333 |
B |
24-Mar-15 |
0USZ11 |
3248 |
F333 - 483.25(m)(2) RESIDENTS FREE OF SIGNIFICANT MED ERRORS The facility must ensure that residents are free of any significant medication errors. The facility failed to ensure the residents were free from significant medication errors. Resident 1 was given several non-prescribed medications and failed to receive her prescribed medications.During an interview on 3/4/15 at 10:00 a.m., the director of nursing (DON) stated admitting licensed vocational nurse C (LVN C) faxed what she thought was Resident 1's discharge medication list from the acute hospital interfacility transfer summary to the facility's pharmacy. Two days later, the DON said the dietary service supervisor (DSS) advised her the medication list submitted from the acute hospital interfacility transfer summary for Resident 1 had a different name. The DON checked and verified the discrepancies. During an interview on 3/4/15 at 10:45 a.m., the DSS stated she reviewed all of the resident's clinical record the day after admission for the initial care conference. While reviewing Resident 1's clinical records, she noticed another person's name on the medication list from the acute hospital. She immediately reported this discrepancy to the administrator (ADM) and DON. During an interview on 3/9/15 at 12:50 p.m., LVN C stated she admitted Resident1 she checked the face sheet and all of the documents including interfacility orders. She stated she did not check the name on the medication order list. She also stated after all of the orders were verified with the primary physician, the medication order list was faxed to the facility's pharmacy. Review of Resident 1's medication administration record (MAR) dated 2/2015 indicated Resident 1 had received several doses of nonprescribed medications including the following; one dose of amiodarone (medication use to regulate heartbeat) 200 Milligrams (mg, unit of measurement), one dose of furosemide (medication that increases the excretion of urine) 20 mg, one dose of metoprolol (medication to lower blood pressure) 25 mg, one dose of potassium chloride (supplement/replacement solution) 20 milliequivalent (meq, unit of measurement), and three doses of hydrocodone/norco (pain management) 5/325 mg.Two days after the discrepancies were identified, a list of Resident 1's interfacility transfer summary medications was obtained from the acute hospital and it included; one dose of amlodipine 5 mg (medication to lower down blood pressure), one dose of aspirin EC 81 mg, one dose of vitamin D3 5000 units (dietary supplement), one dose of plavix 75 mg (medication to help prevent blood clot formation), one dose of fosinopril 20 mg (medication to lower blood pressure), two doses of glipizide 10 mg (medication to helps lower blood sugar), three doses of oxycodone (pain management), two doses of simvastatin 20 mg. (medication to lower blood cholesterol), and two doses of januvia 100 mg (medication to lower blood sugar). The facility failed to ensure the resident was free from significant medication errors. Resident 1 was given several nonprescribed medications and failed to receive her prescribed medications. The violation had a direct or immediate relationship to the health, safety, or security of the resident. |
| 070000626 |
MISSION DE LA CASA NURSING & REHABILITATION CENTER |
070011494 |
A |
27-Jul-15 |
7KN911 |
8220 |
F323 - 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure that Resident 1 received adequate assistance to prevent accidents when the resident sustained a broken arm after a staff member lifted her from her bed to a shower chair and back again without the assistance of a second person or the use of a mechanical lift (an assistive device that allows residents to be transferred between a bed and a chair using hydraulic power).Review of Resident 1's clinical record indicated she was admitted to the facility in 2010 with diagnoses including vascular dementia (brain damage caused by problems in the supply of blood to the brain, typically by a series of minor strokes), aphasia (inability to speak following a stroke) and osteoporosis (depletion of calcium and minerals in the bones, making them weak). She was bedbound from the previous strokes and was totally dependent on the nursing staff for all of her care needs. Her activities of daily living (ADL) care plan, revised on 5/8/14, indicated she was totally dependent and needed two persons to transfer, reposition, dress and shower.A review of the "Skin/Wound note" dated 4/5/15 at 9:00 a.m., indicated Resident 1 had a purplish skin discoloration on her right upper arm. The "Administration Note" dated 4/5/15 at 4:44 p.m., indicated "Tylenol (pain medication) 650 mg (a measure unit) given for facial grimace 8/10 (0 means no pain and 10 is the highest possible pain) right shoulder/humerus pain." The "Change of Condition note" dated 4/5/15 at 5:20 p.m., indicated the attending physician responded at 4:35 p.m. and he ordered an X-ray for the right upper arm. The X-ray company was notified regarding this order at 4:36 p.m. The "Final X-Ray Report" dated 4/5/15, indicated at 5:30 p.m. the X-ray company arrived to the facility and the X-ray of the right arm was done. The "Health Status Note" dated 4/5/15 at 7:25 p.m., indicated at 7:30 p.m. the physician was updated on the X-ray report of acute to subacute nondisplaced humeral neck fracture and for Resident 1 he ordered an arm sling to the right shoulder worn at all times and to schedule a follow-up appointment with an orthopedic surgeon. A review of Resident 1's clinical record indicated there had been a significant increase in Tylenol beginning 4/5/15 when the arm fracture was discovered. The medication administration record (MAR) for April 2015 indicated 17 individual doses of Tylenol tablets were administered from 4/5/15 through 4/13/15. There was no Tylenol administration on the February or March 2015 MARs for Resident 1. A record review of the "Interdisciplinary Team Review" dated 4/6/15 indicated under Area of Concern: "Resident with skin discoloration and swelling on right upper arm." Under Plan of Action: "x-ray done on Right Shoulder and Right Humerus" Under Impression - "Acute to subacute non-displaced humeral neck fracture with minimum cortical step off- Moderate Osteoporosis- Mild degree of OsteoarthritisMD and RP aware MD with new orders: sling on R arm & keep Head of Bed 30 degrees. Appt.with Dr. [Name] (Orthopedic Surgeon)* Disciplinary action on assigned CNA* Staff Education on proper positioning and transfers* Monitor skin discoloration & swelling until resolved." Resident 1 was observed in her room on 4/17/15 at 11:05 a.m. She was awake and alert, but unable to answer questions appropriately. She had a sling on her right arm holding her arm at a ninety degree angle and a large pillow supporting her right arm. She also had bruising on her right upper arm. During an interview on 4/17/15 at 9:55 a.m. with the director of nurses (DON), she stated Resident 1 required the assistance of a Hoyer lift (mechanical lift assist device) to transfer from one surface to another. She stated certified nurse assistant A (CNA A), who was assigned to provide care for Resident 1, did not use the Hoyer lift or ask for assistance from fellow staff members when the resident was moved from her bed to a shower chair and later returned to her bed after a shower. She also stated CNA A had been counseled on a prior occasion when he did not use a Hoyer lift when indicated. The DON stated CNA A admitted he did not ask for help when he moved Resident 1. CNA A was interviewed by telephone on 4/17/15 at 11:50 a.m. He stated he was Resident 1's CNA on the 4/4/15 evening shift and had cared for Resident 1 on prior occasions. He stated, "CNAs are very busy in the afternoon because of getting them (residents) finished before dinner time. I couldn't find anyone to help me lift her into the Hoyer. There is supposed to be two people to lift, I have moved her previously without any problems. If I would have waited for help, the work wouldn't get done. She didn't make any facial expressions of pain when I lifted her and carried her to the chair. She communicates with her eyes and I didn't see any change in her eyes to tell me that she was hurt." During an interview with licensed vocational nurse B (LVN B) by telephone on 4/27/15 at 1 p.m., she stated she was the evening charge nurse on 4/4/15 and supervised CNA A. She stated all of the CNAs were reminded of each resident's ADL and the level of support each resident required during shift rounds. She stated CNA A was very familiar with Resident 1's ADL needs, including the need for a two person lift, since the resident was totally bedbound and dependent. She stated she observed CNA A returning Resident 1 from the shower. She stated she did not observe CNA A moving Resident 1 out of bed or putting her back to bed. She also stated CNA A did not ask her to assist him when he was moving Resident 1 or any other resident. During an interview on 4/17/15 at 2:20 p.m. with CNA C, she stated the assistance of two people was necessary when a mechanical lift was used for the safety of the resident and to prevent injury to the CNAs. She stated sometimes a CNA will have to wait for assistance if all of the nursing staff were busy but help was always necessary to use the lift safely.During an interview on the same day at 2:35 p.m. with CNA D, he stated the facility policy required the assistance of two people when the lift was used.During an interview on 4/27/15 at 1:45 p.m. with CNA E, he stated he was working with CNA A on 4/4/15 and CNA A never asked him for any assistance.During an interview on 4/29/15 at 11:30 a.m. with CNA F, she stated she was working with CNA A on 4/4/15 and CNA A never asked her for any assistance. She also stated she had worked with him on other occasions and he had never asked her for any assistance. In addition, she stated she was familiar with Resident 1's needs and she knew the resident always required the assistance of two persons for ADLs. CNA A's personnel file was reviewed on 4/17/15 at 11:50 a.m. and indicated he lifted another resident without assistance in March 2012. The resident required two people when lifted. Resident 1's attending physician, physician G (Phys G) was interviewed by telephone 6/9/15 at 9 a.m. Phys G stated the facility did an investigation and determined the CNA caring for Resident 1, CNA A, did not follow protocol, and had been "let go" because of that. Additionally, he stated it was not certain if CNA A had caused Resident 1's arm fracture, but that he probably contributed to it. A review of the facility's policy, "Lifting Machine, Using a Portable", revised 12/2013, indicated the resident's care plan should be reviewed to check for any special needs. When a lifting device was used, two nurse assistants were required to perform the procedure.The facility failed to ensure Resident 1 received adequate assistance to prevent accidents when the resident sustained a broken arm after a staff member lifted her from her bed to a shower chair and back again without the assistance of a second person or the use of a mechanical lift. The violation of the regulation presented either imminent danger that serious harm would result or a substantial probability that serious physical harm would result. |
| 070000047 |
MILPITAS CARE CENTER |
070011591 |
B |
24-Jul-15 |
BSD911 |
11574 |
F225 483.139(c)(1)(ii)-(iii), (c)(2) - (4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to report an injury of unknown origin within 24 hours after discovery as per regulatory requirement for one of three sampled residents (Resident 1). On 6/7/15, Resident 1 was identified by certified nurse assistant A (CNA A) to have skin discoloration on her right upper arm. CNA A notified licensed nursing staff on 6/7/15. Licensed nursing staff did not assess why Resident 1 had skin discoloration until 6/9/15. On 6/9/15 it was identified via an X-ray that Resident 1 had suffered a complete displacement and fracture of the right upper arm humerus (long bone) head (right shoulder fracture). The fracture was the cause of Resident 1's skin discoloration. This failure had the potential in further injury to the resident and noncompliance with State and Federal law.Review of Resident 1's 5/19/15 minimum data set (MDS, an assessment tool) indicated the resident was on hospice care (supportive care in the final phase of a terminal illness). Resident 1 had a history of a stroke with right-side weakness, osteoporosis (bones are brittle and fragile), functional decline requiring two-person assistance during repositioning and transfers, cognitive impairment (a decline of mental processes) related to dementia (a brain disorder marked by memory disorders, personality changes, and impaired reasoning), and the inability to communicate and interact with others.Review of Resident 1's medical record indicated the following: a 6/9/15 physician order at 10:30 a.m. indicated for an X-ray of the right shoulder and right elbow. A 6/9/15 physician's order at 2:00 p.m. indicated a referral to an orthopedic surgeon due to a right shoulder fracture. A 6/9/15 written report from the orthopedic doctor indicated a complete displacement and fracture of Resident 1's right upper arm humerus (long bone) head. A 6/10/15 physician's order indicated to transfer Resident 1 to an acute care hospital.Review of Resident 1's acute care hospital "Discharge Summary" dated 6/16/15 indicated the resident was admitted on 6/10/15 with a diagnosis including "right proximal humerus fracture with complete displacement" and "chronic bedridden status". The report indicated Resident 1 had "bruising over her right arm and chest", pain with Range of Motion (ROM, is a measurement of movement around a joint), and "need to watch the arm/shoulder/chestwall compartments closely to look out for any compartment syndrome [a condition resulting from increased pressure within a confined body space]...given the amount of bleeding", "plans were for operative procedure...the patient's [Resident 1] family...opted against having any type of operative procedure".During an interview with CNA A on 6/18/15 at 1:40 p.m., CNA A stated she was the caregiver assigned to Resident 1 from 6/6/15 through 6/8/15. As per Resident 1's routine, CNA A stated she gave Resident 1 a bed bath after breakfast and dressed her for the day. CNA A stated on Sunday morning (6/7/15) she first noticed a greenish-brown skin discoloration on Resident 1's right shoulder down to Resident 1's right upper arm. CNA A stated she showed Resident 1's discolorations to certified nurse assistant B (CNA B) who told CNA A the incident needed to be reported. CNA A stated on 6/7/15 she told registered nurse C (RN C) about Resident 1's skin discoloration. The next day (Monday, 6/8/15), CNA A stated she noticed the appearance of a new greenish discoloration on Resident 1's chest and the worsening of the discoloration on Resident 1's right upper arm which she again reported to RN C on 6/8/15.During an interview with CNA B on 6/18/15 at 2:35 p.m., CNA B stated on Sunday morning (6/7/15), CNA A showed her the dark skin discolorations on Resident 1's right upper arm and light greenish discoloration on Resident 1's chest. CNA B stated she told CNA A to report the discolorations to a nurse. CNA B stated she was by the door of the activity room later that morning when she saw and heard CNA A tell RN C at the nurses' station about the new skin discolorations on Resident 1. CNA B stated when they were all inside the activity room she heard CNA A remind RN C a second time to check Resident 1.During an interview with RN C on 6/18/15 at 2:15 p.m., RN C stated she was busy with the admission of a new resident on 6/7/15, which was Sunday morning. RN C stated she did not recall CNA A telling her about the new skin discoloration on Resident 1. RN C stated she heard about Resident 1's skin discoloration from CNA A on 6/8/15, Monday morning. RN C stated she did the skin assessment and notified the hospice case manager. RN C stated she did not notify the facility's administrator (ADM) or any physician as Resident 1 was a hospice patient. RN C stated no investigation was started as to why and how Resident 1 sustained the skin discolorations.During an interview with licensed vocational nurse D (LVN D) on 6/19/15 at 2:20 p.m., LVN D stated she was the charge nurse assigned to Resident 1 for the afternoon shift on 6/7/15. LVN D stated she did not get a report on Resident 1's skin discoloration from the morning nurse (RN C). LVN D stated she heard about Resident 1's skin discoloration from certified nurse assistant E (CNA E) who was assigned to Resident 1 for the afternoon shift. LVN D stated she saw Resident 1 had a "big bluish" skin discoloration from the outer part of her right upper arm to her underarm and a greenish/blue discoloration on her chest. LVN D stated she did not measure the size of the skin discoloration. LVN D stated she did not check Resident 1's nursing notes, care plan, or the treatment administration record as to whether anything was done for Resident 1. LVN D stated she forgot to document Resident 1's skin discoloration. LVN D stated facility staff was in-serviced that if they (facility staff) found multiple and big skin discolorations on residents they were supposed to report it to a supervisor and complete an incident report. LVN D stated she did not do any of the above and she forgot to endorse Resident 1's change in condition to the night shift (11 p.m. to 730 a.m.) nurse (LVN F).During an interview with LVN F on 7/1/15 at 1:45 p.m., LVN F stated she was Resident 1's nurse on 6/7/15 to 6/8/15 from 11 p.m. to 7:30 a.m. LVN F stated she first heard of Resident 1's skin discoloration from CNA G at approximately 6:30 a.m. on 6/8/15. LVN F stated she saw the discoloration on the right underarm of Resident 1 when she peeked through the sleeve of Resident 1's gown. LVN F stated Resident 1's skin discoloration was a reportable unusual occurrence because Resident 1 had weakness on her right side, was always leaning on her left side, and unable to move in bed by herself. LVN F stated CNA G told her (LVN F) it was already reported to RN C. LVN F stated she did not do Resident 1's skin assessment or check if there was a physician's order for Resident 1's skin discoloration.During an interview with the hospice case manager (HCM) on 6/19/15 at 11:28 a.m., he stated RN C notified him on Monday, 6/8/15 of the new skin issues with Resident 1 but told him it would be acceptable for him to come and look at Resident 1's skin discolorations the following day (Tuesday, 6/9/15). Per the HCM, on Tuesday, 6/9/15, at 9 a.m. he saw Resident 1's right upper arm was swollen with dark bluish skin discolorations which extended up to her right shoulder and across her chest. The HCM stated he notified the ADM and the hospice physician. The HCM stated the physician ordered Resident 1 to have an immediate X-ray of her right shoulder and right elbow.During an interview with the ADM on 6/19/15 at 12:05 p.m., the ADM stated she first became aware of the skin discolorations on Resident 1 on 6/9/15, Tuesday morning the ADM stated she saw Resident 1 had a swollen right upper arm and had skin discolorations from her right upper arm extending up to her chest. The ADM stated nursing should have notified her when the discoloration was first noted as it was an unusual occurrence of unknown origin. The ADM stated Resident 1 was unable to move by herself in bed or in chair. The ADM stated nursing should have started an investigation to identify what caused Resident 1's skin discoloration on Sunday morning (6/7/15) when CNA A first reported the skin discolorations to RN C. The ADM stated there was no documentation in Resident 1's clinical record indicating Resident 1's skin discolorations were assessed. The ADM stated an investigation was not done by RN C or any of the nurses working on 6/7/15. The facility's 07/05 policy, "Facility Abuse, Neglect and Misappropriation Investigation", indicated the facility would "take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source by screen, train, prevent, identify, protect, investigate, and reporting. An Incident and Injury Report Form shall be completed for any injury of unknown and known origin. Identifying events, such as "suspicious bruising, skin tears, or change in social behaviors". The staff member who observes or licensed nurse shall be responsible for completing a physical assessment of the resident involved, notifying attending physician and responsible parties and documenting all pertinent medical findings in the resident's medical record. The licensed nurse shall also initiate a care plan to address findings from the assessment. The Administrator/Designee and the Director of Nursing must be notified as soon as possible but no later than 24 hours after the incident is reported. The Administrator and/or the Director of Nursing shall make a telephone report to the Department of Health (California Department of Public Health) and to the office of the Ombudsman within 24 hours of any alleged abuse incident. SOC Form will also be submitted either by fax or mail service within two working days. On 6/7/15 the facility identified Resident 1 to have a skin discoloration on her right upper shoulder which was caused by a fracture. The facility failed to investigate and report the injury of unknown origin to the Department within 24 hours of identification. |
| 070000047 |
MILPITAS CARE CENTER |
070011592 |
B |
24-Jul-15 |
BSD911 |
11578 |
F225 483.139(c)(1)(ii)-(iii), (c)(2) - (4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to report an injury of unknown origin within 24 hours after discovery as per regulatory requirement for one of three sampled residents (Resident 1). On 6/7/15, Resident 1 was identified by certified nurse assistant A (CNA A) to have skin discoloration on her right upper arm. CNA A notified licensed nursing staff on 6/7/15. Licensed nursing staff did not assess why Resident 1 had skin discoloration until 6/9/15. On 6/9/15 it was identified via an X-ray that Resident 1 had suffered a complete displacement and fracture of the right upper arm humerus (long bone) head (right shoulder fracture). The fracture was the cause of Resident 1's skin discoloration. This failure had the potential in further injury to the resident and noncompliance with State and Federal law.Review of Resident 1's 5/19/15 minimum data set (MDS, an assessment tool) indicated the resident was on hospice care (supportive care in the final phase of a terminal illness). Resident 1 had a history of a stroke with right-side weakness, osteoporosis (bones are brittle and fragile), functional decline requiring two-person assistance during repositioning and transfers, cognitive impairment (a decline of mental processes) related to dementia (a brain disorder marked by memory disorders, personality changes, and impaired reasoning), and the inability to communicate and interact with others.Review of Resident 1's medical record indicated the following: a 6/9/15 physician order at 10:30 a.m. indicated for an X-ray of the right shoulder and right elbow. A 6/9/15 physician's order at 2:00 p.m. indicated a referral to an orthopedic surgeon due to a right shoulder fracture. A 6/9/15 written report from the orthopedic doctor indicated a complete displacement and fracture of Resident 1's right upper arm humerus (long bone) head. A 6/10/15 physician's order indicated to transfer Resident 1 to an acute care hospital.Review of Resident 1's acute care hospital "Discharge Summary" dated 6/16/15 indicated the resident was admitted on 6/10/15 with a diagnosis including "right proximal humerus fracture with complete displacement" and "chronic bedridden status". The report indicated Resident 1 had "bruising over her right arm and chest", pain with Range of Motion (ROM, is a measurement of movement around a joint), and "need to watch the arm/shoulder/chestwall compartments closely to look out for any compartment syndrome [a condition resulting from increased pressure within a confined body space]...given the amount of bleeding", "plans were for operative procedure...the patient's [Resident 1] family...opted against having any type of operative procedure".During an interview with CNA A on 6/18/15 at 1:40 p.m., CNA A stated she was the caregiver assigned to Resident 1 from 6/6/15 through 6/8/15. As per Resident 1's routine, CNA A stated she gave Resident 1 a bed bath after breakfast and dressed her for the day. CNA A stated on Sunday morning (6/7/15) she first noticed a greenish-brown skin discoloration on Resident 1's right shoulder down to Resident 1's right upper arm. CNA A stated she showed Resident 1's discolorations to certified nurse assistant B (CNA B) who told CNA A the incident needed to be reported. CNA A stated on 6/7/15 she told registered nurse C (RN C) about Resident 1's skin discoloration. The next day (Monday, 6/8/15), CNA A stated she noticed the appearance of a new greenish discoloration on Resident 1's chest and the worsening of the discoloration on Resident 1's right upper arm which she again reported to RN C on 6/8/15.During an interview with CNA B on 6/18/15 at 2:35 p.m., CNA B stated on Sunday morning (6/7/15), CNA A showed her the dark skin discolorations on Resident 1's right upper arm and light greenish discoloration on Resident 1's chest. CNA B stated she told CNA A to report the discolorations to a nurse. CNA B stated she was by the door of the activity room later that morning when she saw and heard CNA A tell RN C at the nurses' station about the new skin discolorations on Resident 1. CNA B stated when they were all inside the activity room she heard CNA A remind RN C a second time to check Resident 1.During an interview with RN C on 6/18/15 at 2:15 p.m., RN C stated she was busy with the admission of a new resident on 6/7/15, which was Sunday morning. RN C stated she did not recall CNA A telling her about the new skin discoloration on Resident 1. RN C stated she heard about Resident 1's skin discoloration from CNA A on 6/8/15, Monday morning. RN C stated she did the skin assessment and notified the hospice case manager. RN C stated she did not notify the facility's administrator (ADM) or any physician as Resident 1 was a hospice patient. RN C stated no investigation was started as to why and how Resident 1 sustained the skin discolorations.During an interview with licensed vocational nurse D (LVN D) on 6/19/15 at 2:20 p.m., LVN D stated she was the charge nurse assigned to Resident 1 for the afternoon shift on 6/7/15. LVN D stated she did not receive a report on Resident 1's skin discoloration from the morning nurse (RN C). LVN D stated she heard about Resident 1's skin discoloration from certified nurse assistant E (CNA E) who was assigned to Resident 1 for the afternoon shift. LVN D stated she saw Resident 1 had a "big bluish" skin discoloration from the outer part of her right upper arm to her underarm and a greenish/blue discoloration on her chest. LVN D stated she did not measure the size of the skin discoloration. LVN D stated she did not check Resident 1's nursing notes, care plan, or the treatment administration record as to whether anything was done for Resident 1. LVN D stated she forgot to document Resident 1's skin discoloration. LVN D stated facility staff was in-serviced that if they (facility staff) found multiple and big skin discolorations on residents they were supposed to report it to a supervisor and complete an incident report. LVN D stated she did not do any of the above and she forgot to endorse Resident 1's change in condition to the night shift (11 p.m. to 730 a.m.) nurse (LVN F).During an interview with LVN F on 7/1/15 at 1:45 p.m., LVN F stated she was Resident 1's nurse on 6/7/15 to 6/8/15 from 11 p.m. to 7:30 a.m. LVN F stated she first heard of Resident 1's skin discoloration from CNA G at approximately 6:30 a.m. on 6/8/15. LVN F stated she saw the discoloration on the right underarm of Resident 1 when she peeked through the sleeve of Resident 1's gown. LVN F stated Resident 1's skin discoloration was a reportable unusual occurrence because Resident 1 had weakness on her right side, was always leaning on her left side, and unable to move in bed by herself. LVN F stated CNA G told her (LVN F) it was already reported to RN C. LVN F stated she did not do Resident 1's skin assessment or check if there was a physician's order for Resident 1's skin discoloration.During an interview with the hospice case manager (HCM) on 6/19/15 at 11:28 a.m., he stated RN C notified him on Monday, 6/8/15 of the new skin issues with Resident 1 but told him it would be acceptable for him to come and look at Resident 1's skin discolorations the following day (Tuesday, 6/9/15). Per the HCM, on Tuesday, 6/9/15, at 9 a.m. he saw Resident 1's right upper arm was swollen with dark bluish skin discolorations which extended up to her right shoulder and across her chest. The HCM stated he notified the ADM and the hospice physician. The HCM stated the physician ordered Resident 1 to have an immediate X-ray of her right shoulder and right elbow.During an interview with the ADM on 6/19/15 at 12:05 p.m., the ADM stated she first became aware of the skin discolorations on Resident 1 on 6/9/15, Tuesday morning the ADM stated she saw Resident 1 had a swollen right upper arm and had skin discolorations from her right upper arm extending up to her chest. The ADM stated nursing should have notified her when the discoloration was first noted as it was an unusual occurrence of unknown origin. The ADM stated Resident 1 was unable to move by herself in bed or in chair. The ADM stated nursing should have started an investigation to identify what caused Resident 1's skin discoloration on Sunday morning (6/7/15) when CNA A first reported the skin discolorations to RN C. The ADM stated there was no documentation in Resident 1's clinical record indicating Resident 1's skin discolorations were assessed. The ADM stated an investigation was not done by RN C or any of the nurses working on 6/7/15. The facility's 07/05 policy, "Facility Abuse, Neglect and Misappropriation Investigation", indicated the facility would "take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source by screen, train, prevent, identify, protect, investigate, and reporting. An Incident and Injury Report Form shall be completed for any injury of unknown and known origin. Identifying events, such as "suspicious bruising, skin tears, or change in social behaviors". The staff member who observes or licensed nurse shall be responsible for completing a physical assessment of the resident involved, notifying attending physician and responsible parties and documenting all pertinent medical findings in the resident's medical record. The licensed nurse shall also initiate a care plan to address findings from the assessment. The Administrator/Designee and the Director of Nursing must be notified as soon as possible but no later than 24 hours after the incident is reported. The Administrator and/or the Director of Nursing shall make a telephone report to the Department of Health (California Department of Public Health) and to the office of the Ombudsman within 24 hours of any alleged abuse incident. SOC Form will also be submitted either by fax or mail service within two working days. On 6/7/15 the facility identified Resident 1 to have a skin discoloration on her right upper shoulder which was caused by a fracture. The facility failed to investigate and report the injury of unknown origin to the Department within 24 hours of identification. |
| 070000047 |
MILPITAS CARE CENTER |
070012531 |
B |
31-Aug-16 |
RF3B11 |
3665 |
F 250--483.15(g)(1) PROVISION OF MEDICALLY RELATED SOCIAL SERVICE The facility must provide medically related social service to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to provide medically-related social services for Resident 5. Resident 5 had a prescribed urgent podiatry referral and he was not scheduled. This failure resulted in Resident 5 not receiving the urgent podiatry care and an infection on Resident 5's left big toe. Resident 5's clinical record was reviewed. The resident was admitted on 1/26/2016 with diagnosis of diabetes (high blood sugar). His Minimum Data Set (MDS, assessment tool) dated 2/1/2016, indicated the resident was cognitively intact, required assistance with bed mobility, transfer, hygiene and bathing. Review of Resident 5's physician's order, dated 7/7/2016, indicated Resident 5 needed urgent podiatry care. Review of Resident 5's Situation Background Assessment Recommendation (SBAR, a technique used to facilitate prompt and appropriate communication), dated 7/16/2016, indicated Resident 5's left big toenail fell off. There was no documentation Resident 5 was seen for urgent podiatry care. Review of Resident 5's Treatment Administration Record (TAR), dated 8/14/2016, indicated Resident 5's left big toe was red, swollen with drainage, and there was an order to cleanse with normal saline, pat dry, apply triple antibiotic and cover with dry dressing. Review of Resident 5's physician's order dated 8/14/2016, indicated an order of Augmentin (antibiotic for infection) 875-125 milligrams (mg, unit of measurement) two times a day for infection. Review of Resident 5's antibiotic therapy care plan, dated 8/14/2016, indicated to administer Augmentin 875-125 mg. medication due to his left big toenail infection. During an interview with the social service director (SSD) on 8/17/2016 at 8:50 a.m., she confirmed Resident 5 had an urgent podiatry care order on 7/7/16 to look at his left big toenail but there was none scheduled. SSD verified there was no documentation Resident 5 was seen by a podiatrist since his admission to the facility and she stated no appointment was scheduled regarding the urgent podiatry care order dated 7/7/16. During an observation and interview with licensed vocational nurse D (LVN D) on 8/17/2016 at 10:25 a.m., LVN D measured Resident 5's left big toe's open area. It was approximately 1.5 centimeter (cm, unit of measurement) in length, and 1 cm in width. It was swollen, with yellow discharge, and a black scab on the nail bed. LVN D stated she was the assigned nurse on the day when Resident 5's toenail fell off, and stated Resident 5 should have been seen by a podiatrist on 7/7/2016. During an interview with the administrator (ADM) on 8/17/2016 at 10:40 a.m., she stated she was aware Resident 5 should have been seen by a podiatrist on 7/7/2016 and it should have been followed-up by the SSD. During an interview with the primary physician (PP) on 8/17/2016 at 3:40 p.m., he stated based on Resident 5's urgent podiatry care order, as a diabetic resident, the resident should have been seen by a podiatrist within a week of the order to prevent complication and infection. Review of the facility's undated policy, "Policy and Procedure for Podiatry Services," indicated podiatry services for residents are scheduled every 60 days and if needed per the physician's order. Review of the SSD job description indicated SSD ensured that residents' medical, emotional and social needs are met. These violations had a direct or immediate relationship to the health, safety, or security of the resident. |
| 070000626 |
MISSION DE LA CASA NURSING & REHABILITATION CENTER |
070012940 |
B |
7-Feb-17 |
W6NN11 |
8258 |
F226, 483.12(b)(1)-(3), 483.95(c)(1)-(3) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES
483.12
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95,
483.95
(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on-
(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12.
(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property
(c)(3) Dementia management and resident abuse prevention.
The facility failed to implement the facility's abuse policy when an alleged resident abuse was not reported within 24 hours to the appropriate agencies for Resident 1 and when one staff was not trained annually regarding abuse policies and procedures. These failures had the potential for continued abuse and harm to the resident by a suspected abuser, if the allegation was proven, and failure to maintain annual elder abuse training of policies and procedures for one staff.
1. Review of the form SOC 341 (a form used to report alleged abuse) received by the California Department of Public Health (CDPH) via facsimile on 12/20/16 at 1:23 p.m., indicated an alleged abuse incident occurred on 12/19/16 at 4 p.m. against Resident 1. It indicated voicemail messages were left for the Ombudsman and CDPH on 12/19/16 at 6:50 p.m. It indicated the local police department was notified on 12/19/16 at 5:39 p.m.
During an interview on 12/30/16 at 7:30 a.m. with the administrator, he stated Resident 1's family members (FMs) came into the facility for a meeting on 12/19/16 at approximate 3:30 p.m. and informed him staff was showing the resident cell phone videos of a sexual nature, and was inappropriately touching and abusing the resident. Resident 1's skin was checked and no scratch was noted. The administrator stated he found out about the alleged abuse late on 12/19/16 so the SOC 341 was not faxed to CDPH until 12/20/16 at 1:23 p.m.
During an interview on 12/30/16 at 1:06 p.m. with Resident 1's family member (FM), he stated on 12/18/16 at 7:50 a.m. the resident was mumbling he did not want certified nurse assistant A (CNA A) caring for him as he was rough with him, threw him on the bed, touched him inappropriately, and scratched him on his abdomen. The FM stated CNA A also invited the resident to watch a pornographic video with him on his cell phone.
During an interview on 12/30/16 at 9:12 a.m. with CNA B, she stated on 12/18/16, she was in the room feeding breakfast to Resident 1's roommate when she heard Resident 1 complain (in a language other than English) to his FMs, CNA A scratched him during care and showed him a sex film on his cell phone on Friday, 12/16/16. CNA B replied to Resident 1 and his FMs, if the resident had a complaint he should report it to the licensed nurse supervisor and the social worker on Monday (12/20/16).
During a continued interview with CNA B, she stated she would consider it alleged abuse if a CNA was showing a video of a sexual nature to a resident. She stated she reported to registered nurse C (RN C) only that Resident 1's FMs did not want CNA A to care for the resident. She stated she should have informed RN C of the alleged sexual video shown to the resident and the allegation of being scratched on the abdomen by CNA A.
During an interview on 12/30/16 at 9:40 a.m. with RN C, she stated Resident 1's FMs came to her on 12/18/16 at approximately 9:30 a.m. and asked for the names of Resident 1's nurse and CNA. She stated she gave a note with licensed vocational nurse D (LVN D's) name and CNA A's name on it. She asked the FMs why they were requesting staff names and was informed CNA A handled Resident 1 roughly and showed the resident an inappropriate video. RN C stated she was shocked and never had this kind of case. She stated she was not the regular nurse and was not sure what to do. She asked the FM to talk to the supervisor "tomorrow." She stated she considered the allegations potential for sexual and physical abuse, but did not further investigate.
During an interview on 12/30/16 at 10:15 a.m. with the social service director (SSD), she stated Resident 1's FM's had a meeting with staff at approximately 3:30 p.m. on 12/19/16, voicing concerns of CNA A touching the resident and showing him pornographic videos. The SSD stated it was after the meeting on Monday, 12/19/16 at approximately 7 p.m. she reported the alleged abuse to the agencies.
During an interview on 12/30/16 at 8:50 a.m. with CNA A, he stated he continued caring for Resident 1 on 12/19/16 during the day, as he was his permanent resident. CNA A stated Resident 1 informed him "[name of ethnic group] are no good," but he was unaware at that time of the FM's and Resident 1's allegation of abuse regarding him.
During an interview on 1/23/17 at 12:09 p.m. with RN E, she stated on 12/19/16, she scheduled CNA F to assist CNA A whenever he gave care to Resident 1, so as to witness any comments or concerns the resident might have had. There was no mention by LVN D to RN E regarding the alleged sexual cell phone videos or abuse by CNA A.
During an interview on 1/23/17 at 11:54 a.m. with CNA F, she stated on 12/19/16 she and CNA A together went into Resident 1's room twice during the day together to change his briefs.
During an interview on 1/23/17 at 12:22 p.m. with LVN D, she stated she was informed on 12/19/16 at approximately 8 a.m., Resident 1 did not like CNA A, as he did not take out his garbage and change his bed linens. RN E stated she was not aware of alleged sexual abuse by CNA A until approximately 10:30 a.m., and did not know the extent of it or she would not have assigned CNA A to care for Resident 1 on 12/19/16.
Review on 12/30/16 of the facility's 12/12/14 revised policy "Abuse and Neglect Prohibition Policy" indicated, "All facility staff is identified as mandatory reporters. As mandatory reporters, they will be, and have been, instructed, to immediately report any suspected...abuse to one of the following: Charge Nurse, Immediate Supervisor, Social Services Designee, The Director of Nursing, or the Administrator." Additionally, they are informed that they will be assisted in calling the allegation of abuse to the Ombudsman and the Department of Health Services immediately. They will also be assisted in completing the SOC 341 as necessary. A report will also be made to the local police department within 24 hours if there was no serious injury.
2. During an interview on 12/30/16 at 8 a.m. with the administrator, he reviewed a complaint from Resident 2 indicating he was hurt during a transfer from his wheelchair to his bed on 12/27/16. He stated Resident 2 complained of left arm pain after certified nurse assistant G (CNA G) picked up Resident 2 by his armpits and transferred him to his bed.
During an interview on 12/30/16 at 12:15 p.m. with the director of staff development (DSD), she stated staff mandatory, annual elder abuse prevention training inservices were completed in January. She reviewed her January, 2016 abuse training attendance record and stated CNA G did not attend. The DSD stated he missed the training and should have attended. It was his responsibility.
A review on 12/30/16 of an attendance record dated 12/14/16 for annual mandatory inservice on elder abuse prevention indicated CNA G did not have his training until the end of the year in December, 2016.
Review on 12/30/16 of the facility's 12/12/14 revised policy "Abuse and Neglect Prohibition Policy" indicated the facility will train each employee regarding elder abuse prevention policies and procedures on an annual basis.
The violation of this regulation had a direct or immediate relationship to the health, safety, or security of residents. |
| 220001016 |
MOUNTAIN VIEW HEALTHCARE CENTER |
070012958 |
B |
8-Feb-17 |
UKNF11 |
5178 |
F206 -- 483.15(e)(1)(2) POLICY TO PERMIT READMISSION BEYOND BED-HOLD
(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.
(ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.
(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in ? 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.
The facility failed to readmit Resident 1 following a hospitalization during a seven-day bed hold period and to follow the Department of Health Care Services' Administrative Appeals' order to readmit the resident.
Resident 1's clinical record was reviewed and indicated she was admitted to the facility in XXXXXXX2016. Her Minimum Data Set (MDS, an assessment tool), dated 10/20/16, indicated she was cognitively intact. A physician order, dated 7/14/16, indicated she was capable of making healthcare decisions.
Resident 1's progress note, dated 7/13/16, indicated the resident refused to sign the Standard Admission Agreement. Resident 1 deferred to a family member and he also refused to sign the agreement. There was no documentation indicating the family member was the responsible party (RP, individual designated to make medical decisions) or had power of attorney. Numerous attempts were made by the facility to have the Standard Admission Agreement signed, but to no avail.
Resident 1's progress note, dated 12/28/16, indicated she had a fever and a headache. Her physician was called and a chest X-ray and laboratory tests were ordered. The family member refused to allow the laboratory tests to be drawn.
Resident 1's progress note, dated 1/2/17, indicated she vomited. Her physician was called and visited on 1/3/17. A physician order, dated 1/3/17, indicated she was to be transferred to the hospital for further evaluation. The Bed Hold Request Form, dated 1/3/17, indicated the resident consented to a seven-day bed hold.
During interviews with the administrator (ADM) on 1/19/17, at 11 a.m., and 2/1/17, at 1:15 p.m., she stated Resident 1 refused to sign any documents and never produced any documents indicating her family member was the RP or had power of attorney. She stated when the hospital called on 1/9/17 to transfer the resident back pursuant to the bed hold, the facility refused unless the Standard Admission Agreement was signed.
The ADM stated a hearing was held before the State of California Department of Health Care Services on 1/19/17 and the hearing officer ordered the facility to take back Resident 1. She stated the facility refused to take back the resident, and she was transferred to another facility on XXXXXXX17.
The ADM further stated Resident 1 became ill at the other facility and was transferred back to the hospital six days later. She stated the resident needed surgery and remained hospitalized.
During an interview with the hospital social worker (HSW) on 2/2/17, at 10:30 a.m., she stated Resident 1 was transferred to the hospital on XXXXXXX17 for treatment of pneumonia. She stated while the resident was a patient in the hospital she refused to sign any papers as did her family member. The HSW stated the facility refused to take back the resident so the resident was transferred to another facility where she also refused to sign any papers. She stated after Resident 1 became ill at the other facility on 1/26/17, she was transferred to the hospital where she remained hospitalized. The HSW stated Resident 1's physician thought the resident needed surgery but the resident would not consent.
Review of the Department of Health Services' Administrative Appeals Final Decision and Order, dated 1/30/17, indicated the facility must immediately readmit Resident 1.
The facility failed to readmit Resident 1 following a hospitalization during a seven-day bed hold period and to follow the Department of Health Care Services' Administrative Appeals' order to readmit the resident.
These violations had a direct or immediate relationship to the health, safety, or security of the resident. |
| 220001016 |
MOUNTAIN VIEW HEALTHCARE CENTER |
070013115 |
B |
11-Apr-17 |
EPM011 |
16446 |
F314 483.25(b) 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 implement their prevention of pressure ulcers (injury to the skin and the underlying tissue resulting from prolonged pressure on the skin) policy, including evaluating and assessing the residents' clinical conditions, implementing interventions, and monitoring and evaluating the impact of the interventions to promote healing, prevent infection, and prevent new ulcers from developing, for Residents 1, 2, and 3.
1. Resident 1's clinical record was reviewed and indicated he was admitted in XXXXXXX2017 for rehabilitation following spinal surgery. His Minimum Data Set (MDS, an assessment tool), dated 2/17/17, indicated he was incontinent (insufficient control) of urine and feces and had Parkinson's disease (a disorder of the central nervous system affecting movement and often including tremors). His admission assessment did not indicate he had any pressure sores.
Resident 1's Wound Assessment Report, dated 2/17/17, indicated he had a moisture related excoriation (abrasion or wearing off of the skin) on his coccyx (tailbone) measuring 8 centimeters (cm, unit of measurement) in length and 5 cm in width with a small amount of serosanguinous drainage (drainage composed of plasma and blood). His nurses notes, dated 2/17/17, indicated he was subsequently seen by a nurse practitioner (NP) later the same day who staged (classified) the open area on his buttocks as a Stage II (presents as an abrasion, blister or shallow crater) pressure ulcer.
The facility's 24 Hour Reports (reports completed each shift to monitor nursing home residents and documenting any changes in the residents' status), dated 2/17/17, 2/18/17, and 2/19/17 indicated there was no documentation regarding Resident 1's pressure sore. The nursing notes, dated 2/18/17, 2/19/17, and 2/20/17 did not document any further assessments of his pressure sore and any evaluation of the impact of the interventions.
Resident 1's physician progress note, dated 2/20/17, indicated he developed pressure ulcers on both of his buttocks. His right buttock had a Stage II pressure ulcer and his left buttock had an unstageable deep tissue injury (injury to tissues under the skin) with a larger area of non-blanchable erythema (intact skin with redness in a localized area not affected by light finger pressure).
Resident 1's Wound Assessment Report, dated 2/21/17, indicated he had a deteriorated pressure ulcer on his coccyx measuring 8 cm in length by 6 cm in width. His nurses' notes, dated 2/21/17, indicated a physician reassessed his pressure sore and determined the wound was unstageable because the base of the ulcer was covered by eschar (dark patch of dead skin on the wound surface).
Resident 1's laboratory tests, dated 2/22/17, indicated he had an infection. He was started on antibiotics.
Resident 1's nurses notes, dated 2/23/17, indicated he had an 0.1 cm by 0.1 cm open area draining 120 cubic centimeters (cc, unit of measurement) of fluid, in addition to the pressure sore. His physician progress notes, 2/23/17, indicated the drainage was coming from the base of the scrotum (a pouch of skin containing the testicles). He was transferred to the acute hospital for further evaluation.
Resident 1's hospital records, dated 2/23/17, indicated he was taken to the operating room for debridement (removal of damaged tissue) from the buttock wound. On 2/24/17, he returned to the operating room for further debridement. On 2/25/17, he returned again to the operating room for an incision and drainage (minor surgical procedure to release pus or pressure build up under the skin) of a perianal abscess (a collection of pus around the anus) and a colostomy (a surgical operation in which a piece of the intestine is diverted to an artificial opening in the abdomen to bypass the damaged portion of the intestine).
During an interview on 3/7/17, at 12:45 p.m., with the director of nurses (DON), she stated Resident 1 had back surgery and was admitted to the facility for rehabilitation. She stated he was up and walking with physical therapy and could walk to the bathroom.
During an interview on 3/7/17, at 2:25 p.m., with certified nurse assistant A (CNA A), she stated she provided care for Resident 1 on 2/11/17, 2/12/17, 2/17/17, and 2/18/17. She stated on 2/11/17 and 2/12/17, the skin on Resident 1's buttocks was fine. She stated on 2/17/17, she noted a purple discoloration around his rectum. CNA A stated she called her supervisor, the treatment nurse, and the case manager. She stated the treatment nurse applied some cream.
During an interview on 3/7/17, at 2:35 p.m., licensed vocational nurse B (LVN B) stated she was the supervisor CNA A called after the purple discoloration was noted on Resident 1's buttocks. She stated she thought Resident 1 had an excoriation around his anus. She stated she called the treatment nurse and the NP. LVN B stated the NP thought he had a Stage II pressure ulcer. LVN B stated Resident 1's physician came in a few days later and said he had a Stage II pressure ulcer on the right buttock and a deep tissue injury on the left buttock. She stated a few days after the physician diagnosed the pressure ulcer and the deep tissue injury, the treatment nurse asked her to look at Resident 1's buttocks. LVN B stated she observed a boil (painful, pus-filled bump under the skin) on his scrotum which was draining fluid in addition to the pressure sore and the deep tissue injury. She stated she called the case manager who called the physician.
During an interview on 3/7/17, at 2:45 p.m., with CNA C, she stated she provided care for Resident 1 on 2/13/17, 2/14/17, 2/15/17, and 2/19/17. She stated he walked to the bathroom by himself and on 2/13/17, when she was helping him clean up, she noted he had redness on his buttocks. She stated she reported her findings to the charge nurse, registered nurse D (RN D). She stated she did not know what the RN did after she made her report.
During an interview on 3/7/17, at 2:55 p.m., with LVN E, she stated she was one of the treatment nurses who are LVNs. She stated as an LVN, she provided treatment but she did not assess or describe the wound. She stated the RNs were supposed to assess the wound every shift for 72 hours after the resident had a change in condition. She stated the discovery of Resident 1's pressure sore on 2/17/17 was a change of condition and there should have been an assessment every shift for the next 72 hours. She reviewed Resident 1's clinical record and stated there were no assessments of Resident 1's pressure sore between 2/17/17 and 2/21/17 and no evaluation of the impact of the interventions.
During an interview on 3/17/17, at 1:05 p.m., with LVN F, she stated she was one of the treatment nurses. She stated she performed Resident 1's initial skin assessment when he was admitted and she did not see any discoloration or pressure sores on his buttocks. She stated she was asked to see Resident 1 on 2/17/17 and she saw an excoriation on his buttock. She stated the charge nurse called the case manager and Resident 1 was seen by the NP who thought the resident had a Stage II pressure sore. LVN F stated when a resident has a change of condition, such as a pressure sore, the RN on each shift should chart an assessment of the pressure sore for the next 72 hours. She reviewed the clinical record and stated there was no charting regarding Resident 1's pressure sore for the next three days.
During an interview on 3/17/17, at 1:55 p.m., RN D stated she was the nurse who provided care for Resident 1 from 2/12/17 through 2/15/17 and on 2/18/17 through 2/21/17 on the day shift. She stated she has no recollection of anyone telling her Resident 1 had redness on his buttocks on 2/14/17. She also stated she has no recollection of anyone telling her he had a Stage II pressure ulcer on his buttocks on 2/18/17, 2/19/17, and 2/20/17. She stated when a resident has a change in condition, such as a pressure sore, the RN on each shift should chart an assessment of the pressure sore for the next 72 hours. She stated she did not assess his pressure sore from 2/18/17 through 2/20/17, because she did not know he had a pressure sore. She also stated there was no documentation on the 24 Hour Report indicating Resident 1 had a pressure sore until 2/20/17.
During an interview on 3/17/17, at 2:20 p.m., with the director of staff development (DSD), she stated when a resident has a change in condition, such as a pressure sore, the RN on each shift should chart an assessment of the pressure sore for the next 72 hours and the information regarding the change of condition should be documented on the 24 Hour Report. She reviewed the 24 Hour Reports from 2/17/17 through 2/20/17 and stated there was no documentation indicating Resident 1 had a pressure sore until 2/20/17.
2. Resident 2's clinical record was reviewed and indicated she was admitted in XXXXXXX2017 following a cerebral infarction (a lack of blood flow resulting in severe brain damage) with left sided hemiplegia (paralysis), a tracheostomy (a tube inserted in her windpipe to open a restricted airway and enable breathing), a gastrostomy tube (a tube inserted through the abdominal wall into the stomach for the infusion of nutrition and medications), and an indwelling catheter (a tube inserted into the bladder to drain urine). Her initial assessment indicated she was incontinent. No discoloration on her buttocks was noted.
A physician order, dated 2/9/17, indicated a barrier cream was to be applied to Resident 2's buttocks every shift as a preventive measure. Her Treatment Administration Record (TAR) indicated the barrier cream was applied only once a day.
Resident 2's nurse's note, dated 2/16/17, indicated she had an excoriation on her left buttock with no bleeding or drainage noted. Her Wound Assessment Report, dated 2/16/17, indicated the excoriation was 4 cm by 3 cm and red.
Resident 2's nurse's note, dated 2/23/17, indicated the excoriation on her buttock was reassessed and was healing well. Her Wound Assessment Report, dated 2/23/17, indicated her excoriation was 4 cm by 2.7 cm.
Resident 2's nurse's note, dated 3/2/17, indicated the excoriation on her buttocks increased in size and the drainage remained the same. Her Wound Assessment Report, dated 3/2/17, indicated her excoriation was 5 cm by 4 cm and had increased in size.
Resident 2's nurse's note, dated 3/9/17, indicated the excoriation on her buttocks increased in size and scant sanguineous drainage (fresh blood) was noted. Her Wound Assessment Report, dated 3/9/17, indicated her excoriation was 7.3 cm by 5 cm and the size and the amount of drainage had increased.
Resident 2's nurse's note, dated 3/16/17, indicated the DON reassessed the left coccyx wound and noted the 8 cm by 8 cm wound was a suspected deep tissue injury due to a rapid deterioration of the wound with 50% granulation (indication healing taking place) and 50% eschar tissue. Her Wound Assessment Report, dated 3/16/16, indicated she had an unstageable 8 cm by 8 cm pressure sore. The pressure sore was unstageable due to slough (yellow nonviable tissue) and eschar.
Resident 2's nurses notes for the 72 hours after the excoriation was initially noted on 2/16/17 did not include any documentation of additional assessments performed by each shift. The nurses' notes, dated 3/2/17 and 3/9/17, when the excoriation was increasing in size and when there was a change in the drainage, did not document any additional assessments performed by each shift in the following 72 hours. The nurses notes, dated 3/17/17, the day following the documentation of the suspected deep tissue injury, did not indicate any further assessments of her pressure sore were performed.
During an interview on 3/17/17, at 2:30 p.m., with the director of staff development (DSD), she reviewed Resident 2's chart and stated there was an order to apply a barrier cream to the resident's buttocks every shift for preventative measures starting 2/9/17. She stated the documentation in the chart indicated the cream was only applied once a day and not every shift. She also stated when a resident has a change in condition, the RN on each shift should chart an assessment of the excoriation or pressure sore for the next 72 hours. She confirmed the nurses notes for the 72 hours after the excoriation was initially noted on 2/16/17 did not include any documentation of additional assessments performed by each shift; the nurses notes, dated 3/2/17 and 3/9/17, when the excoriation was increasing in size and when there was a change in the drainage, did not document any additional assessments performed by each shift in the following 72 hours; and the nurses notes, dated 3/17/17, the day following the documentation of the suspected deep tissue injury, did not indicate any further assessments of her pressure sore were performed.
3. Resident 3's clinical record was reviewed and indicated he was admitted in 2/2017 following a left total knee revision due to an infected total knee arthroplasty (surgical reconstruction or replacement of a joint). His initial assessment did not indicate he had any pressure ulcers on his heels.
Resident 3's nurses notes, dated 2/9/17 through 2/27/17, indicated he had a foot cradle (a wire frame raising sheets, blankets, and covers up above the users feet, keeping the weight off the lower legs and feet) in place. On 2/27/17, his nurses notes indicated he was seen by his physician because his right foot was irritated by the foot cradle and some blanchable redness (loss of all redness when pressed) was noted on his heel. The foot cradle was removed and a longer bed was requested to accommodate his height.
Resident 3's nurses notes, dated 2/28/17, indicated he was seen by the NP who assessed his right heel and noted a suspected deep tissue injury. His physician order, dated 2/28/17, indicated he was to wear heel protectors while he was in bed.
During an observation on 3/17/17, at 2:50 p.m., Resident 3 was sitting up in bed reading. He was dressed in a hospital gown with a blanket over his legs but not his feet. His feet were exposed and he was not wearing any heel protectors.
During an interview and observation on 3/17/17, at 3 p.m., RN D confirmed Resident 3 was not wearing any heel protectors. She stated he was supposed to wear heel protectors while he was in bed.
Review of the facility's 2001 policy, revised in 10/2010, "Prevention of Pressure Ulcers", indicated a timely assessment should be performed and pressure sores are made worse by continual pressure, moisture, and irritating substances on the resident's skin such as feces and urine. A change in the condition of the pressure sore should be recognized, evaluated, reported to the physician, and addressed timely. The condition of the resident's skin should be routinely assessed and documented and signs of a developing pressure ulcer should be immediately reported to the supervisor. Efforts should be made to stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate. Causes of moisture should be addressed, skin should be protected by a skin barrier, and heels should be protected with devices prescribed by the physician.
The facility failed to implement their prevention of pressure ulcers policy, including evaluating and assessing the residents' clinical conditions, implementing interventions, and monitoring and evaluating the impact of the interventions to promote healing, prevent infection, and prevent new ulcers from developing, for three residents.
These violations had a direct or immediate relationship to the health, safety, or security of the residents. |
| 070000047 |
MILPITAS CARE CENTER |
070013422 |
B |
10-Aug-17 |
VRDN11 |
10100 |
F323-483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to implement the intervention of placing a wheelchair alarm to prevent falls for two of 10 sampled residents (Resident 4 and Resident 6). These failures resulted in a fall, scalp laceration that required staples and hospitalization for Resident 4, and recurrent falls and the potential for injury for Resident 6.
1. Review of Resident 4's clinical record indicated she had diagnoses of dementia (decline in mental capacity affecting daily function) and history of falling.
Review of Resident 4's Morse Fall Scale (an assessment tool that can predict the likelihood that a person will fall), dated 10/24/16 indicated her score was 90. A score of 45 and higher indicated a high risk for falls.
Review of Resident 4's fall care plan, dated 10/24/16, indicated an intervention that staff should ensure a chair/bed electronic alarm device was in place. There was no documentation that indicated staff ensured Resident 4 had a chair electronic alarm in place.
Review of Resident 4's Minimum Data Set (MDS, an assessment tool), dated 11/6/16 indicated her cognition was moderately impaired and she required extensive assistance with activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring).
Review of Resident 4's Situation Background Assessment Recommendation (SBAR) Communication Form (communication tool) and progress notes, dated 1/17/17, indicated that at 4 p.m., registered nurse A (RN A) saw Resident 4 on the floor in the dining room and blood was dripping from her head. RN A applied pressure to the cut with a clean cloth until the bleeding stopped. It further indicated Resident 4 said she was trying to reach for something when she fell.
Review of the facility's investigation summary, dated 1/17/17, indicated activity assistant B (AA B) was attending to the needs of another resident, heard a "thump," and saw Resident 4 lying on the floor. It further indicated Resident 4 had a lacerated wound to her head measuring five centimeters (cm, unit of measurement) by 0.5 cm with moderate bleeding.
Review of the Resident 4's Non-pressure Skin Condition Report, dated 1/23/17, indicated she had nine staples in her occipital (back of the head) area, measuring five cm by 0.5 cm.
During an observation on 8/1/17 at 12:05 p.m., Resident 4 was in the dining room, sitting in a wheelchair with no alarm in place.
During an interview on 8/1/17 at 12:10 p.m., certified nursing assistant C (CNA C) stated Resident 4 did not have a wheelchair alarm. CNA C stated she was unsure if Resident 4 needed a wheelchair alarm.
During observations on 8/1/17 at 12:25 p.m. and 2:45 p.m., Resident 4 was in the dining room, sitting in a wheelchair with no alarm in place.
During observations on 8/2/17 at 9:15 a.m. and 10 a.m., Resident 4 was in the dining room, sitting in a wheelchair with no alarm in place.
During an interview on 8/2/17 at 10:40 a.m. CNA D stated every time Resident 4 was up in her wheelchair, there was no wheelchair alarm attached.
During an interview on 8/2/17 at 10:42 a.m., CNA E stated Resident 4 did not have a wheelchair alarm when in her wheelchair. CNA E stated she was not aware that Resident 4 needed a wheelchair alarm.
During an interview on 8/2/17 at 10:45 a.m., licensed vocational nurse F (LVN F) stated Resident 4 needs a bed and wheelchair alarm for fall prevention because she had a history of falls and was a high risk for falls. LVN F confirmed Resident 4 was in her wheelchair without an alarm, and should have one.
During an interview on 8/2/17 at 11:05 a.m., the director of nursing (DON) stated Resident 4 had a history of falls and her care plan included interventions of a wheelchair alarm when up in a wheelchair.
During an interview on 8/2/17 at 2:25 p.m., Resident 4 stated staff placed an alarm on her wheelchair "today". Resident 4 stated she never had a wheelchair alarm before this day.
During an interview on 8/2/17 at 3:05 p.m., CNA G stated he worked with Resident 4 on 1/17/17, assisted her from bed to the wheelchair, and brought her to the dining room. He stated Resident 4's wheelchair did not have an alarm in place. CNA G stated he was not aware that Resident 4 should have an alarm when up in the wheelchair.
During a telephone interview on 8/2/17 at 4:35 p.m., RN A stated she was working on 1/17/17 and was by the door of the dining room when Resident 4 fell. RN A stated Resident 4 fell back with her wheelchair and hit the edge of the wall. RN A stated there was no sound of a wheelchair alarm and was unsure if Resident 4 had a wheelchair alarm.
During a telephone interview on 8/3/17 at 10:30 a.m., AA B stated on 1/17/17 Resident 4 did not have an alarm on her wheelchair and her wheelchair was not locked. AA B stated Resident 4 fell with her wheelchair when she was trying to reach something. AA B stated Resident 4 hit the edge of the wall. AA B stated she was assisting another resident when Resident 4 fell.
2. Review of Resident 6's clinical record indicated she had diagnoses including Parkinson's disease (disorder of the nervous systems that affects movement and can cause tremors) and repeated falls.
Review of Resident 6's fall care plan, dated 7/8/16, indicated an intervention that staff should ensure a chair/bed electronic alarm device was in place.
Review of Resident 6's Morse Fall Scale, dated 10/15/16, indicated her score was 65. A score of 45 and higher indicated a high risk for falls.
Review of Resident 6's SBAR Communication Form and progress notes, dated 10/30/16, indicated Resident 6 was in bed at 12 a.m. The notes further indicated at 3 a.m., Resident 6 was found lying on the floor. The notes did not indicate whether there was a bed alarm in place. There was no documentation that indicated what staff would do to prevent future falls.
Review of Resident 6's SBAR Communication Form and progress notes, dated 1/4/17, indicated Resident 6 was in a wheelchair in the dining room and slipped from the wheelchair. The notes did not indicate whether there was a wheelchair alarm in place. There was no documentation that indicated what staff would do to prevent future falls.
Review of Resident 6's SBAR Communication Form and progress notes, dated 1/31/17, indicated Resident 6 fell to the floor in the dining room from a standing position. There was no documentation that indicated what staff will do to prevent future falls.
Review of Resident 6's SBAR Communication Form and progress notes, dated 3/17/17, indicated Resident 6 was found lying on the floor mat next to her bed. The notes did not indicate whether there was a bed alarm in place. There was no documentation that indicated what staff would do to prevent future falls.
During an observation on 8/2/17 at 3:15 p.m., Resident 6 was up in her wheelchair with no alarm in place, and staff wheeled her to the dining room.
During medication pass observation on 8/2/17 at 4:10 p.m., LVN H confirmed Resident 6 did not have a wheelchair alarm. When asked if Resident 6 needed a wheelchair alarm, LVN H replied, "No."
During an observation on 8/2/17 at 4:35 p.m., Resident 6 was in the dining room, sitting in her wheelchair with no alarm in place.
During an interview on 8/2/17 at 4:35 p.m., CNA I stated Resident 6 did not have an alarm while up in her wheelchair. CNA I stated she did not think Resident 6 was supposed to have an alarm in her wheelchair.
During an observation on 8/3/17 at 11 a.m., Resident 6 was in the dining room, sitting in her wheelchair with no alarm in place.
During an interview on 8/3/17 at 11 a.m., certified nursing assistant J (CNA J) confirmed Resident 6 did not have a wheelchair alarm.
During an interview on 8/3/17 at 11:05 a.m., the DON stated Resident 6 needed a wheelchair and bed alarm, and the nurses and CNAs should be aware that Resident 6 needed the alarms in place. The DON stated there should be an interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) meeting when a resident has multiple falls. The DON stated he could not find documentation of IDT meetings after each of Resident 6's falls. The DON confirmed there was no documentation of any new interventions to prevent future falls after each of Resident 6's falls.
During an interview on 8/3/17 at 2 p.m., LVN K stated she was unsure if Resident 6 had a wheelchair alarm. LVN K stated she should check to make sure Resident 6's wheelchair alarm was in place.
Review of the facility's 12/2007 policy, "Managing Falls and Fall Risk," indicated "staff will identify appropriate interventions to reduce the risk of falls." The policy also indicated, "if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remain relevant." It further indicated, "staff will monitor and document each resident's response to interventions."
The facility failed to implement the interventions to prevent falls.
The above violation had a direct or immediate relationship to the health, safety, or security of residents. |
| 090000312 |
Mountain Shadows Community Homes - Lemon |
090009474 |
B |
05-Sep-12 |
XN4D11 |
4265 |
76872. (f) The primary responsibility of direct care staff shall be the care and training of the clients as follows: (2) Direct Care Staff shall not be diverted from their primary responsibilities by excessive housekeeping, clerical duties or activities not related to client care when clients are physically present in the facility. The facility failed to provide a responsible staff to provide a stand by assist for Client 1 that led to a fall causing a left leg fracture (break in bone). Client 1 called the staff for assistance before transferring back into bed. The staff did not come to provide the necessary assistance. The staff was on the phone in the living room watching television. As a result, Client 1 attempted to transfer himself back into bed and fell and broke his left leg.Client 1 was admitted to the facility on 7/21/05 with diagnoses that included mild mental retardation per the Admission Information Sheet. Client 1's level of understanding per the "Resident Assessment," indicated as "high, can understand staff and speak, sometimes hard to understand." Per the "Lifting and Transferring Instruction, Client 1 is a stand by assist. Client 1 can transfer himself if he is positioned close to where he is trying to transfer. Make sure the bed is lowered and the armrest is removed before transferring into bed. Provide stand by assistance at all time."An interview was conducted on 5/4/12 at 2:40 P.M. with the registered nurse (RN). The RN stated, "The fall incident happened on the night shift. The night staff found Client 1 on the floor. He was taken to the hospital the following morning. The x-ray showed a fracture left tibia (large shin bone in the leg)." An interview was conducted on 5/4/12 at 2:45 P.M. with the qualified mental retardation professional (QMRP). The QMRP stated, "I am the covering QMRP. The night shift direct care staff did not report the incident of Client 1's fall. It was the day shift staff who reported the incident to us. Client 1 was taken to the acute hospital the next morning. The night shift staff no longer works here. "A joint observation and an interview were conducted on 5/4/12 at 2:20 P.M. and on 5/25/12 at 1:50 P.M. with Client 1. Client 1 was in a hospital bed with his left leg in a long cast that was elevated on pillows. Client 1 stated, "I called her. She was on the phone and watching television over there. It was late when she came in. I went boom. I was going back into bed." A review of the general acute hospital Emergency Physician Documentation was conducted on 5/11/12 at 3:30 P.M. Client 1 was seen at the general acute hospital on 4/30/12 at 10:06 A.M. X-rays of the left leg were performed and the results indicated, "Minimally Displaced Spiral Fracture, Distal Shaft of the Tibia." Client 1's left leg was immobilized with a long leg cast with bivalve splitting.An interview was conducted on 5/15/12 at 4:40 P.M. with the day shift direct care staff (DCS) 1. DCS 1 stated, "On 4/30/12, I came to work at 5:30 A.M. I noticed Client 1 made noise. I asked Client 1, What's wrong? Client 1 complained of pain. I talked to the night shift direct care staff as to what happened to Client 1 why he was complaining of pain. The night shift direct care staff told me that Client 1 fell on the floor from the bed but he was okay and did not complain of pain after falling. I asked Client 1 how he fell on the floor. Client 1 said that he called for her but she was on the phone watching television in the living room. The "big guy" next door came to help put him back into bed. An interview was conducted on 5/29/12 at 8:35 A.M. with DCS 2, staff who was called to help to put Client 1 back in to bed. DCS 2 stated, "On 4/29/12 about 11:30 P.M., was when I received a call for help to put Client 1 back into bed. I saw Client 1 on the floor in the bedroom. We put him back into bed and I went right back in to my facility afterwards."The facility failed to provide a responsible staff to provide a stand by assist to prevent Client 1 from falling when transferring in to bed. This had a direct cause for the fall that resulted into Client 1's left leg fracture. A violation of this regulation had a direct or immediate relationship to the health, safety, and or security of this client. |
| 090001316 |
Miller Home |
090009614 |
B |
20-Nov-12 |
SHZH11 |
8132 |
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. Based on interview and record review the facility failed to: 1. Protect 1 sampled Client (1) from physical abuse. The residential service technician (RST) 1 held onto Client 1's feet and dragged Client 1 on the cement sidewalk. 2. Implement its own policy and procedures and remove the staff from care giving of residents. 3. Ensure the immediate safety of the client and promptly examine the client for injuries. These violations had a direct relationship to the health, safety and security of Client 1 and other client's in the house.On 3/27/12 at 3:10 P.M., an unannounced visit was made to the facility to investigate a complaint regarding an incident of alleged client abuse. Client 1 was admitted to the facility on 3/22/04 with diagnoses that included moderate mental retardation and intermittent explosive behavior per the Individual Data sheet. According to the Individual Service Plan (ISP) dated 11/8/11, indicated that Client 1 had continued transportation refusal that "...averaged 23 incidents over the past 6 months..." The Transportation Refusal (ISP Program) dated 7/27/10 indicated "...It is especially hard for her ...when she is approached in the wrong way..." Client 1's Psychological/Behavioral Assessment (PBA) dated 5/15/11 indicated "...there remain a number of behavioral challenges to be addressed on an ongoing basis..." and "...Staff find a calm, quiet manner helpful, with direct praise and encouragement, and clear redirection..." The PBA further indicated "...Emotional outburst indicated15-30x (times)/ (per) month...Aggression indicate 9x/month...Refusals indicate 15-30 incidents/month..."On 3/27/12, at 3:40 P.M., an interview was conducted with the day program van driver (VD) 1. VD 1 stated that on 3/23/12 at 2:00 P.M., the van was parked on the street.Client 1 was seated in the front seat of the van. Client 1 was yelling and screaming. VD 1 further stated that RST 1 approached the van and RST 1 took Client 1's shirt at the waist line and pulled Client 1 out of the van. RST 1 then proceeded to lunged towards Client 1 and RST 1 fell to the ground.VD 1 stated that VD 1 assisted Client 1 to the ground. RST 1 stood up and took a hold of Client 1's feet and dragged Client 1 on Client 1's buttocks one square of the concrete sidewalk, which is 3 feet in length.On 3/27/12, at 4:00 P.M., an interview was conducted with RST 2. RST 2 stated that on 3/23/12 around 2:05 P.M., RST 1 exited the house to the van. RST 2 stated that she also exited the facility to assist with the clients. RST 2 walked back into the house when RST 1 yelled at her.RST 2 indicated she heard commotion outside. RST 2 stated she saw RST 1 roughly swing Client 1 out of the van by grabbing Client 1's shirt and Client 1 fell. RST 1 re-entered the facility and RST 2 asked where Client 1 was. RST 1 answered she left Client 1 out front by herself.RST 2 stated RST 2 did not report the roughness that RST 2 witnessed to the house manager (HM) or qualified mental retardation professional (QMRP). On 3/28/12, at 9:15 A.M., an interview with the QMRP was conducted. The QMRP stated RST 1 worked 3/23, 24, 25/12.The QMRP stated that a phone message was received from the day program manager (DPM) about the incident on 3/23/12. The QMRP stated that message from the DPM was that VD 1 did not feel "Comfortable" with RST 1 pulling on Client 1's shirt and left the facility. The QMRP stated that RST 1 was to be terminated 3/28/12 regarding the incident. A record review was conducted of the Employee Time Cards dated 3/28/12. The Employee Time Cards indicated RST 1 worked 3/23/12 from 2:01 P.M. to 10:10 P.M., 3/24/12 from 1:56 P.M. to 10:02 P.M., and 3/25/12 from 2:02 P.M. to 9:55 P.M. The QMRP further stated, unsure if nursing was contacted to come and assess Client 1.On 3/28/12, at 10:00 A.M., an interview with the licensed nurse (LN) 1 was conducted. LN 1 stated that the QMRP, HM, and the RST did not notify the LN of the incident on 3/23/12. LN 1 further stated that LN 1 was notified by the QMRP on 3/26/12 of the incident. LN 1 stated that LN 1 did not assess Client 1 due to "it was several days later after the incident." LN 1 acknowledged that the facility procedure post an incident was for the LN to assess the client for injuries.On 3/28/12, at 1:00 P.M., a record review of the computer data ISP Data Collection (staff documentation on a computer program) was conducted. On 3/23/12, Client 1 had 9 incidents of aggression, 11 emotional outbursts, and 6 task refusals.On 3/28/12, at 2:00 P.M., a record review of the Unusual Incident /Injury Report dated 3/26/12 was reviewed. The report from the day program indicated that on 3/23/12 the day program van driver transported Client 1 to the facility. Client 1 was yelling and refusing to get out of the van. The house staff approached the van in an angry, upset manner. The residential staff lunged at Client 1, grabbed the clothes and pulled Client 1 forcefully away from the van. The residential staff fell. Client 1 began to fall and the van driver grabbed Client 1 and directed her to the ground. Client 1 continued to yell and curse at staff. The residential staff got up and started pulling Client 1's legs across the sidewalk. The van driver reported the incident to the program manager. The program manager immediately called the QMRP to report what had happened, but was only able to leave a message. The program manager called the HM who said she would look into it.On 4/17/12, at 9:30 A.M., an interview with the DPM was conducted. The DPM stated that a contact call was made around 3:00 P.M. to the QMRP after the van driver reported to the DPM on 3/23/12 regarding the dragging of Client 1 across the cement sidewalk by Client 1's feet. The QMRP was not available, DPM left a voice message. The DPM further stated a contact call to the HM was conducted. The DPM stated that the DPM spoke with the HM and informed the HM of the incident of abuse.On 7/25/12, at 2:55 P.M. a declaration from VD 1 was obtained. The declaration indicated that "...able to turn Client 1 facing out of the van. Client 1 did not want to get out, so the staff pulled her out. Client 1 was now standing and Client 1 did not want to move. The staff lunged at Client 1 fast pulling Client 1 and both Client and staff fell to the ground. The staff got up fast and started pulling on Client 1 across the ground. VD 1 reported the incident to the manager." VD 1 stated that the staff involved was RST 1 and the incident occurred on 3/23/12.On 7/25/12, at 3:05 P.M. a declaration from the DPM was obtained. The declaration indicated that "after the driver called regarding the incident that occurred with Client 1, DPM immediately called the QMRP, the QMRP did not answer the phone, so DPM left a message. DPM the called the HM and explained what my driver had told me, the HM stated HM would look into it." DPM stated and confirmed the date of incident to be 3/23/12 and that the HM was informed regarding the dragging of Client 1 across the concrete sidewalk.The facility failed to ensure that Client 1 was not physically abused when DCS 1 dragged Client 1 with her feet on the cement.Client 1 was subject to inappropriate actions of the RST 1; as a result Client 1 was disrespected and humiliated. The violation of the above regulation had a direct or immediate relationship to patient health, safety, or security. |
| 090000134 |
Mountain Shadows Community Homes - Olive |
090009926 |
B |
31-May-13 |
RUPV11 |
12094 |
Welfare and Institutions code 4502. (d) A right to prompt medical care and treatment.The facility failed to ensure that one developmentally disabled client (Client 1) received prompt medical care and treatment when the client developed significant changes in the condition of his skin. The facility staff failed to promptly inform the physician of the client's skin condition changes. Furthermore, facility staff performed skin treatments without physician's orders. In addition, the facility neglected to perform appropriate nursing assessments and had not developed individualized health care plans that met the needs of the client. Client 1 developed a stage II wound (partial thickness loss of dermis skin layer) on the back of the head eight (8) days after admission to the facility. Client 1 then developed skin changes on the coccyx, which were first identified as "blisters" on 2/24/13. On 3/6/13, the coccyx skin changes had progressed and were diagnosed as a stage IV wound (full thickness tissue loss with exposed bone, tendon, or muscle) on the coccyx (tailbone). Client 1's coccyx wound developed thirty six (36) days after being admitted to the facility.Client 1 was admitted to the facility on 1/29/13 with diagnoses which included quadriplegia (inability to voluntarily move arms and legs), contractures (permanent stiffness of muscles/joints) and global development delay per the facility client information form. Client 1 required a wheelchair for mobility and a mechanical lift for transfers from the wheelchair to other surfaces. The "Admit Physical", dated 1/29/13, indicated that Client 1 was non-verbal and non-ambulatory. The Nursing Admission Note and Assessment form, dated 1/29/13, indicated that Client 1 had no skin conditions such as redness, excoriations (abrasions), rash or pressure sores upon admission to the facility. The same form indicated that the client was "Total Assist" for all self-care skills and had "sensitive skin".A review of the facility Nursing Care Plan, dated 1/31/13, identified the problem "Potential for altered skin integrity secondary to: incontinent of bowel and bladder Decreased mobility". The care plan "Approaches/Interventions" included "inspect skin daily during routine care for signs of altered skin integrity...report altered skin integrity to RN/MD: redness, open skin...reposition every 2 hours and as necessary...get client out of wheelchair as much as possible...". The care plan had not been individualized or identified specific repositioning procedures, times or monitoring methods to be implemented for the consistency of care. The care plan had not included the use of pressure relieving devices or identified skin protection methods.During an interview on 3/14/13 at 2:15 P.M., Staff 1 stated she worked both day and evening shifts and was familiar with Client 1. Staff 1 stated that the client was "very sensitive" and was repositioned every 2 hours, however, Staff 1 was unable to state how the client's position changes were planned, scheduled or monitored for consistency.During an interview on 3/14/13 at 3:00 P.M., Staff 3 stated she worked evening shifts.Staff 3 was unable to state how Client 1's position changes were planned, scheduled or monitored for consistency.A review of the facility Interdisciplinary Team Progress Notes, dated 2/7/13 at 3:50 P.M., included "...redness found back of head 3" (inches) x4"...serosanguineous (light bloody) drainage present...cleaned area, applied bacitracin (antibiotic medication)...RN (registered nurse) notified...will cont. (continue) to monitor." There was no indication that the client's primary physician had been notified of the scalp wound. Furthermore, a review of the Physician's Orders had not indicated an order for the bacitracin treatment. In addition, the client's record had no evidence of an RN assessment or continued monitoring/treatment of the identified scalp wound, until 2/24/13. Over 2 weeks after the wound area was initially identified. The RN's entry in the Interdisciplinary Team Progress Notes, dated, 2/24/13 at 11:50 A.M., included "...area of hair loss measures 4" in diameter and presents around wound that was first noted on 2/7/13. LVN (licensed vocational nurse) reports that wound has not improved...wound bed is currently crusted over...semi hardened mass noted under skin at wound site measuring 1.5" x 1"...". The same note indicated that the client's primary physician had then ordered a referral to a wound care clinic (WCC). A review of a Temporary Nursing Care Plan, dated 2/7/13, identified the problem "Altered Skin Integrity: Redness to back of head, left side". The "Approaches/Interventions" included "...follow physician's orders for medication and treatment...monitor area and notify RN/MD of: increased size/depth, increased redness...keep pressure off area". The care plan had not been individualized to identify the specific treatments, care or monitoring procedures be implemented for the consistency of care. A review of the client's Physician's Orders and the Medication Administration Recordforms had not indicated medication or treatment orders related to the wound identified on the back of Client 1's head. On 3/15/13 at 1:50 P.M. an interview was conducted with licensed nurse (LN) 4. LN 4 stated that Client 1's daily schedule "depended on the business of the house". LN 4 clarified that there was no set schedule for repositioning the client until the scalp wound was discovered. LN 4 stated that the facility had not established a procedure of monitoring the client's repositioning. LN 4 stated that she discovered Client 1's scalp wound on 2/7/13. LN 4 acknowledged that she did not call the physician with the change of condition of the client's skin and did not obtain an order prior to the initiation of the bacitracin wound treatment. LN 4 was not able to identify how the scalp wound was to be monitored.A review of an internal communication entitled (Facility Name) Administrative Report form, dated 2/24/13 at 7:15 P.M., included "...Type of incident...Blisters...Description of incident...found these blisters by the patient's coccyx (tailbone) area. One of which is a quarter size already popped. RN was notified...Treatment Given: cleaned wound...bacitracin ointment". The same report indicated a "follow up" exam on 2/25/13. The "exam" indicated "site red, unblanchable (abnormal finding of no skin color change with light touch), dark area in center, 6 cm (centimeters) x 7 cm, no tunneling, scant sanguineous (bloody) drainage, periwound red with small blisters. Site cleansed and bacitracin applied. The same report indicated that the facility qualified mental retardation professional (QMRP) had then been informed of the coccyx wound site and had "consulted with RN".However, there was no evidence found in the client's record, of a registered nurse assessment, follow up monitoring or treatment of the coccyx wound. In addition, there was no indication that Client 1's primary physician had been informed of the coccyx wound.A review of the client's Physician's Orders had not included an order for the bacitracin wound treatment and the facility's Medication Administration Record forms had not indicated medication or treatment orders related to the coccyx wound. On 3/14/13 at 3:30 P.M., an interview was conducted with LN 1. LN 1 acknowledged that she had discovered Client 1's coccyx "blisters" on 2/24/13, but did not call the primary physician to inform or obtain an order for the bacitracin treatment. LN 1 was unable to identify how the client's coccyx wound was to be monitored.On 3/14/13 at 4:00 P.M., an interview was conducted with LN 2. LN 2 acknowledged awareness of the skin changes on Client 1's coccyx on 2/25/13. LN 2 acknowledged that the primary physician was not informed of the change of condition and that a wound treatment had been initiated without a physician's order or an RN assessment. LN 2 stated that the client's plan of care was "vague" and that the facility staff had not realized the seriousness of the observed skin changes on the client's coccyx. LN 2 was unable to identify how the client's wound was to be monitored. On 3/27/13 at 3:50 P.M., an interview was conducted with the qualified mental retardation professional (QMRP). The QMRP acknowledged that she had reviewed the "Administrative Report" form, dated 2/24/13 and 2/25/13. The QMRP acknowledged that the primary physician had not been notified of the coccyx wound description and that the wound was not assessed by an RN when the wound was identified. A review of the Interdisciplinary Team Progress Notes, dated 3/4/13 at 8:00 A.M., included "Popped blister was first seen last 2/24/13...Over the past few days the wound grows larger in size." There were no measurements, descriptions of the wound characteristics/treatments or evidence of a registered nurse or primary physician assessment. The same note included that Client 1 had a WCC appointment scheduled for 3/6/13.A review of the Interdisciplinary Team Progress Notes, dated 3/8/13 at 2:30 P.M., included "Late entry for 3/5/13: Examined wound area noted a change of condition: wound open, measuring about 3 cm x 2 cm diameter, located between gluteal fold above anus. Cleaned area with sterile NS (normal saline), applied bacitracin along outer border of open wound...notified RN. Will continue to monitor..." There is no evidence that the primary physician was informed of the skin "change of condition" or that an order for the wound treatment was obtained from the physician. In addition, there is no evidence of RN wound assessment or monitoring. A joint interview and record review was conducted at the WCC (wound care center) with the WCN (wound care nurse) on 3/15/13 at 11:45 A.M. The WCN stated that Client 1 had been scheduled for a scalp wound evaluation at the WCC on 3/6/13. The WCN stated that Client 1's scalp wound was debrided (sharp instrument excision of dead tissue) and assessed as a stage II. The WCN stated that the location of the scalp wound aligned with the point of contact made with the client's wheelchair headrest. The WCN stated that facility staff requested an examination of client 1's coccyx wound at the time of the same appointment. The WCN stated that the coccyx wound was assessed as a stage IV (full thickness tissue loss with exposed bone, tendon or muscle). The WCN stated that the wound had a foul odor and that a laboratory culture had been obtained. The WCN stated that the wound was then treated with Silvadine cream (a topical antibiotic cream) and that oral antibiotic mediations had been prescribed. In addition, the WCC physician had ordered pressure relieving measures/mattress; wound treatments, laboratory blood tests, x-rays and nutritional supplements. A review of the WCC physician assessment included "...scalp ulceration...I suspect that this is mainly secondary to pressure" and "...concern is in relation to the coccygeal ulceration, which is extensive and deep with bone exposure as well as necrotic tissue found in the cavity. This will be classified as a stage IV pressure ulceration...stage IV ulcerations typically do not heal without surgical treatment."A review of the "Emergency Department Physician Notes", dated 3/7/13, indicated an evaluation of the coccyx pressure wound and a laboratory blood test. Client 1 was then admitted to the acute care hospital for treatment care of the pressure ulcer and antibiotic therapy.The facility failed to provide prompt medical care treatment when a physician was not informed of changes in skin condition and medical treatments were initiated without physician orders. In addition, the facility failed to provide nursing assessments and to develop a plan of care that protected Client 1 from the development of pressure ulcers. As a result, Client 1 developed a stage II pressure ulcer on the scalp 8 days after admission to the facility and a stage IV pressure ulcer on the coccyx 36 days after admission to the facility. These violations had a direct relationship to the health, safety and security of the client. |
| 090000277 |
Mountain Shadows Community Homes - Ash |
090010419 |
B |
28-Mar-14 |
None |
5631 |
76873 (c) (13) The facility shall require that all direct care staff, in addition to eight hours (8) hours of orientation, receive at least (3) hours per month, 36 hours annually, of planned in-service training which shall be documented and shall include, but not be limited to the following topics: Fire and accident prevention and safety. The facility failed to ensure that accident prevention and safety training was provided when the DCS 1 (direct care staff) failed to provide an accident free and safe environment for Client A, a developmentally disabled client, who was blind, non-verbal and totally dependent on DCS to provide a safe environment. As a result, Client A suffered a second degree burn on his left leg/thigh, that caused peeling skin with multiple large and small blisters. Client A was observed at the facility on Tuesday, 1/7/14 at 11:00 A.M. He was asleep in his recliner, wearing short pants, with the burn on his left leg/thigh open to air, with an application of silvadene cream according to the physician's orders. The wound areas were assessed as described by the nurse's notes and the photos: the reddened burned skin was now "a darker purple-red and measured 5" from top to bottom on the top of his thigh/quad above his knee. The widest area of reddened skin on the lateral side of his leg measures 3" from top to bottom and the widest area of reddened skin on the medial side measures 2" from top to bottom. Loose skin present on all sides; top, lateral and medial from ruptured blisters...No s/s of infection." According to the DCS with the client, he was staying home from his day program because he would not allow a dressing on his leg.Client A was a 51 year old male with diagnoses of a severe mental disability, blind (since birth) and hearing loss. According to the nurse's notes dated 1/4/14 at 7:30 P.M., Client A was assessed by the facility's registered nurse after it was reported on 1/4/14 at 5:50 P.M. by the DCS that he "had knocked over his hot tea off of the table, spilling it onto his left leg. Erythema (redness) noted above the knee, measuring 6" from top to bottom and wrapping across the top of his leg from side to side. Multiple blisters noted. No swelling or charred skin. Appears to be second degree burn. Attempted to pour cool water on burn site and put cool wet rag on leg, but (Client's name) was uncooperative. He shows no evidence of pain/discomfort, instructed (staff) to give Tylenol per prn (as needed) orders and apply aloe to skin. No changes noted in ability to use leg or walk. Notified (physician's name), he instructed to continue to monitor and apply Silvadene to site BID (twice a day) if blisters rupture." On 1/7/14 at 2:15 P.M. The nurse's notes indicated that the client's pain was managed with Tylenol and the reddened skin was now "a darker purple-red and measured 5" from top to bottom on the top of his thigh/quad above his knee. The widest area of reddened skin on the lateral side of his leg measures 3" from top to bottom and the widest area of reddened skin on the medial side measures 2" from top to bottom. Loose skin present on all sides; top, lateral and medial from ruptured blisters...No s/s of infection... wound beds appear dark pink to bright red around the edges." The 6:15 P.M. nurse's notes indicated that the physician wanted the treatment to be continued with Silvadene and for a kerlex/non adhering dressing applied however, the client became agitated when there were repeated attempts to cover the wound. Per the notes the client stayed home from day program since the burn site could not be covered. Also at this time two additional red, burn areas were noted on both buttocks. The left buttock measured 4"x2" and on the right buttock 1.5"x1". The physician ordered the same Silvadene treatment for the buttocks. The Qualified Intellectual Disabilities Professional (QIDP) was interviewed on 1/7/14 at 11:15 A.M. She stated that on Saturday, 1/4/14 at 5:30 P.M., DCS 1 was preparing chai tea in the microwave located in the dining room on a side table, for Client A. It was heated for 2 minutes in a tall, plastic cup. DCS 1 took the tea out of the microwave when it was done heating, but it was not ready to be served since it still needed milk to be put in it. At this time, another client (Client B) was having a behavior so the DCS 1 put the hot liquid on the dining room table where Client A was sitting. As she went to redirect the other client away from the kitchen, Client A reached for the cup and knocked it over spilling the hot tea onto himself. According to the QIDP, current inservices include serving blind clients so they are aware of where things are and ensuring the correct temperatures of food items being served. However, the heating and serving of hot liquids to maintain a safe environment for clients, was not included in the inservices. DCS 1 was interviewed on 1/16/14 at 1:30 P.M. She stated that when Client B went into the kitchen, "I set the cup down so quickly, that I don't remember how far away from him it was on the table. I went to redirect Client B away from the kitchen and I heard the cup fall." According to DCS 1, when Client A sits at the table he just reaches out with a sweeping motion to see if anything is there for him. He didn't pick up the cup, he knocked it over. The facility failed to provide in-service training for heating hot liquids and ensuring their safe serving temperature to prevent accidents and ensure a safe environment for all clients.The violation of the above regulation had a direct or immediate relationship to the health, safety or security of the clients. |
| 090000003 |
Magnolia Post Acute Care |
090010914 |
B |
09-Oct-14 |
OLD111 |
8827 |
CLASS B CITATION - Title 22, 72311(2), Nursing Service - general: Implementing of each patient's care plan according to the methods indicated. The facility failed to ensure that the licensed nurses (LNs) monitored Patient A's skin condition and prevented the development of pressure ulcers (any lesion caused by unrelieved pressure that results in damage to the underlying tissues). LNs failed to assess and monitor Patient A's skin condition routinely, and failed to document Patient A's skin condition on the Weekly Nurses Progress Notes for 9 weeks; and failed to document Patient A's skin condition on the facility's Nurses Notes for 11 days.The failure to monitor Patient A's skin resulted in the developed pressure ulcers on both heels, as identified by a family member and validated by a licensed nurse, on 2/11/14. Patient A was admitted to the facility on 12/4/13, with diagnoses which included diabetes mellitus (a disorder causing high blood sugar) without mention of complication, per the Face Sheet. Patient A also had vascular insufficiency (poor blood circulation) to both feet, according to the Podiatry Consult Report, dated 12/12/13. On admission, Patient A did not have pressure ulcers and the patient's skin condition was normal, according to Patient A's Admission sheet.An interview and a joint record review with LN 2 was conducted on 5/21/14at 3:00 P.M. Patient A was designated moderate risk for the development of pressure ulcers, according to the weekly Braden Risk Assessment tool (a tool to assess the patient's level of risk for the development of pressure ulcers), dated 1/23/14. However, there was no LN documentation on the Braden Risk Assessment from 1/24/14 to 2/26/14. LN 2 acknowledged that the Braden Risk Assessment had not been completed, before and/or after Patient A's pressure ulcers were discovered.An interview and a joint record review with the director of nursing (DON) and the director of staff development (DSD) was conducted at 4:00 P.M. on 5/21/14. The nurses failed to documented evidence on the Departmental notes that LNs had assessed and monitored Patient A's skin condition for 11 days between 2/1/14 to 2/11/14. The DON acknowledged that LNs did not identify Patient A's skin condition and any changes. In further record review there was no evidence documented that the weekly skin assessment had been performed by the LN in the Weekly nurses Progress notes dated between 12/4/13 until 2/15/14. In addition, in the Weekly Nurse's Progress Note, dated 2/15/14 and 2/22/14, the section "Skin Condition: Wounds-Decubitus (pressure) Ulcer Location and Description," were left blank. The DON and DSD acknowledged that LNs did not monitor for skin condition changes and did not document as required.On the Nurses Notes dated 2/12/14 at 4:20 P.M., LN 1 documented: "Dtr (daughter) reported that resident has fluid filled blisters to both heels. Both measure 4 x 6 cm (centimeter), also abrasion to R (right) knee."The DON acknowledged that Patient A's pressure ulcers were found by the family member and not the LNs. The Resident Care Plan for at risk skin breakdown, dated 12/4/13, indicated: "Observe for S/S (sign and symptom) of skin breakdown." The DON acknowledged that LNs did not implement the plan of care for skin observation, and LNs did not assess Patient A's skin for S/S that might increase the risk for breakdown. Continued interview and joint record review with the DON reviewed an undated facility policy and procedures, titled: "Job Description Licensed Vocational Nurse, Skilled Care," which indicated: "Job Summary: implementing nursing interventions according to the patient's care plan, documenting the patient's response to the nursing interventions and plan of care."And: "Essential Functions: Observes, records and reports unusual conditions." The DON acknowledged that LNs had not complied with the duty statement for the implementation of nursing care plans, as indicated by the facility's job description for a licensed nurse.An interview and a joint record review with LN 1 were conducted on 5/21/14 at 5:09 P.M. LN 1 stated that she completed the Wound Assessment Report on 2/11/14, and documented: "Pressure Ulcer Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough.)...Right Heel, New Wound, Measurements: Length 4.00 cm (centimeter), Width 6.00 cm" and "Pressure Ulcer Stage 2...Left Heel, New Wound, Measurements: Length 4.00 cm, Width 6.00 cm.." LN 1 further stated that the Wound Assessment Reports had not been done from 12/4/14 to 2/11/14.A telephone interview with the DON and DSD were conducted at 5:00 P.M. on 5/29/14. The DSD stated that the facility provided a shower to the residents twice a week. The DSD stated that "CNAs conduct skin assessments during the shower and document the skin observation results on the Skin Observation-Bath/Shower/Other Sheet. And then the CNAs submit the Skin Observation Sheets to the charge nurses." The DSD stated the charge nurse review the Skin Observation Sheets completed by the CNAs and if the CNA identified any skin issues, the charge nurse was to go back to the resident and conduct a skin assessment. The DSD also stated that the charge nurses notify the wound nurse and the wound nurse was to review the CNAs observation sheets and also conduct a skin assessment. Review of the Skin Observation Sheet for Patient A dated 2/3/14, noted that CNA 1 documented that Patient A had red, swollen area and marked a circle on the groin area of body picture. CNA 1 also documented that the "Resident is not feeling well, refuse shower and bed bath." The Skin Observation Sheet was reviewed and signed by the charge nurse, but the section for "skin nurse" was left blank. No further documentation was found in the record by LNs regarding CNA 1's documentation of Patient A's skin, on 2/3/14. The DON acknowledged that a charge nurse did not act upon the findings of CNA 1 regarding Patient A's skin condition.On 2/6/14, CNA 1 documented by drawing a circle that Patient A had rashes and a red area on the groin, and marked a circle on both feet on the body picture of the skin observation sheet. The sheet was reviewed and signed by the charge nurse but the section of "skin nurse" was left blank. No further documentation was found in the record by LNs regarding CNA 1's documentation on 2/6/14. The DON acknowledged that a charge nurse had not acted upon CNA 1 identification of skin problem and there was no evidence in the record that a charge nurse conducted a skin assessment for Patient A on 2/6/14. The Skin Observation Sheet dated 2/10/14, was also incomplete and documented that Patient A had "bruises" but no location identified, and commented "no new skin issues." The sheet was not signed by a charge nurse or wound nurse. No further documentation was found in the record by LNs regarding CNA 4's documentation on 2/10/14. The DON acknowledged that the sheet was incomplete and a charge nurse had not review and had not act upon the CNA 4's findings.Patients in skilled nursing facilities have medical conditions such as fragile skin, lack of mobility, incontinence, and inadequate nutrition that put them at increased risk for developing pressure ulcers. As a consequence, the facility's licensed nursing staff's failure to implement measures to prevent skin impairment, contributed to the development of Patient A's pressure ulcers. The failure of the LNs to adequately assess, monitor and document changes to Patient A' skin, contributed to the delayed identification of Patient A's pressure ulcers. The licensed nurse's lack of review and follow through of the CNAs documentation of the skin observations of patients during showers, also delayed the identification of Patient A's pressure ulcers in the early stages of development. Patient A developed stage 2 pressure ulcers on each heel, which caused Patient A discomfort and delayed physical healing and impaired Patient A's overall well-being.The Facility failed to: 1. Implement Patient A's plan of care for skin assessment and the prevention of pressure ulcers 2. Observe for signs and symptoms of skin breakdown. 3. Adequately assess and monitor Patient A's skin to identify pressure ulcers in the early stages of development and provide immediate measures to prevent the formation of pressure ulcers. 4. Ensure that LNs documented Patient A's skin condition on the Weekly Nurse's Progress Notes, Nurses Notes, and on the weekly Braden Risk Assessment Sheets. 5. Ensure that the Skin Observation-BathShowerOther Sheets were completed by LNs and that LNs acted upon the findings of the CNAs when patient's skin problems were first identified. A violation of this regulation had a direct or immediate relationship to the health, safety or security of patients. |
| 090000311 |
Mountain Shadows Community Homes - Spruce |
090011414 |
B |
24-Apr-15 |
13Y111 |
7345 |
76873 (b) Developmental Program Services-Orientation and In-Service Training. The facility shall require that all new staff, prior to providing direct care services, receive eight (8) hours of orientation which shall be documented and be completed during the first 40 hours of employment. (H) Use of adaptive equipment or devices (c) The facility shall require that all direct care staff, in addition to eight (8) hours of orientation, receive at least three (3) hours per month, 36 hours annually, of planned in-service training which shall be documented and shall include, but not be limited to, the following topics: (3) Evaluation and assessment techniques.Client 1 was a 44 year old male admitted to the facility on 6/17/14, with diagnoses that included a profound intellectual disability, seizure disorder and spastic quadriplegia. Client 1 was observed on 3/3/15 at 3:45 P.M., at the facility. He was non-verbal, dependent on staff for his activities of daily living (ADL's) that included pushing his manual wheelchair (W/C). The Qualified Intellectual Disability Professional (QIDP) was interviewed on 3/3/15 at 11:00 A.M. The QIDP provided a verbal scenario of the events that occurred at a church outing on 2/22/15, as well as the General Event Report (GER) dated 2/22/15, and an incident report from the church dated 2/23/15, by the church volunteer (witness). The GER dated 2/22/15, entered by the DCS at 1:46 P.M., indicated that there were 3 clients (in wcs) on the bus, for a church outing. When they got to the church, the bus driver was pushing the wc for Client 2 to the church, while the DCS tried to push the other 2 clients (1&3). Per the same report, the DCS couldn't push both of the clients, so she took Client 3 to the water fountain and when she got back to Client 1, he was on the ground. According to the report, the DCS said, "I realized that I forgot to put the breack (brakes) on. someone from church help me getting him up. driver called the Q ON CALL. don't know how it happened."The GER: Injury information: Type:scrape Cause: fall Time: 11:00 A.M. Location: church Treatment:ER/Hospital Time of Treatment: 11:30 A.M. Severity:Moderate Body Part(s):"Face Finger Little Right Forehead." GER Review/Follow up comments: The registered nurse (RN) wrote on 2/22/15, at 02:47 P.M., "(I have reviewed this report) Client 1 has redness/swelling to right cheek, an abrasion to right forehead, small scratch to right hand. This was an un-witnessed fall. He was sent to the ER for evaluation." The Church Incident Report dated 2/23/15, completed by the church volunteer, provided information on Client 1as follows: "Location: Church unloading area near crosses and rock. Description of Incident: "Approximately 10:30 A.M. February 22, 2015 two (facility) staff were trying to wheel three wheelchairs with clients (1,2 & 3) from parked bus to the church (south to north). The bus driver had (client) and wheeled him to church, the other two including (Client 1) were being moved from the unloading area toward church. The staff was having difficulty rolling two wheelchairs at one time. Client 1 was on the left side (high side) as they moved left to right. The staff positioned (Client 1) parallel to the curb and stopped; to allow the staff and other wheel chair to be moved toward church. As I was 25 yards away, I saw (Client 1's) chair slightly turn, I began running and witnessed his wheelchair rolling off the curb, resulting in an overturned wheelchair and (Client 1) faced down on the parking lot. I yelled out as I ran towards (Client 1) and at the same time the staff returned and we (staff and I) up-righted the wheel chair and rolled the wheelchair to a safe location. The staff (DCS) immediately contacted the bus driver for contact information and direction regarding appropriate steps. Initial appearances indicated a bump on the forehead and abrasions. I inquired if they needed emergency medical assistance. The bus driver took control of situation and during a 10 minute period I was with (Client 1), by myself, comforting, and monitoring his condition. At approximately 10:45-10:50 am, the bus driver loaded (Client 1) on the bus and returned him back to the (facility). Description of treatment provided for injury: Up-righted wheel-chair, notice bump above eye on forehead and several non-bleeding scrapes on forehead and hands, kept (Client 1) warm with my jacket until loaded back into bus for immediate return back to (Facility)." The RN was interviewed on 3/3/15 at 12:00 P.M. According to the RN , the DCS notified her of Client 1's injuries as being only minor scratches, therefore they were told to bring the client back to the facility. Per the RN the DCS never mentioned that Client 1 had a bump or bruise on his forehead. The RN stated that Client 1 was reevaluated when he came back to the facility and he was sent by ambulance to the ER at 11:30 A.M. The bus driver was interviewed on 3/3/15 at 4:00 P.M. She stated that usually there were more volunteers at the church to help with the clients. Therefore, she told the DCS to wait with the other 2 clients (1&3) at the bus while she took Client 2 up to the church. When the bus driver turned around she saw the DCS pushing both clients (1&3) and placing Client 1 by the curb. While the DCS was pushing Client 3 the bus driver saw Client 1 fall over in his W/C. The bus driver stated that she called the QIDP (Qualified Intellectual Disability Professional) and the DCS spoke with the R.N. and gave report. The DCS was interviewed on 3/3/15 at 4:15 P.M. She stated, "The driver took Client 2 up to the church and I didn't know where she went, so I started to push both Clients 1 & 3 but I couldn't do it. So I left Client 1 close to the curb and pushed Client 3 up to the fountain. I completely forgot to put the brakes on Client 1's wheelchair. I only noticed scratches on his right eyebrow, right cheek and right hand. I did not see any bumps or bruises." The DCS was asked again if the client had a bump on his forehead or a bruise and she said, "No, I only noticed scratches." The nurse administrator was interviewed on 3/3/15 at 4:30 P.M. She acknowledged that the DCS did not provide the facility nurse with accurate information about the client's injuries, in order for the facility nurse to make an accurate assessment of his health needs. The facility failed to ensure that the staff orientation and in-service training was implemented for the use of adaptive equipment, when the staff failed to apply the brakes on a wheelchair belonging to a disabled client, who was totally dependent on staff to ensure his physical safety. As a direct result, the client sustained a bump above his eye on his forehead and several scratches on his forehead and hands. In addition, the facility failed to ensure that the staff orientation and in-service training was adequate and implemented for the evaluation and assessment techniques of a disabled client's injuries to his forehead, sustained during a fall when his wheelchair overturned. As a direct result, the client's immediate health needs were delayed when the staff failed to provide the facility nurse with accurate information about the client's injuries. The violation of the above regulations had a direct or immediate relationship to the health, safety or security of the clients. |
| 090000312 |
Mountain Shadows Community Homes - Lemon |
090011586 |
B |
30-Jun-15 |
I7IB11 |
11048 |
CLASS B CITATION -76867 (a)(b)(c)(d) Developmental Program Services-Restraints. (a) Restraints (a device on the body which restricts movement) shall only be used as temporary emergency measures to protect the client from injury to self or others and only upon a written or telephone order of a physician or clinical psychologist. Telephone orders shall be recorded immediately in the client's record and shall be signed by the prescriber within 5 days. Restraints shall not be used as punishment, a substitute for more effective programming or for the convenience of the staff. (b) Orders for physical restraints shall be in force for not longer than 12 hours. (c) There shall be no PRN (as needed) orders for physical restraints. (d) The client's record shall include an entry noting the time of application and removal of restraints, justification for and authorization of all periods of restraints and signature of the person applying the restraints. 76868 (a)(2)(3) Developmental Program Services-Application of Restraints. (a) In the use of physical restraints, each of the following requirements shall be met: (2) A client placed in restraint shall be checked at least every 15 minutes by the staff to assure that the restraint is properly applied. Written documentation of these checks identifying staff responsible for performing the check shall be kept in the Unit Client record. (3) Physical restraints shall be designed and used in such a way as not to cause physical injury and to assure the least possible discomfort to the client. Opportunity for motion and exercise shall be provided for a period of not less than 10 minutes during each 2 hours in which restraint is applied. The exercise periods shall be documented in the client's record. The facility failed to maintain the client's rights to be free from unnecessary physical restraints. The facility used physical restraints, cloth ties and hand mittens to bilateral wrists, and a cloth tie restraint to one ankle daily, from 2/17/15 to 4/17/15, to manage or control Client 1's behavior, and without specific physician's orders for restraints. The physical restraints were not used as a temporary, emergent medical or surgical condition.Client 1 admitted to the facility on 2/17/15, with diagnoses that included Lesch-Nyhan Syndrome (neurological impairment causing uncontrollable, often violent muscle movements, poor muscle control/coordination and moderate intellectual disability) , per the facility Face Sheet. On 4/17/15 at 2:00 P.M., Client 1 was observed sitting in a wheelchair with both wrists restrained by cloth ties, tied to the arms of the wheelchair. Client 1 was not able to move his forearms because they were restricted by the restraints. Client 1 was calm and was not struggling to get out of the restraints when observed, as the HFEN (health facilities evaluator nurse) spoke to him. Client 1 stated: "I'm Ok, I asked for it (restraints). I wanted it. (the restraints applied)."DCS (direct care staff) 1 was standing by Client 1. DCS 1 stated that Client 1 requests to be put in restraints, and staff had been applying wrist restraints to Client 1 daily, since his admission.On 4/17/15 at 2:50 P.M., DCS 1 stated that Client 1 is totally dependent on staff for all of his care needs, such as feeding, toileting, transferring, repositioning. Client 1 was not able to remove the restraints himself. Client 1 is non-ambulatory and is wheelchair bound. On 4/17/15 at 3:55 P.M., an interview and record review was conducted with LN 1 (licensed nurse 1) and the QIDP (Qualified Intellectual Disabilities Professional).LN 1 stated that the physical restraints were used for Client 1 at all the times, since 2/17/15, per Client 1 and his RP's (responsible party's) request.LN 1 stated that she or another LN, did not provide in-service training for the use of physical restraints to the DCS. The QIDP stated that the QIDP (a non-licensed staff) provided an in-service training to the DCS on 4/15/15, 63 days after the physical restraints were implemented. However, the in-service presented was titled "Postural Supports," which was not an accurate representation of the physical restraints that were actually applied to Client 1. A review of an in-service training record, dated 4/15/15, was presented to the HFEN by the QIDP and the HM (house manager) and indicated:"Postural Supports: The postural supports will stay tied to the base of the wheelchair and the frame of Client 1's bed. When Client 1 had been transferred, turn the wrists up and wrap the restraint around the wrist as tightly as he requested. This applies to the supports in his bedroom. When he feels he may be harmful to himself or others he will request they be tightened. Once they are wrapped, tuck the white cotton "ribbon" around the silver buckle and pull tightly. When Client 1 is comfortable with the security of the supports, tie the remaining cotton ribbon around the wrists and tuck to maintain security of supports. Ask Client 1 if this feels ok and he is safe. If he says no, continue to adjust until they are to his liking."During a same concurrent interview and record review, LN 1 acknowledged that, the "postural supports" as described above, are NOT postural supports, and that, they are actual physical restraints. Restraints should not be used on any client at any time in this type of licensed facility (the community residential setting level of care), except under specific medical or surgical circumstances, and only for short term, infrequent use, per State and Federal regulations.On 4/17/15 at 3:35 P.M., the DCS 2 was interviewed. DCS 2 stated that Client 1 asks to be put in restraints, and that, "he does not like Not being in restraints" so, Client 1 is supposed to have restraints all day.On 4/17/15 at 3:50 P.M., the HM was interviewed. The HM stated that Client 1 wanted to have the restraints and staff are supposed to leave them on at all times. On 4/17/15 at 5:15 P.M., an interview and record review with LN 1, the DRC (director of residential services), and the QIDP was conducted. The DRC, QIDP and LN 1 stated that staff applied the restraints to both wrists when Client 1 was in his wheelchair. They stated that staff apply a right wrist restraint and hand mittens, and a tie restraint to the client's left ankle at night, when Client 1 is in bed. The DRC, QIDP and LN 1 stated that the facility used the physical restraints daily on Client 1, from 2/17/15 to 4/17/15. The physician's orders dated 2/17/15, were reviewed and indicated: "May wear mechanical support seat belt when in wheelchair. Wear stabilizer belt while lying down in bed to provide safety belt for inability to control arm movement. Wear gloves as needed as tolerated/to prevent skin picking."The physician's order does not describe the actual physical restraints that were used on Client 1. Written or telephone orders from a physician, were not obtained before the facility staff applied physical restraints to Client 1. When interviewed on 4/29/15, at 11:14 A.M., regarding the restraints and restraint orders, the physician stated that he wrote an order for a stabilizer belt to be applied to the client in bed, and for postural supports, but further stated he did not know what kind of device the stabilizer belt really was, however he, "wrote an order because the staff asked for it."He further stated he did not discuss an informed consent with the client or responsible party for the application of physical restraints or the long term application of physical restraints and the risks of physical restraints. In addition, the facility obtained PRN (as needed) orders for the use of restraints on Client 1 on 4/13/15. However, PRN orders for restraints are not permitted by the regulations. There was no evidence in the records that indicated that the restraints were used as a temporary, emergency measure, to protect Client 1 from injury to self or others. Further, the restraints were not removed when Client 1 was calm or no longer was a danger to self or others.Continued record review noted that the facility failed to use and document, a physical restraint observation sheet, while Client 1 was in restraints, from 2/17/15 to 4/17/15. The facility did not have evidence that the staff conducted skin checks of the client's wrists and ankle, at least every 15 minutes, to assure that the restraints were properly applied. There was no evidence that the staff provided or offered food, water and toileting, to Client 1 every 2 hours and motion and exercises every 2 hours to prevent pressure ulcers, and muscle and joint contraction or pain.No facility policies and procedures and protocols were found in the record or in the facility, to guide staff in the proper application of restraints, and adequate documentation of physical restraints.Noted in the record were 18 General Events Reports, describing 18 incidents/accidents sustained by Client 1, since his admission to the facility and the daily use of physical restraints.The following are examples of the incidents that occurred while Client 1 was in restraints: 1. 2/21/15 at 9:10 P.M. "Fell out of bed and ended up with a scrape on his right knee. Client 1 had his restraints on while in bed, but it is possible they were not tight enough and he was able to maneuver out of them. The bed rails were also up. It is possible that Client 1 slid down the end of his bed." 2. 3/3/15 at 7:15 A.M. "Client 1 was on the floor...we are reevaluating his restraints to ensure he stays secure in his bed." 3. 3/6/15 at 6:50 A.M. "Discovered a blister on Client 1's left wrist from the straps...suspect the blisters are from his newer wrist straps...staff instructed to tuck shirt into wrist area before putting on straps to limit friction and further injury." 4. 3/9/15 at 3:15 A.M. "Fall with laceration. Purchase more secure postural supports, solid bed rail, bed rail padding and fall mat." 5. 3/16/15 at 12:31 P.M. "Client 1 was half on the floor and half still in the bed. Client 1 was inbetween the space in in the side railings. Client 1's left upper extremity was behind his back...new more sturdy restraints have been ordered. Mat to be added to floor to reduce head injury if another fall occurs." 6. 4/8/15 at 3:35 A.M. "Client 1 attempted to fall off his bed. This was due to a broken postural support that he himself broke out of. Postural support was replaced...Purchase more supports, possible more sturdy ones." The facility staff violated the client's human rights, when staff applied physical restraints to Client 1, which resulted in an increased risk for negative outcomes and physical injuries.The facility failed to ensure compliance with all applicable laws and regulations, related to client's rights and use of physical restraints. This practice resulted in the prolonged use of physical restraints on Client 1, compromised Client 1's safety, and violated his basic human rights. The violation of these regulations had a direct or immediate relationship to the health, safety or security of the client. |
| 090000039 |
Mission Hills Post Acute Care |
090011869 |
B |
24-Nov-15 |
9ZR111 |
11279 |
72311 Nursing Service -General (a) Nursing Service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at least the following: 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. Patient 1 was admitted to the facility on 10/21/14, for aftercare following a traumatic hip fracture on 10/19/14, as the result of a fall, per the facility Face Sheet. The acute hospital operative report dated 10/19/14, indicated that Patient 1 had a left hip hemiarthroplasty (hip surgery) on 10/19/14.On 10/26/14, the facility failed to ensure a safe transfer from the bed to a bedside commode, for Patient 1 during a one person assist. Patient 1 sustained a periprosthetic fracture (a broken bone that occurs around the components or implants of a hip replacement), which required Patient 1 to be transferred to an acute care hospital emergency room for further treatment, which resulted in a second surgical intervention to repair Patient 1's previously fractured left hip.The facility failed to ensure that the required assistance related to Patient 1's mobility and transfer needs, was accurately addressed in the nursing care plan.Patient 1's Minimum Data Set Assessment was not accurately reflected in the nursing plan of care, related to the nursing interventions to prevent falls and further injury to Patient 1.On 8/11/15 at 11:10 A.M., a telephone interview was conducted with Patient 1. Patient 1 stated that there were two instances when she was not provided with sufficient assist to the commode. The first one was, "on 10/25/14, after midnight," she was assisted to the bathroom by CNA 1. She stated, "I almost slipped and he dropped me to the commode." She stated that CNA 1 was alone when he assisted her to the bedside commode. She stated that CNA 1 started to use a gait belt "but the gait belt didn't fit me."She stated that she had previously complained to a male charge nurse that CNA 1 was "rough" on her. Patient 1 stated that the second incident "was on 10/26/14, around 5:00 A.M.," when CNA 1 "came to her room alone and tried to help her to get to the bedside commode." She stated that during the process of transferring her from bed to the bedside commode, her "legs gave up," causing her to fall to the floor hitting her (left) hip on the floor. Patient 1 stated that while she was lying on the floor, she asked the staff if she could use the bathroom. She stated that one of the staff said to her, "it's ok to pee on the floor, and that the staff will clean her." Patient 1 stated, "It was humiliating to me." Patient 1 stated that she was in pain and she asked to be taken to the hospital.On 8/12/15, Patient 1's medical record was reviewed. The Minimum Data Set (MDS) assessment, Section G0110 Activities of Daily Living (ADL), dated 10/26/14, indicated that Patient 1's assistance for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) was coded "3" which indicated that Patient 1 needed a "Two or more person physical assist." The Fall Risk Assessment dated 10/21/14, indicated that Patient 1 had a total score of "7," which the Risk Assessment indicated that a score of "10 and below = Limited Risk."On 8/12/15, at 2:30 P.M., an interview was conducted with the director of nursing (DON).The DON stated that on 10/26/14, at approximately 5:50 A.M., Patient 1 called for assist to use the bedside commode. Certified nursing assistant (CNA) 1 answered the call light and went to patient's room by himself. The DON stated that Patient 1 was lying in bed on her back, when CNA 1 entered her room. The DON stated that Patient 1 asked CNA 1 for assist to the bedside commode. The DON stated that Patient 1 asked CNA 1 to place the walker in front of the bed. She stated that Patient 1 tried to sit up by holding CNA 1's hand and holding the walker with her other hand. The DON stated that during this process, Patient 1 informed CNA 1 that she was in pain and unable to stand on her feet. The DON stated that, "CNA 1 couldn't put her back to bed because of her weight." The DON stated that CNA 1 eased her down to the floor in sitting position. The DON stated that Patient 1 requested to use the phone to call a family member. The DON stated that Patient 1 was given the corded facility phone which was located on Patient 1's bedside table. She stated that while patient 1 was seated on the floor, CNA 2 and other staff members offered Patient 1 a Hoyer Lift (a device used to move immobile patients) and Patient 1 refused the Hoyer Lift. The DON stated that Patient 1 was yelling, "Help, Help." The DON stated that Patient 1 complained of pain in her left lower extremity and requested to be taken to the hospital. She stated that 9-1-1 was called and the 9-1-1 responders lifted the patient off the floor to the gurney.Patient 1 was taken to the acute hospital.On 8/26/15, at 9:25 A.M., an interview was conducted with CNA 1. He stated that it was between 1:30 A.M. and 2:00 A.M., he saw Patient 1"s call light was turned on, the morning of 10/26/14. He stated that he went inside her room and he asked the patient if she needed help. He stated that Patient 1 requested to use the bedside commode. He stated that he saw Patient 1's bedside commode on the right side, at the head part of her bed. CNA 1 stated that he held her hands and helped her to sit at the edge of the bed. He then asked to put her feet on the floor. He stated that he tried to use the gait belt but the gait belt that he had at that time was "too short for her." He stated that when the patient's toes were already touching the floor the patient started yelling, "I am sliding, I am sliding." CNA 1 stated, "She tried to drop herself on the floor." CNA 1 stated that he hugged the resident's upper body and sat her on the floor with her legs in straight position. He stated that as soon as he sat her down to the floor, he stood by the patient's door and yelled for help while he was watching Patient 1 seated on the floor. He stated that licensed nurse (LN) 1 who was in the hallway came to help. He stated that LN 1 assessed Patient 1. He stated that LN 1 offered to use the bed sheet to lift her back to bed, but the patient refused. He stated that Patient 1 laid herself on her back on the floor. He also stated that Patient 1 was yelling and telling the staff to call a family member. CNA 1 stated that he did not know that Patient 1 required two or more person physical assist for transfer. He stated that "AM shift (7:00 A.M.), PM shift (3:00 P.M. - 11:00 P.M. and NOC shift (11:00 PM -7:00 A.M.) had been transferring Patient 1 from bed to chair with one person assist. He also stated that there was no licensed nurse that gave information to him as to the number of persons physical assistance needed to transfer Patient 1 from bed to chair and vice versa. CNA 1 acknowledged that he assisted to transfer Patient 1 alone from the bed to the bedside commode. CNA 1 stated that Patient 1 was not able to use the bedside commode because he was not able to transfer her to the bedside commode. On 8/26/15 at 10:30 A.M., an interview was conducted with CNA 2. She stated that she came to help CNA 1. She stated that CNA 1 informed her that a patient was on the floor. CNA 2 stated that when she and CNA 1 entered Patient 1's room, Patient 1 was in sitting position with her legs straight on the floor by the bed. She stated that she saw LN 1 asking Patient 1 if they can lift her back to bed using a bedsheet. CNA 2 stated that Patient 1 refused. CNA 2 stated that LN 1 also asked if they could use a Hoyer Lift but the patient also refused. CNA 2 stated that Patient 1 was yelling 'help, help, help and seemed upset with CNA 1 and LN 1." CNA 2 stated that while patient was sitting on the floor, Patient 1 asked for a telephone to call a family member. CNA 2 stated that she gave Patient 1's the corded facility telephone which was located at Patient 1's bedside table. CNA 2 stated that patient 1 was upset with the family member on the phone and the patient threw the phone on the floor. She stated that the ambulance came and picked her up. CNA 2 acknowledged that Patient 1 needed 2 persons assist to transfer. On 8/26/15 at 11:05 A.M., an interview was conducted with the physical therapist (PT) 1. PT 1 stated that on 10/22/14, Patient 1 was evaluated by the PT1 for declining functional mobility after hip surgery. She stated that Patient 1 required maximum assist for bed mobility. PT 1 stated that Patient 1 had physical therapy treatments on 10/22/14, 10/23/14. On 10/24/14, Patient 1 refused physical therapy due to her leg was swollen and painful. On 8/26/15 at 12:10 P.M., the nursing care plan dated 10/23/14, was reviewed. The nursing care plan indicated: "PROBLEM: At risk for Falls or injury R/T: Relevant/Risk factors: Unsteady gait, balance instability, hypo/hyperglycemia, pschotropics, pain, other: hemiarthroplasty (hip surgery). GOALS: Resident will be free of injury daily through 11/23/14. APPROACHES/INTERVENTIONS: Preventative measures were not identified. Use of gait belt was not identified either. The use of non-slip footwear did not indicate as to when the resident should be wearing them.On 8/26/15 at 12:21 P.M., an interview and joint record review of Patient 1's MDS assessment, dated 10/26/14, and nursing care plan, was conducted with the minimum data set coordinator nurse (MDSC). The MDSC stated that the nursing care plan should include the number of persons needed to safely transfer the patient, as was indicated on the MDS activities of daily living (ADL). The MDSC stated that the patient was admitted to the facility for rehabilitation after hip surgery. The MDSC acknowledged that Patient 1 required 2 or more persons assistance to transfer from bed to chair and vice versa.According to the operative report sheet dated 11/1/14, Resident 1 underwent a "left femoral component with open reduction and internal fixation of the proximal femoral fracture."A review of the facility's policy and procedure titled: Resident Assessment Subject: Fall Management System indicated: "Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents."The facility failed to review, evaluate and update Patient 1's care plan according to the Patient 1's medical care needs as identified on Patient 1's MDS assessment of activities of daily living (ADL). The facility failed to provide accurate assessments and interventions to prevent injuries to Patient 1 and transferred Patient 1 without adequate assist, thereby compromising Patient 1's safety and security. As a result, Patient 1 dropped to the floor on 10/26/14, hitting her recently fractured left hip, causing Patient 1 to re-fracture her left hip, and undergo a second surgery to repair the re-fractured left hip.The violation of the above regulations had a direct or immediate relationship to patient's health, safety, or security. |
| 090000119 |
Mount Vernon Group Home |
090012650 |
B |
13-Oct-16 |
4XZ511 |
10338 |
Federal Regulation, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), section 483.420 Client Protections, W 153, the facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures. Injuries of unknown source that give rise to a suspicion that they may be the result of abuse or neglect, should be reported immediately. Health and Safety Code - ?1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident [synonymous with client as used herein] of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. Based on observation, interview, and record review, the facility failed to assure that an incident of employee-to-client abusive conduct toward Client 1 was timely reported to the CDPH within 24 hours. Findings: On 6/1/16 at 3:30 P.M., an entity reported incident reported was investigated regarding a client abuse by the employee. The facility failed to ensure that Patient 1 was kept free from abuse, when a direct care staff (DCS 1) was observed to have thrown a cup at Client 1 and yelled at the client on 5/27/16. This failure compromised Client 1's safety, which resulted in an increased risk for mental and physical stress. Furthermore, the facility failed to ensure staff implemented facility policy and procedure related to abuse reporting when another DCS 2 failed to report an observed injury of unknown origin on the same date and shift, to a supervisor, until three days later. This resulted in the facility delay reporting possible abuse incident timely to the California Department of Public Health (CDPH). Also, the abuser staff (DCS 1) continued to work the following two days without any intervention or investigation by the facility putting Client 1 and other clients in the facility at risk for further abusive conduct by DCS1. Facility staff failed to report an abuse incident within the required time frame as indicated by state law. This violated state law and had the potential to put Client 1's health, safety, and security at risk. Client 1 and Client 2 were admitted to the facility with diagnoses that included an intellectual disability per the facility Individual Data sheet. On 6/1/16 between 3:45 P.M. and 5:30 P.M., Client 1 was observed eating dinner. Client 1 was observed to require verbal prompts, and guidance, to eat and for all activities of daily living. Client 1 was observed to be ambulatory and able to follow the verbal prompts when calm. Client 1 was observed to yell at times repeating the same phrase over and over, yelling louder, as he repeated it. Client 1 was observed to not follow verbal prompts to stop yelling, but did comply with a request to take a medication. On 6/1/16 at 4:40 P.M., an interview was conducted with another client (Client 2) at the facility. Client 2 stated that on the last Friday (5/27/16) Client 1 became angry about the TV. Client 2 stated seeing and hearing Client 1 yelling, and saw Client 1 throw a pillow and a cup of water at DCS 1 (identified by name). Client 2 stated that DCS 1 yelled at Client 1, "Don't throw the F-ing cup at me." Client 2 stated observing DCS 1 throw the cup back at Client 1. Client 2 stated telling DCS 2 what he had seen on Monday (5/30/16). Client 2 stated she/he would have called someone sooner, but did not know how. On 6/1/16 a Special Incident Report (SIR) faxed to the Department 6/1/16 was reviewed. The SIR indicated that Client 1 had informed DCS 2 that when Client 1 was having a behavior Client 1 had thrown a pillow and a cup at DCS 1. DCS 1 had thrown back the cup and had stated, "Don't throw sh-t at me." Client 2 told DCS 2 that DCS 1 had caused a "bruise" located on the middle of Client 1's left arm. However, Client 2 stated she/he had not witnessed the bruise occurring. On 6/1/16 at 4:55 P.M. an interview was conducted with DCS 2. DCS 2 stated he was on duty in the afternoon/evening of 5/27/16. DCS 2 stated he went with three clients to another facility for dinner. DCS 2 stated DCS 1 was at the facility with Clients 1 and 2. DCS 2 stated when he returned DCS 1 was crying and Client 1 was outside the facility and pacing agitated. DCS 2 stated he later noticed a bruise on the arm of Client 1. DCS 2 stated he photographed the bruise on his cell phone. DCS 2 stated he asked DCS 1 to call the QIDP and tell the QIDP what had happened. DCS 2 stated he went to provide care to a client while the DCS 1 called the QIDP. DCS 2 stated he believed at the time that DCS 1 had told the QIDP whatever had happened. DCS 2 stated he did not forward the photograph of the bruise to the QIDP until 5/30/16. DCS 2 acknowledged that he was a mandated reporter and stated he thought the events at the facility had been relayed to the QIDP by DCS 1 when she was on the phone the evening of the incident. DCS 2 stated maybe he should have handled the situation differently now that he knew more about what happened. On 6/1/16 at 5 P.M., an interview was conducted with the Qualified Intellectual Disabilities Professional (QIDP). The QIDP acknowledged that Client 2 had reported on 5/30/16 that DCS 1 was observed to throw a cup at Client 1 and yell at the client on 5/27/16, the date of the incident. The QIDP stated that Client 2 was a reliable witness to events and was found to have no motivation to embellish or alter the truth. The QIDP stated that Client 2 had not informed the facility of the incident until Monday 5/30/16. The QIDP stated that Client 2 could have reported on a special facility phone number but the number and procedure for calling was not clearly available to Client 2. The QIDP stated that during the facility investigation, DCS 1 had stated that, "things were flying and something went from her hand to [Client 1]." The QIDP confirmed that DCS 2 had photographed a mark on Client 1's arm on 5/27/16, the date of the incident, but DCS 2 had not transmitted the photo to the QIDP, house manager, or the nurse, or shared any concerns that day. At 5:15 P.M. a further interview was conducted with the QIDP. The QIDP stated that she first received the photo of Client 1's arm with a visible mark on it on 5/30/16 after Client 2 had come forward and told DCS 2 about the incident. The QIDP stated that she was not aware of a cup being thrown or any injury to Client 1 until 5/30/16. The QIDP stated she had been called by DCS 1 on the evening of the incident, and DCS 1 only stated that Client 1 had a behavior, but nothing about the cup, yelling, or any injury of unknown origin. The QIDP stated that DCS 2 had not called or transmitted the picture on 5/27/16. The QIDP stated that DCS 2 should have sent her the photo and/or a text to inform her of the injury to Client 1's arm based on it being an injury of unknown origin. The QIDP stated that DCS 2 should have called or texted a supervisor regarding DCS 1 crying and Client 1 being unattended outside and agitated. The QIDP stated DCS 2 should have informed a supervisor, even if DCS 2 had to do that without DCS 1 knowing. The QIDP acknowledged that the procedure used by DCS 2 did not follow the facility policy and procedure regarding the reporting of an injury of unknown origin or for suspected abuse. The QIDP stated and confirmed that DCS 1 had returned to the facility on 5/28/16 and 5/29/16 to work because no investigation of the bruise had been initiated until DCS 2 transmitted it to the QIDP on 5/30/16. On 6/1/16 a SOC 341 (a form of report of suspected dependent adult/elder abuse) was reviewed. The SOC 341 indicated it was submitted to the Department (CDPH) on 6/1/16 and indicated that DCS 1 was a suspected abuser for an incident on 5/27/16 that resulted in an unwitnessed, "bruise'" on Client 1. On 6/1/16 at 5:25 P.M. a further interview was conducted with the QIDP. The QIDP acknowledged that, since DCS 2 did not report directly to her on 5/27/16, she was unaware that the incident as described had taken place. The QIDP stated that pursuant to the facility policies, DCS 2 should have immediately reported Client 1's bruise as an injury of unknown origin, to her, the house manager, and/or the nurse, at the moment he noticed it and took a photograph of it. The facility policy and procedure entitled, "Consumer Rights and Protections," (abuse policy) was also reviewed. The abuse policy indicated that the facility and all employees were mandated reporters and as such was required to immediately report any incidents of reasonably suspected abuse to the Ombudsman, local police, San Diego regional Center and the Department. The Abuse policy indicated that staff do not have to witness or have proof that an incident occurred. Failure it report is a misdemeanor punishable by not more than six months in jail and/or a fine not to exceed $1000. If great bodily harm or death occurs the punishment increases. The facility failed to ensure that facility policy regarding abuse reporting was implemented, when DCS 1 was observed to have thrown a cup at Client 1 and yelled at the client on 5/27/16. In addition, the facility failed to assure that an injury of unknown origin, that occurred on the same shift, to the same client, was reported to a supervisor. As a result the DCS 1 and 2 were not investigated. Also, the client was not safeguarded when DCS1 worked two additional days after the incident with no additional scrutiny or supervision. All facility employees are mandated reporters, and as required by state laws are required to report alleged or suspected abuse within 24 hours to the Ombudsman, the CDPH, and law enforcement. Despite knowledge of an injury of unknown origin photographed by DCS2, coupled with the unusual behavior of DCS 1 found crying, and Client 1 agitated outside the facility, which were direct signals for potential, or suspected abuse, nothing was reported within the required time frame by facility staff. The above violations, either jointly, separately, or in any combination, had a direct or immediate relationship to health, safety, or security of Client 1 and other clients at the facility. |
| 010001124 |
MONTE VERDE |
110008845 |
B |
08-Aug-12 |
JI5511 |
4174 |
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 violated the regulation by failing to report to the department, within 24 hours, verbal and physical abuse of three clients which subjected clients to further abuse. The facility faxed the following statements to the department on 6/1/11: 1. In a documented statement dated 6/1/11, DCS (Direct Care Staff) A indicated on 5/24/2011, Client 1 reported that a staff member (DCS B) screamed at Client 1 and Client 2. DCS A documented, that Client 1 stated that DCS B called Client 2 names. DCS A also documented that, on one occasion, DCS A witnessed DCS B call the clients names.2. A document, dated 6/1/11, from Administrator C, indicated that on 6/1/11 was the first date that Client 1 could be interviewed about the incident due to Client 1 going out of town, hospitalization and holiday activities. The Administrator documented that, Client 1 stated, that the event he reported to DCS A, occurred approximately 3 months ago. 3. A statement, dated 6/1/11, from the QMRP (Qualified Mental Retardation Professional) indicated, on 5/25/11, DCS A reported that DCS B had spoken rudely to Client 1. As a result of a conversation with DCS D, on 5/29/11, the QMRP documented that Client 1 did not want DCS B to work with him, as DCS B did not talk nicely to him and smacked Client 2 on the butt. The QMRP documented that she reported the conversations to the Administrator on 5/27/11 and 6/1/11.During an telephone interview on 6/27/11 at 10:14 a.m., DCS E stated that she saw DCS B become frustrated and was "cursing". DCS E stated that she did not know if she should report it because Client 3 was fighting, and needed a procedure. DCS E stated that now she knows it was not right because DCS B got frustrated and her behavior should have been reported right away. DCS E stated that the event happened approximately on a Saturday, 5/28/11 or Sunday, 5/29/11, the same week that the administrator talked to client about his complaint of DCS B on Wednesday, 6/1/11.During an telephone interview on 6/27/11 at 11 a.m., DCS D stated that a few weeks ago, on a Saturday, 5/7/11 or Sunday 5/8/11, in the afternoon, Client 1 had mentioned to her that he heard DCS B smack Client 2 on the butt, but Client 2 didn't want to report it and DCS D did not think it was abuse. DCS D also stated that Client 1 stated that he was "sick" of DCS B. DCS D stated that she should have reported it immediately as it was not her job to determine if it really was abuse but it was her job to report.During an interview on 6/2/11 at 2:35 p.m., Administrator C stated that on 5/27/11, she first heard about verbal and physical abuse issues.During an interview on 6/2/11 at 3 p.m., Administrative Staff F stated that staff did not report incidents because they did not want DCS B to get in trouble, but felt that staff should have thought about the client's more. On 8/12/11 at 9:25 a.m., review of the facility "Comprehensive Policy on Prevention of Abuse and Neglect Quality Assurance Program" dated 1991, indicated that verbal abuse included swearing, yelling, abusive language like calling people "retarded, stupid, racial slurs, swear words" and name calling in general, any communications that are purposefully hurtful to to another staff or clients. Other abuse, such as physical abuse, included hitting a client. If a staff member observed or overheard abuse of a client, their primary reporting responsibility is by phone to the local ombudsman and the call should be made immediately or no longer than immediately after leaving their shift.Therefore, the facility violated the regulation by failing to report to the department, within 24 hours, verbal and physical abuse of three clients which subjected clients to further abuse.The facility failed to report incidents of alleged abuse to the CDPH within 24 hours, leaving clients susceptible to ongoing abuse. This failure has a direct and immediate relationship to the health, safety, or security of the clients. |
| 010001124 |
MONTE VERDE |
110008846 |
B |
08-Aug-12 |
JI5511 |
7019 |
45029(h) Welfare & Institution 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 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 violated the regulation by failing to ensure the rights of three clients, (Clients 1, 2, and 3), when DCS B was observed grabbing Client 2 by the back of his pants and stood him up while saying "little M_ _ _ _ _ F _ _ _ _ _" (exemplificative deleted) and Client 2 became irritated. DCS B physically and verbally abused clients on multiple occasions, when it was reported by Client 1 that DCS B used "Four letter words". Facility staff observed DCS B telling Client 3 to "get your ass in bed", hit and grabbed Client 3 on the arm. These incidents of verbal and physical abuse exhibited by DCS B caused Client 1, 2, and 3 emotional distress and physical harm.DCS E's statement, dated 6/1/11, indicated that Client 1 made a comment on 5/07/11, that Client 1 did not want DCS B to work with Client 1 anymore because Client 1 did not like the way DCS B talked to Client 1 and because DCS B smacked Client 2. DCS E also documented that, while DCS B provided care for Client 3, DCS B told Client 3 to "get in there and get your ass in bed", Client 3 got upset and swatted at DCS B. DCS B got really mad and smacked Client 3 on the arm. DCS A's statement, dated 6/1/11, indicated, on 5/24/11, Client 1 told DCS A that Client 1 wanted to report DCS B for screaming at Client 2 and himself and that DCS B called Client 2 "little M_ _ _ _ _F_ _ _ _ _" (exemplificative deleted). DCS A also documented that DCS A witnessed DCS B call Client 2 "little M_ _ _ _ _ F _ _ _ _ _" (exemplificative deleted), when Client 2 didn't stand up for a transfer, DCS B grabbed Client 2 by the back of his pants and stood him up. DCS D's statement, undated, indicated on 5/8/11, Client 1 reported to staff that DCS B smacked Client 2 on the buttocks one morning while DCS B was getting him ready.During an interview on 6/2/11 at 3:05 p.m., DCS (Direct Care Staff) A stated that she witnessed DCS B use abusive language with Client 2, (an incident that happened approximately 4 months earlier), when DCS B was trying to transfer Client 2 from the chair to the bed and Client 2 slipped down to the floor. DCS A stated that Client 2 became irritated. DCS A stated that Client 2's roommate, Client 1, stated that he wanted to report DCS B, because Client 1 did not like the way DCS B treated him and his roommate, who could not talk. DCS A also stated that she witnessed DCS B grab Client 3's hand forcefully, during a catheterization (tube placed in the urinary bladder) procedure. DCS A stated that DCS B stated to Client 3 to stay still, and stop moving in an authoritative voice. Client 3 cried and yelled "No, No, No". On 6/20/11 at 3:33 p.m., during a telephone interview, DCS B stated that she used verbally abusive language around the clients, but it was never directed at them. DCS B stated that she did curse and was frustrated with the job. DCS B stated that she held the client's hands down, not viciously, but so they did not bite themselves. DCS B stated that one Client was hitting her a lot and stated that she may have swatted the client's arm with the back of her arm. DCS B stated that she was stressed out with personal family problems and felt that she "did cross the line" and felt she was "guilty" of the accusations.On 6/27/11 at 10:14 a.m., during a telephone interview, DCS E stated that she worked one weekend and DCS B was frustrated and cursing. DCS E stated that, on Saturday, 5/28/11 or Sunday, 5/29/11, she watched from a hallway when DCS B smacked Client 3 on the arm with her hand, which caused Client 3 to cry. Client 3 was in the chair and did not want to go back in the bed to have her catheter (tube used for bladder drainage) put in. Client 3 was giving DCS B a hard time and hit DCS B and DCS B hit her back. Client 3 cried afterward. On 8/12/11, review of Client 3's "Behavior Change Program" updated 1/31/11 indicated that the client had self-injurious behaviors accompanied by yelling. Interventions listed for self-injurious behaviors included for staff to not attempt to interact if she was self-injurious or aggressive, as Client 3 could not be reasoned with at those times, and needed time to reset and regain composure. DCS B failed to follow the behavioral program which indicated to not interact with Client 3 when Client 3 was exhibiting aggressive behaviors.On 8/12/11, review of Client 1's informal behavior plan reviewed 2/2011, indicated that he had a history of anxiety which was related to not liking what he heard. The plan indicated that the anxiety led to verbal and physical aggression of the client. DCS B did not follow the plan but increased Client 1 anxiety through verbally abusive language.On 8/12/11, review of Client 2's "Comprehensive Functional Assessment" dated 6/11, indicated that Client 2 was sensitive to the environmental sounds such as peers screaming. Client 2 could get upset, hitting and poking at his hands and chest. DCS B increased Client 2's anxiety when he was exposed to verbal and physical abuse.On 8/12/11 at 9:25 a.m., review of the facility "Comprehensive Policy On Prevention Of Abuse and Neglect Quality Assurance Program" dated 1991, indicated that verbal abuse included swearing, yelling, abusive language like calling people "retarded, stupid, racial slurs, swear words and name calling in general, any communications that are purposefully hurtful to another staff or clients. Other abuse such as physical included hitting a client.Therefore, The facility violated the regulation by failing to ensure the rights of three clients, (Clients 1, 2, and 3), when DCS B was observed grabbing Client 2 by the back of his pants and stood him up while saying "little M_ _ _ _ _ F _ _ _ _ _" (exemplificative deleted) and Client 2 became irritated. DCS B physically abused clients on multiple occasions, when it was reported by Client 1 that DCS B used "Four letter words", Facility staff observed DCS B telling Client 3 to "get your ass in bed", hit and grabbed Client 3 on the arm. These incidents of verbal and physical abuse exhibited by DCS B caused Client 1, 2 and 3 emotional distress and physical harm.The facility failed to prevent verbal or physical abuse of three clients which had a direct and immediate relationship to the health, safety or security of the clients. |
| 010000951 |
Marin Convalescent & Rehabilitation Hospital |
110008866 |
B |
08-Mar-12 |
XJ2R11 |
21745 |
72319(a) Nursing Service-Restraints and Postural Support (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. 72319(b) Nursing Service-Restraints and Postural Support (b) Restraints shall only be used with a written order of a physician or other person lawfully authorized to prescribe care. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints. 72319(d) Nursing Service-Restraints and Postural Support (d) Restraints of any type shall not be used as punishment, as a substitute for more effective medical and nursing care, or for the convenience of staff.72319(i)(2)(A) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (A) Physical restraints for behavioral control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of, the behavior for which the restraint is applied. There shall be no PRN orders for behavioral restraints. 72319(i)(2)(B) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (B) Each patient care plan which includes the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method. 72319(i)(2)(C) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (C) Patients shall be restrained only in an area that is under supervision of staff and shall be afforded protection from other patients who may be in the area. 72319(j)(2) Nursing Service-Restraints and Postural Support (j) When drugs are used to restrain or control behavior or to treat a disordered thought process, the following shall apply: (2) The plan of care for each patient specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions. Resident 1: The facility violated the regulation when facility staff: 1. Failed to obtain a physician order prior to restraining Resident 1 in bed, 2. Failed to manage Resident 1's behavior without using physical restraints for staff convenience, 3. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 1's behavior, 4. Failed to develop a care plan for the use physical restraints that specified the behavior to be eliminated and a time limit for the use of the restraint for Resident 1, 5. Failed to provide supervision Resident 1, who was physically restrained, 6. Failed to develop a care plan for the use psychotherapeutic medications for Resident 1, 7. Failed to follow policies and procedures for the use of physical restraints. This failure resulted in the potential for unrecognized adverse effects of psychotherapeutic medications, symptoms of withdrawal, depression, reduced social contact, decreased range of motion, contractures (abnormal, usually permanent, bending of joints which may result from immobilization), pressure ulcers (open wounds that form over bony parts of the body due to prolonged pressure, i.e. immobilization), incontinence, decreased ability to ambulate, pain, increased risk of falls, strangulation, and death. Review of the, undated facility policy, "Physical Restraints," provided by the Director of Nursing (DON) on 10/26/11, from the, "Resident Care" policy and procedure (P&P) manual, reviewed by the facility P&P committee 11/11/08, defined:1. Physical Restraints; are any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement or normal access to one's body. (Federal register 483.13) 2. Behavioral Restraints; are physical devices used to control a resident's behavior such as assaultiveness /agitation which is non-responsive to alternate means of intervention and may endanger the welfare of the resident and/or others. Behavioral restraints are used temporarily and are to lead to the elimination of the behavior for which the restraint is applied. Behavioral restraints require the denial of resident rights and necessitate the completion of appropriate paperwork for such denial. 3. Convenience; is defined as action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest. Restraints may not be used for staff convenience. If the resident needs emergency care, restraints may be used for brief periods of time to permit medical treatment to proceed unless the facility has received a notice indicating the resident has previously made a valid refusal of a treatment in question. If as resident's unanticipated violent or aggressive behavior places him/her at or other residents in imminent danger, the resident does not have right to refuse the use of restraints. In this situation, the use of restraints is a measure of last resort to protect the safety of the resident or others and must not extend beyond the immediate episode. The policy, "Physical Restraints," identified the following: 1. Bed Rails: risks/potential risks included; bruises, skin tears, inserting limbs between rails, and increased risk for falling. The policy identified less restrictive devices to the use of raised side rails included no side rails or a low bed. 2. Waist Restraint in Bed: risks/potential risks included; decreased sense of independence, potential for agitation, potential for sense of tightness at waist, potential for decline in functional ability. Less restrictive devices included, bolster, pillows, padded side rails, self- releasing roll belt, bed alarm. 3. Wheelchair Belt Non-Release Type: risks/potential risks included; may increase weakness and loss of muscular strength in lower extremities, decrease sense of independence, potential for development of contractures of lower extremities, pressure on coccyx, potential decline in functional ability, potential for symptoms of withdrawal, depression, or social isolation, increased incidence if infection. Less restrictive devices included, self- release WC belt, cushions, wedges, or pillows, posture glide. During an observation and concurrent interview on 10/25/11 at 11:14 a.m., the door to Resident 1's darkened room was nearly closed, revealing a small portion of a pulled curtain, at the foot of Resident 1's bed and obstructing observation of Resident 1. Entering the room and passing the curtain at the foot of Resident 1's bed, revealed Resident 1 was unattended, positioned flat on her back, restrained to the bed with a waist restraint and all of the bed rails were raised on the bed. Resident 1 did not move in her bed. Licensed Nurse (LN) C stated facility staff restrained Resident 1 with the waist restraint and administered Ativan (a medication used to treat anxiety and agitation) around the clock (ATC) because, "Even in bed she moves." During observation on 10/25/11 at 12:40 p.m., the door to Resident 1's darkened room was nearly closed, revealing a small portion of a pulled curtain, at the foot of Resident 1's bed and obstructing observation of Resident 1. Entering the room and passing the foot of the bed revealed all of the bed rails were raised on both sides of the bed. Resident 1 remained positioned flat on her back, restrained to the bed with a waist restraint. Resident 1 was unattended. Resident 1 did not move in her bed.During observation on 10/26/11 at 8:30 a.m., the door to Resident 1's darkened room was nearly closed, revealing a small portion of a pulled curtain, at the foot of Resident 1's bed and obstructing observation of Resident 1. Entering the room and passing the foot of the bed revealed all of the bed rails were raised on both sides of the bed. Resident 1 remained positioned flat on her back, restrained to the bed with a waist restraint. Resident 1 was unattended. Resident 1 did not move in her bed.During an interview on 11/3/11 at 9 a.m., CNA B stated facility staff restrained Resident 1 with a waist restraint in bed. CNA B further stated Resident 1 did not ring her call light for help. During an interview on 10/25/11 at 2:45 p.m., LN E stated facility staff restrained Resident 1 with the waist restraint because Resident 1 was, "restless," and, "They were afraid she was going to fall." LN E stated the facility recently ordered a bed with higher side rails for Resident 1 because she (Resident 1) positioned herself diagonally and put her legs over the side rails. LN E stated facility staff administered Ativan as needed because Resident 1 got "squirmy" and "wouldn't keep still in bed." LN E stated Resident 1's Ativan orders were changed to every four around the clock (ATC). LN E described Resident 1's mental status after the change in Ativan orders as sleeping, opening her eyes to greeting.During an interview on 10/27/11 at 10:40 a.m., LN D stated she called Resident 1's conservator (a person appointed by the court to make decision for a person that can't make decisions for themselves) for consent to restrain Resident 1 in bed with the waist restraint on 10/23/11 until she (the conservator) could get to the facility. LN D stated facility staff could not supervise Resident 1 because other residents had a history of falling and wandering. During an interview on 10/27/11 at 1 p.m., Resident 1's conservator stated LN D called her on 10/23/11 and requested to restrain Resident 1 with the waist restraint in bed, "which I hate." The conservator stated she was not aware facility staff was still restraining Resident 1 with the waist restraint in bed. When queried about Resident 1's current mental status, the conservator described Resident 1 as being, "completely out of it, unable to rouse, not moving," and indicated that the increased medications may have contributed to her current mental status. Record review on 10/25/11 at 12:48 p.m., revealed Resident 1 was admitted to the facility on 10/20/11, suffered from mental illness and was conserved.Physician orders, dated 10/1/11 - 10/31/11, signed by the physician on 10/21/11, indicated:1. Webbed belt in wheelchair (WC) or STPS (soft tie positional support, non - releasing waist belt) in recliner, dated 10/20/11. The order did not specify the duration the restraint was to be used and was not designed to lead to a less restrictive way of managing, and ultimately the elimination of the behavior for which it was applied. 2. All four bed rails up for postural support, dated 10/20/11. The order did not specify the duration the restraint was to be used and was not designed to lead to a less restrictive way of managing, and ultimately the elimination of the behavior for which it was applied. 3. There was no physician order for the use of a waist restraint in bed. During an interview on 11/1/11 at 3 p.m., Resident 1's physician stated he was not contacted when the waist restraint in bed was applied to Resident 1.4. Ativan, one milligram (mg) by mouth, every four hours around the clock, dated 10/23/11. 5. Ativan, one mg by mouth every hour, as needed for restlessness/agitation, dated 10/23/11. 6. Seroquel, 100 mg by mouth, every morning and at 17:00, dated 10/23/11. Nurse's notes dated 10/23/11, indicated facility staff administered Ativan and Seroquel for behaviors. The note also indicated LN D documented Resident 1's conservator agreed to restrain Resident 1 with waist restraint while in bed. The note did not indicate which facility staff member applied the belt. The clinical record did not contain a care plan which specified behaviors to be eliminated, the physical restraints used and a time limit for the use of the restraints. There was no care plan related to the use of psycho-therapeutic medications in the clinical record. Review of the, "Nursing Services Procedures Manual," provided by DON on 10/26/11, last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Use of Restraints," which indicated: 1. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. 2. Physical restraints for behavior control shall only be used on the signed order of a physician, except in an emergency which threatens to bring immediate injury to the resident or others. In such an emergency an order may be received by telephone, and shall be signed by the physician within 48 hours.3. Physical restraints for behavior control shall only be used with a written order designed to lead to a less restrictive way of managing and ultimately the elimination of the behavior for which the restraint was applied.4. Care plans which include the use of physical restraints for behavior shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method. 5. When drugs are used to restrain or control behavior or to treat a disordered thought process, the following shall apply: a. The plan of care for each resident specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions. 6. Should a resident not be capable of making a decision, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. "Note: The surrogate/sponsor may not give permission to use restraints for the sake of disciple or staff convenience or when the restraint is not necessary to treat the resident's medical condition." Review of the, "Nursing Services Procedures Manual," last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Physical Restraint Application," indicated: 1. Restraints will only be used after other alternatives have been tried unsuccessfully, and only with informed consent from the resident, physician, and/or sponsor. 2. Practices that are not permitted included; using bed rails to keep a resident from voluntarily getting out of bed. 3. Written P&P's delineate the following; ú Orders indicate the specific reason, type, and period of time for the use of restraints. Restraints may only be used as a last resort and the medical record must indicate the events leading up to the necessity of the restraint. ú The use of restraints is temporary, and the resident will not be restrained for an indefinite amount of time. ú Orders for restraints will not be enforced for longer than twelve hours, unless the resident's condition requires continued treatment. ú A resident placed in a restraint will be observed at least every 30 minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. ú Reorders are issued only after a review of the resident's condition by his her physician. ú The use of restraints is not employed for the convenience of staff or as a substitute for supervision. 4. The need for restraints will be reevaluated at least quarterly to determine their need. Every effort will be made to eliminate their use. 5. An interdisciplinary assessment team, in coordination with the resident and his/her family or representative (sponsor) develops and maintains a comprehensive care plan which identifies: ú The medical symptom that warranted the use of the restraint ú The symptom being treated ú The type of restraint being used ú When the restraint is to be used ú The plan for release of device for exercise and toileting every two hours ú The plan for monitoring every 30 minutes ú How the use of the restraint will assist the resident in reaching his/her highest level of physical and psychosocial well-being ú The care plan "must" indicate that the continued use of a restraint has been reevaluated and that a reorder from the physician is so noted. Review of the, "Nursing Services Procedures Manual," provided by the DON on 10/26/11, last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Proper Use of Bed Rails," which indicated: 1. Bed rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). 2. The use of bed rails is prohibited unless they are necessary to treat a resident's medical symptoms. 3. Less restrictive interventions that the facility might incorporate in care planning include: providing restorative care to enhance abilities to safely stand and walk, a trapeze to increase bed mobility, placing the bed lower to the floor and surrounding with soft mat, equipping the resident with a device that monitors attempts to rise, provide frequent staff monitoring at night with periodic assisted toileting for residents attempting to rise and use the bathroom, furnishing visual and verbal reminders to use the call bell for residents who are able to comprehend the information. 4. If less restrictive approaches are not successful, then the facility must document this and obtain orders to apply and monitor the use of bed rails for a specific time frame. During an interview on 10/26/11 at 1 p.m., when queried about the use of physical restraints on Resident 1, the Director of Nursing stated LN D restrained Resident 1 with the waist restraint in bed, "emergently." The DON stated LN D should have called the physician for an order. The DON further stated if residents were, "Trying to fight the aliens, we look at chemical restraints." During an interview on 11/1/11 at 3:18 p.m., the facility medical director (FMD) stated facility staff restrained residents found partly out of bed, WC, or lounger and to prevent falls. The FMD stated he was not aware that staff was implementing the use of restraints without physician orders.When queried about the use of least restrictive measures, the FMD stated he was not aware facility staff should implement least restrictive measures and, "Clearly I haven't been looking at that." The FMD stated he generally took the recommendations of staff for restraint application. The FMD stated licensed nurses made recommendations about which restraints to use and when to use the restraints on residents. The FMD stated, "I'm basically very trusting of their skills, so I'm rubber stamping their recommendations." 1. Therefore the facility violated the regulations when facility staff failed to: 1. Obtain a physician order prior to restraining Resident 1 in bed, 2. Manage Resident 1's behavior without using physical restraints for staff convenience, 3. Write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 1's behavior, 4. Develop a care plan for the use physical restraints that specified the behavior to be eliminated and a time limit for the use of the restraint for Resident 1, 5. Provide supervision Resident 1, who was physically restrained, 6. Develop a care plan for the use psychotherapeutic medications for Resident 1, and 7. Follow policies and procedures for the use of physical restraints. These failure resulted in the potential for unrecognized adverse effects of psychotherapeutic medications, symptoms of withdrawal, depression, reduced social contact, decreased range of motion, contractures (abnormal, usually permanent, bending of joints which may result from immobilization), pressure ulcers (open wounds that form over bony parts of the body due to prolonged pressure, i.e. immobilization), incontinence, decreased ability to ambulate, pain, increased risk of falls, strangulation, and death. These failures had a direct or immediate relationship to patient health, safety, or security. |
| 010000951 |
Marin Convalescent & Rehabilitation Hospital |
110008867 |
B |
08-Mar-12 |
XJ2R11 |
15967 |
72319(a) Nursing Service-Restraints and Postural Support (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. 72319(i)(2) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. 72319(i)(2)(A) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (A) Physical restraints for behavioral control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of, the behavior for which the restraint is applied. There shall be no PRN orders for behavioral restraints. Resident 2: The facility violated the regulation when facility staff: 1. Failed to ensure that restraints applied on an emergency basis were removed after the emergent event passed for Resident 2, 2. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 2's behavior, 3. Failed to follow policies and procedures for the use of physical restraints. These failures resulted in the potential for symptoms of withdrawal, depression, reduced social contact, decreased range of motion, contractures (abnormal, usually permanent, bending of joints which may result from immobilization), pressure ulcers (open wounds that form over bony parts of the body due to prolonged pressure, i.e. immobilization), incontinence, decreased ability to ambulate, pain, increased risk of falls, strangulation, and death. Review of the, undated facility policy, "Physical Restraints," provided by the Director of Nursing (DON) on 10/26/11, from the "Resident Care" policy and procedure (P&P) manual, reviewed by the facility P&P committee 11/11/08, defined:1. Physical Restraints; are any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement or normal access to one ' s body. (Federal register 483.13) 2. Behavioral Restraints; are physical devices used to control a resident's behavior such as assaultiveness/agitation which is non-responsive to alternate means of intervention and may endanger the welfare of the resident and/or others. Behavioral restraints are used temporarily and are to lead to the elimination of the behavior for which the restraint is applied. Behavioral restraints require the denial of resident rights and necessitate the completion of appropriate paperwork for such denial. The policy, "Physical Restraints," identified the following: 1. Bed Rails: risks/potential risks included; bruises, skin tears, inserting limbs between rails, and increased risk for falling. The policy identified less restrictive devices to the use of raised side rails included no side rails or a low bed. 2. Geri-Chair in Reclined Position: risks/potential risks included; limiting the ability to propel self, difficult for resident / family / staff to move, pressure on coccyx /hips, potential circulatory impairment of lower extremities, potential for contractures, further decline in functional ability, potential for symptoms of withdrawal, depression, or social isolation, and increased incidence of infection. Less restrictive devices identified included, Geri-chair in upright position, wheelchair (WC), cushions, wedges, or pillows. 3. Waist Restraint in Bed: risks/potential risks included; decreased sense of independence, potential for agitation, potential for sense of tightness at waist, potential for decline in functional ability. Less restrictive devices included, bolster, pillows, padded side rails, self- releasing roll belt, bed alarm. 4. Wheelchair Belt Non-Release Type: risks/potential risks included; may increase weakness and loss of muscular strength in lower extremities, decrease sense of independence, potential for development of contractures of lower extremities, pressure on coccyx, potential decline in functional ability, potential for symptoms of withdrawal, depression, or social isolation, increased incidence if infection. Less restrictive devices included, self- release WC belt, cushions, wedges, or pillows, posture glide. During an observation and concurrent interview on 10/25/11 at 10:17 a.m., Resident 2 was sleeping flat on his back in his room unattended. Resident 2's bed was against one wall, all of the bed rails were raised on both sides of the bed, and a bed rail cover encased the upper and lower bed rails on the side of the bed opposite of the wall. LN C observed Resident 2's bed and stated there was not a bed alarm in Resident 2's bed to detect if the resident tried to get up. LN C lifted Resident 2's linen, revealing Resident 2 was restrained to the bed with a waist restraint. When queried about the use of the waist restraint, LN C stated Resident 2 tried to get out of bed and one time he got really confused, "That's when we started the soft tie" (waist restraint). During an interview on 11/3/11 at 9 a.m., certified nursing assistant (CNA) B stated she worked the day shift and had worked at the facility 40 years. CNA B stated "all" of the facility residents, (except one, who refused interview), had dementia and wore belts, including; webbed belts, soft tie positional support (STPS) in bed or chair/wheelchair, or Geri-chairs (a Geri-chair is a large heavily padded wheelchair with reclining positions and a foot rest). CNA B stated the purpose was to prevent residents from getting up and falling down. CNA B stated Resident 2 was, "Completely unable" to ring his call light either in his bed or chair. During an interview on 10/25/11 at 2:45 p.m., LN E described Resident 2's previous mental status as alert and confused, but stated Resident 2 had become "restless." LN E stated Resident 2 threw his legs over the side rails of his bed and the arms of his Geri-chair. LN E stated facility staff restrained Resident 2 in the Geri-chair because he (Resident 2) "Throws his legs up." LN E stated facility staff placed the bed rail cover over the bed rails on Resident 2's bed to, "Form a barrier," because Resident 2 sat up and tried to get out of bed between the upper and lower rails. LN E stated facility staff began restraining Resident 2 with waist restraint in bed a, "Few months ago" because Resident 2 sat up and tried to get over the side rails. During an observation and concurrent joint interview on 10/26/11 at 9 a.m., all four bed rails were raised on Resident 2's bed, and a bed rail cover was observed on the foot of the bed. Resident 2 was lying on his back in bed while Certified Nursing Assistant (CNA) G provided morning care. Resident 2 was passive and did not resist care. CNA G stated Resident 2 had contractures at his knees, and his ankles came together. Observation of Resident 2's right ankle revealed a small pink wound covered by a padded bandage. The Director of Nursing (DON) stated Resident 2 developed the wound when Resident 2 began rubbing his ankles together. Observation of Resident 2's buttocks revealed a stage II pressure ulcer, (A stage II pressure ulcer is a shallow, open ulcer, caused by unrelieved pressure) covered with barrier cream above his gluteal cleft (between the buttocks). When queried, CNA G stated Resident 2 had not previously and did not resist care she provided. CNA G further stated Resident 2 did not attempt to get out of bed. CNA G stated facility staff restrained Resident 2 with waist restraint when in bed and opened Resident 2's nightstand drawer, revealing the waist restraint. CNA G stated she removed the waist restraint from Resident 2 when she started her shift that morning (10/26/11).During an observation and concurrent interview on 10/26/11 at 9:50 a.m., Resident 2 was observed in the solarium restrained to his WC with a waist restraint. LN E stated Resident 2 could not get could not release the waist restraint.During an interview and concurrent record review on 10/25/11 at 3:55 p.m., LN D stated she (LN D) used her "judgment" to determine when to physically restrain residents. LN D further stated she restrained residents prior to obtaining physician orders.Review of the clinical record on 10/27/11 revealed Resident 2 was admitted to the facility on 11/30/07 and suffered dementia.Physician orders, 10/1/11 - 10/31/11, signed by the facility medical director (FMD) on 10/4/11:1. Webbed belt (waist restraint) in WC to prevent self-transfers due to unstable level of consciousness and inability to stand alone, order date 6/8/09, two years and four months prior to the 10/26/11 observation of Resident 2 restrained to his WC. 2. All four bed rails up when in bed for postural support, order date 2/11/09, two years and eight months prior to the 10/25/11 observation of Resident 2 restrained in his bed. 3. Soft tie (waist restraint) positional support when in Geri-chair for postural support, order date 4/11/11, 10 months prior to LN E?s statement on 10/25/11. 4. Soft tie (waist restraint) when in bed for postural support, order date 4/11/11, six months prior to the 10/25/11 observation of Resident 2 restrained to his bed. 5. Side rail (bed rail) cover on bed for postural support and the prevention of falls, order date 4/27/11, nearly six months prior to the 10/25/11 observation of Resident 2 restrained in his bed. The physician orders were not designed to lead to a less restrictive way of managing, and ultimately the elimination of the behavior for which they were applied.A nurse's note dated, 4/10/11, indicated Resident 2 became confused and afraid, sat on the edge of the bed and struggled to get out of bed. The note indicated a waist restraint in bed was applied on an emergency basis for safety and that the physician was notified of, "temporary use" of the waist restraint six months prior to the 10/25/11 observation.Review of the, "Nursing Services Procedures Manual," provided by DON on 10/26/11, last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Use of Restraints," which indicated: 1. Physical restraints for behavior control shall only be used on the signed order of a physician, except in an emergency which threatens to bring immediate injury to the resident or others. In such an emergency an order may be received by telephone, and shall be signed by the physician within 48 hours. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time, and the name of the individual applying such measures shall be entered in the resident's medical record. 2. Physical restraints for behavior control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately the elimination of, the behavior for which the restraint was applied. There shall be no PRN (as needed) orders for behavioral restraints. Review of the, "Nursing Services Procedures Manual," last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Physical Restraint Application," indicated: 1. Written P&P's delineate the following; ? Orders indicate the specific reason, type, and period of time for the use of restraints. The use of restraints is temporary, and the resident will not be restrained for an indefinite amount of time. ? Orders for restraints will not be enforced for longer than twelve hours, unless the resident's condition requires continued treatment. 2. The need for restraints will be reevaluated at least quarterly to determine their need. Every effort will be made to eliminate their use. Review of the, "Nursing Services Procedures Manual," provided by the DON on 10/26/11, last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Proper Use of Bed Rails,? which indicated: 1. Bed rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). 2. The use of bed rails is prohibited unless they are necessary to treat a resident's medical symptoms. During an interview and concurrent document review on 10/26/11 at 12:48 p.m., the DON stated facility staff restrained residents that were restless, had a previously fell, or were at risk for falling. The DON identified pain, hunger, and needing to use the restroom as situations that put residents at risk for falling. Review of, "Resident Incident Log," dated 10/10 - 6/11, revealed no incidents of falls for Resident 2. When queried about the facility policy and procedure for restraint reduction, the DON stated she was the head of the facility restraints committee (FRC). The DON stated members of the FRC included the facility Medical Director (FMD), Administrator, DON, DSD, and licensed nurses. The DON stated the FRC met quarterly. The DON stated restraint reduction assessments were done quarterly but, "we (FRC) don't always spell out who has what." During an interview on 11/1/11 at 3:18 p.m., the FMD stated facility staff restrained residents found partly out of bed, WC, or lounger and to prevent falls. The FMD stated he was not aware that staff was implementing the use of restraints without physician orders.When queried about the use of least restrictive measures, the FMD stated he was not aware facility staff should implement least restrictive measures and, "Clearly I haven't been looking at that." The FMD stated he generally took the recommendations of staff for restraint application. The FMD stated licensed nurses made recommendations about which restraints to use and when to use the restraints on residents. The FMD stated, "I'm basically very trusting of their skills, so I'm rubber stamping their recommendations." Therefore the facility violated the regulations when facility staff: 1. Failed to ensure that restraints applied on an emergency basis were removed after the emergent event passed for Resident 2, 2. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 2's behavior and, 3. Failed to follow policies and procedures for the use of physical restraints. These failures resulted in the potential for symptoms of withdrawal, depression, reduced social contact, decreased range of motion, contractures (abnormal, usually permanent, bending of joints which may result from immobilization), pressure ulcers (open wounds that form over bony parts of the body due to prolonged pressure, i.e. immobilization), incontinence, decreased ability to ambulate, pain, increased risk of falls, strangulation, and death. These failures had a direct or immediate relationship to patient health, safety, or security. |
| 010000951 |
Marin Convalescent & Rehabilitation Hospital |
110008868 |
B |
08-Mar-12 |
XJ2R11 |
15293 |
72319(a) Nursing Service-Restraints and Postural Support (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. 72319(b) Nursing Service-Restraints and Postural Support (b) Restraints shall only be used with a written order of a physician or other person lawfully authorized to prescribe care. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints. 72319(i)(2)(A) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (A) Physical restraints for behavioral control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of, the behavior for which the restraint is applied. There shall be no PRN orders for behavioral restraints. 72319(i)(2)(B) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (B) Each patient care plan which includes the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method. Resident 3: The facility violated the regulation when facility staff: 1. Failed to obtain a physician order prior to restraining Resident 3 in bed, 2. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 3's behavior, 3. Failed to develop a care plan for the use physical restraints that specified the behavior to be eliminated and a time limit for the use of the restraint for Resident 3, 4. Failed to follow policies and procedures for the use of physical restraints. These failures resulted in the potential for symptoms of withdrawal, depression, reduced social contact, decreased range of motion, contractures (abnormal, usually permanent, bending of joints which may result from immobilization), pressure ulcers (open wounds that form over bony parts of the body due to prolonged pressure, i.e. immobilization), incontinence, decreased ability to ambulate, pain, increased risk of falls, strangulation, and death.Review of the, undated facility policy, "Physical Restraints," provided by the Director of Nursing (DON) on 10/26/11, from the "Resident Care" policy and procedure (P&P) manual, reviewed by the facility P&P committee 11/11/08, defined:1. Physical Restraints; are any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement or normal access to one's body. (Federal register 483.13) 2. Behavioral Restraints; are physical devices used to control a resident's behavior such as assaultiveness/agitation which is non-responsive to alternate means of intervention and may endanger the welfare of the resident and/or others. Behavioral restraints are used temporarily and are to lead to the elimination of the behavior for which the restraint is applied.The policy, "Physical Restraints,? identified the following: 1. Bed Rails: risks/potential risks included; bruises, skin tears, inserting limbs between rails, and increased risk for falling. The policy identified less restrictive devices to the use of raised side rails included no side rails or a low bed. 2. Waist Restraint in Bed: risks/potential risks included; decreased sense of independence, potential for agitation, potential for sense of tightness at waist, potential for decline in functional ability. Less restrictive devices included, bolster, pillows, padded side rails, self- releasing roll belt, bed alarm. 3. Wheelchair Belt Non-Release Type: risks/potential risks included; may increase weakness and loss of muscular strength in lower extremities, decrease sense of independence, potential for development of contractures of lower extremities, pressure on coccyx, potential decline in functional ability, potential for symptoms of withdrawal, depression, or social isolation, increased incidence if infection. Less restrictive devices included, self-release WC belt, cushions, wedges, or pillows, posture glide. During an observation on 10/25/11 at 10:48 a.m., Resident 3 was observed in the solarium restrained to her WC with a waist restraint. During an observation and concurrent interview on 10/26/11 at 9:50 a.m., Resident 3 was observed in the solarium restrained to her WC with a waist restraint. LN E stated Resident 3 could not release the waist restraint.During an observation on 10/25/11 at 10:35 a.m., Resident 3's bed was positioned with the length of one side against the wall in her room. Pads which cover upper and lower side rails in the raised position were observed on Resident 3's bed.During an interview on 10/25/11 at 2:45 p.m., LN E stated facility staff restrained Resident 3 with a waist restraint in her WC and in her bed at night, "Just to make sure she stays in her bed or recliner chair." LN E stated facility staff raised the full bed rails on Resident 3's bed because she (Resident 3), "Squirms side to side" and dangles her feet over the side of the bed. LN E stated the bed rail pads were to prevent Resident 3 from bruising. During an interview on 11/3/11 at 9 a.m., certified nursing assistant (CNA) B stated she worked the day shift and had worked at the facility 40 years. CNA B stated "all" of the facility residents, except one (refused interview), had dementia and wore belts, including; webbed belts, soft tie positional support (STPS) in bed or chair/wheelchair. CNA B stated the purpose was to prevent residents from getting up and falling down. CNA B stated Resident 3 was restrained in bed with a waist restraint when she (CNA B) started her shift in the morning on 11/3/11. CNA B further stated Resident 3 was, "Absolutely not able to ring" her call light for help. Review of Resident 3's clinical record on 11/1/11 at 10:30 a.m., revealed Resident 3 was admitted to the facility on 9/28/10 and suffered dementia. Physician orders, dated 10/1/11 - 10/31/11, signed by the physician on 10/21/11:1. Bed alarm when in bed. Monitor position and function when in bed, dated 9/28/10. 2. WC alarm when in WC or recliner, dated 9/28/10. 3. STPS (waist restraint) in bed to prevent impulsive self-transfers in the presence of weakness and ataxia (unsteadiness), dated 9/29/10, one year and one month prior to the 10/25/11 observation and interview. 4. May use STPS (waist restraint) in recliner to prevent impulsive self-transfers in the presence of weakness and ataxia, dated 9/29/10, one year and one month prior to the 10/25/11 observation. 5. Webbed belt (waist restraint) in WC to prevent impulsive self- transfers in the presence of weakness and ataxia, dated 9/29/10, one year and one month prior to the 10/25/11 observation. 6. There was no physician order for raised full bed rails. During an interview and concurrent record review on 10/25/11 at 3:55 p.m., LN D stated she (LN D) used her "judgment" to determine when to physically restrain residents. LN D further stated she restrained residents prior to obtaining physician orders. The physician orders were not designed to lead to a less restrictive way of managing, and ultimately the elimination of the behavior for which they were applied. A nurse's note dated, 9/28/10, indicated Resident 3 sat on the edge of her bed with the side rails up, "Trying to get out of bed many times." Nurse's notes, dated 9/28/10 - 12/9/10, did not indicate facility staff restrained Resident 3 in a WC, recliner, or in bed with waist restraints. The clinical record did not contain a care plan which specified behaviors to be eliminated and the physical restraints used and a time limit for the use of the restraints. Review of the, "Nursing Services Procedures Manual," provided by DON on 10/26/11, last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Use of Restraints," which indicated: 1. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. 2. Physical restraints for behavior control shall only be used on the signed order of a physician, except in an emergency which threatens to bring immediate injury to the resident or others. In such an emergency an order may be received by telephone, and shall be signed by the physician within 48 hours. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time, and the name of the individual applying such measures shall be entered in the resident's medical record. 3. Physical restraints for behavior control shall only be used with a written order designed to lead to a less restrictive way of managing and ultimately the elimination of the behavior for which the restraint was applied.4. Care plans which include the use of physical restraints for behavior shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method. Review of the, "Nursing Services Procedures Manual," last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Physical Restraint Application," indicated: 1. Restraints will only be used after other alternatives have been tried unsuccessfully. 2. Practices that are not permitted included; using bed rails to keep a resident from voluntarily getting out of bed. 3. Written P&P's delineate the following; ? Orders indicate the specific reason, type, and period of time for the use of restraints.? The use of restraints is temporary, and the resident will not be restrained for an indefinite amount of time. ? Orders for restraints will not be enforced for longer than twelve hours, unless the resident's condition requires continued treatment. 4. The need for restraints will be reevaluated at least quarterly to determine their need. Every effort will be made to eliminate their use. 5. An interdisciplinary assessment team, in coordination with the resident and his/her family or representative (sponsor) develops and maintains a comprehensive care plan which identifies: ? The medical symptom that warranted the use of the restraint ? The symptom being treated ? The type of restraint being used ? When the restraint is to be used ? The plan for release of device for exercise and toileting every two hours ? The plan for monitoring every 30 minutes ? How the use of the restraint will assist the resident in reaching his/her highest level of physical and psychosocial well-being ? The care plan "must" indicate that the continued use of a restraint has been reevaluated and that a reorder from the physician is so noted. Review of the, "Nursing Services Procedures Manual," provided by the DON on 10/26/11, last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Proper Use of Bed Rails,? which indicated: 1. Bed rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). 2. The use of bed rails is prohibited unless they are necessary to treat a resident's medical symptoms. 3. If less restrictive approaches are not successful, then the facility must document this and obtain orders to apply and monitor the use of bed rails for a specific time frame. During an interview and concurrent document review on 10/26/11 at 12:48 p.m., the DON stated facility staff restrained residents without physician orders. The DON stated facility staff restrained residents that were restless, had a previously fell, or were at risk for falling. The DON identified pain, hunger, and needing to use the restroom as situations that put residents at risk for falling. The DON stated licensed nurses filed incident reports when resident fell. Review of, "Resident Incident Log," dated 10/10 - 6/11, revealed no incidents of falls for Resident 3. During an interview on 11/1/11 at 3:18 p.m., the FMD stated facility staff restrained residents found partly out of bed, WC, or lounger and to prevent falls. The FMD stated he was not aware that staff was implementing the use of restraints without physician orders.When queried about the use of least restrictive measures, the FMD stated he was not aware facility staff should implement least restrictive measures and, "Clearly I haven't been looking at that." The FMD stated he generally took the recommendations of staff for restraint application. The FMD stated licensed nurses made recommendations about which restraints to use and when to use the restraints on residents. The FMD stated, "I'm basically very trusting of their skills, so I'm rubber stamping their recommendations." The facility violated the regulation when facility staff: 1. Failed to obtain a physician order prior to restraining Resident 3 in bed, 2. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 3's behavior, 3. Failed to develop a care plan for the use physical restraints that specified the behavior to be eliminated and a time limit for the use of the restraint for Resident 3 and, 4. Failed to follow policies and procedures for the use of physical restraints. These failures resulted in the potential for symptoms of withdrawal, depression, reduced social contact, decreased range of motion, contractures (abnormal, usually permanent, bending of joints which may result from immobilization), pressure ulcers (open wounds that form over bony parts of the body due to prolonged pressure, i.e. immobilization), incontinence, decreased ability to ambulate, pain, increased risk of falls, strangulation, and death. These failures had a direct or immediate relationship to patient health, safety, or security. |
| 010000951 |
Marin Convalescent & Rehabilitation Hospital |
110008869 |
B |
08-Mar-12 |
XJ2R11 |
13659 |
72319(a) Nursing Service-Restraints and Postural Support (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. 72319(b) Nursing Service-Restraints and Postural Support (b) Restraints shall only be used with a written order of a physician or other person lawfully authorized to prescribe care. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints.72319(i)(2)(A) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (A) Physical restraints for behavioral control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of, the behavior for which the restraint is applied. There shall be no PRN orders for behavioral restraints. 72319 (i)(2)(B) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (B) Each patient care plan which includes the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method. Resident 4: The facility violated the regulation when facility staff: 1. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 4's behavior, 2. Failed to develop a care plan for the use physical restraints that specified the behavior to be eliminated and a time limit for the use of the restraint for Resident 4, 3. Failed to follow policies and procedures for the use of physical restraints. These failures resulted in the potential for symptoms of withdrawal, depression, reduced social contact, decreased range of motion, contractures (abnormal, usually permanent, bending of joints which may result from immobilization), pressure ulcers (open wounds that form over bony parts of the body due to prolonged pressure, i.e. immobilization), incontinence, decreased ability to ambulate, pain, increased risk of falls, strangulation, and death. Review of the, undated facility policy, "Physical Restraints," provided by the Director of Nursing (DON) on 10/26/11, from the "Resident Care" policy and procedure (P&P) manual, reviewed by the facility P&P committee 11/11/08, defined:1. Physical Restraints; are any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement or normal access to one ' s body. (Federal register 483.13) 2. Behavioral Restraints; are physical devices used to control a resident's behavior such as assaultiveness/agitation which is non-responsive to alternate means of intervention and may endanger the welfare of the resident and/or others. Behavioral restraints are used temporarily and are to lead to the elimination of the behavior for which the restraint is applied. Behavioral restraints require the denial of resident rights and necessitate the completion of appropriate paperwork for such denial. The policy, "Physical Restraints," identified the following: 1. Waist Restraint in Bed: risks/potential risks included; decreased sense of independence, potential for agitation, potential for sense of tightness at waist, potential for decline in functional ability. Less restrictive devices included, bolster, pillows, padded side rails, self- releasing roll belt, bed alarm. 2. Wheelchair Belt Non-Release Type: risks/potential risks included; may increase weakness and loss of muscular strength in lower extremities, decrease sense of independence, potential for development of contractures of lower extremities, pressure on coccyx, potential decline in functional ability, potential for symptoms of withdrawal, depression, or social isolation, increased incidence if infection. Less restrictive devices included, self- release WC belt, cushions, wedges, or pillows, posture glide. During an observation on 10/25/11 at 9:20 a.m., Resident 4 was restrained to a high backed WC with a waist restraint that crossed the Resident's lap and attached to the back of her WC. Resident 4 did not respond to attempt to interview. During an interview on 10/25/11 at 2:45 p.m., licensed nurse (LN) E stated facility staff restrained Resident 4 with a waist restraint in her WC and in bed at night because she (Resident 4) got anxious and threw her legs over the arms of the WC and over the bed rails. During an observation on 10/26/11 at 9:35 a.m., a waist restraint was observed on the unoccupied bed in Resident 4 ' s room. Hospice Staff (HS) F was assisting Resident 4 in the hall near her room.During an interview in Resident 4? s room, on 10/26/11 at 9:45 a.m., HS F stated Resident 4 was restrained in bed with the waist restraint when he entered Resident 4 ' s room that morning (10/26/11) and was restrained with the waist restraint each morning he arrived for the past six months. During an interview on 11/3/11 at 9 a.m., certified nursing assistant (CNA) B stated she worked the day shift and had worked at the facility 40 years. CNA B stated "all" of the facility residents, except one (refused interview), had dementia and wore belts, including; webbed belts, soft tie positional support (STPS) in bed or chair/wheelchair. CNA B stated the purpose was to prevent residents from getting up and falling down. CNA B stated facility staff restrained Resident 4 with a waist restraint in bed. CNA B further stated Resident 4, "Very seldom" tried to use her call light and her (Resident 4's) success using the call light was, "Hit or miss."Review of Resident 4's clinical record on 11/1/11 at 10 a.m., revealed Resident 4 was admitted to the facility on 12/28/10 and suffered dementia. Physician orders, dated 10/1/11 - 10/31/11, signed by the physician on 10/4/11: 1. Webbed belt (waist restraint) in WC or STPS (waist restraint) in recliner to prevent falls due to dementia with ataxia (unsteadiness), dated 3/22/11, seven months prior to the 10/25/11 observation. 2. Soft tie (waist restraint) in bed to prevent falls due to dementia with ataxia, dated 3/22/11, seven months prior to the 10/25/11 observation and interview. 3. Bed alarm when in bed, dated 3/22/11. 4. Landing pad at bedside when in bed to help prevent injury, dated 3/22/11. The physician orders did not indicate the duration of use of the restraints and were not designed to lead to a less restrictive way of managing, and ultimately the elimination of the behavior for which they were applied. A nurses' weekly progress note, dated 3/20/11- 3/26/11, indicated Resident 4 was restrained with a waist restraint in WC, recliner, and bed to prevent self-transfer and falls. The clinical record did not contain a care plan which specified behaviors to be eliminated, the physical restraints used and a time limit for the use of the restraints. A, "Physical Restraint Elimination Assessment," (PREA) indicated restrained resident should be evaluated, "At least quarterly," to determine whether or not they are candidates for restraint reduction, less restrictive restraining measures, or total restraint elimination. Resident 4 scored 28 points on 3/11 and 6/11, indicating Resident 4 was a good candidate, but the clinical record lacked evidence of attempt at restraint reduction. During an interview and concurrent document review on 10/26/11 at 12:48 p.m., when queried about the facility policy and procedure for restraint reduction, the DON stated she was the head of the facility restraints committee (FRC). The DON stated members of the FRC included the facility Medical Director (FMD), Administrator, DON, DSD, and licensed nurses. The DON stated the FRC met quarterly. The DON stated restraint reduction assessments were done quarterly but, "we (FRC) don't always spell out who has what."Review of the, "Nursing Services Procedures Manual," provided by DON on 10/26/11, last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Use of Restraints," which indicated: 1. Physical restraints for behavior control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately the elimination of, the behavior for which the restraint was applied.2. Care plans which include the use of physical restraints for behavior shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method. Review of the, "Nursing Services Procedures Manual," last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Physical Restraint Application," indicated: 1. Restraints will only be used after other alternatives have been tried unsuccessfully. 2. Written P&P's delineate the following; ? Orders indicate the specific reason, type, and period of time for the use of restraints.? The use of restraints is temporary, and the resident will not be restrained for an indefinite amount of time. ? Orders for restraints will not be enforced for longer than twelve hours, unless the resident's condition requires continued treatment. 3. The need for restraints will be reevaluated at least quarterly to determine their need. Every effort will be made to eliminate their use. 4. An interdisciplinary assessment team, in coordination with the resident and his/her family or representative (sponsor) develops and maintains a comprehensive care plan which identifies: ? The medical symptom that warranted the use of the restraint ? The symptom being treated ? The type of restraint being used ? When the restraint is to be used ? The plan for release of device for exercise and toileting every two hours ? The plan for monitoring every 30 minutes ? How the use of the restraint will assist the resident in reaching his/her highest level of physical and psychosocial well-being ? The care plan "must" indicate that the continued use of a restraint has been reevaluated and that a reorder from the physician is so noted. During an interview and concurrent document review on 10/26/11 at 12:48 p.m., the DON stated facility staff restrained residents that were restless, had a previously fell, or were at risk for falling. The DON identified pain, hunger, and needing to use the restroom as situations that put residents at risk for falling. The DON stated licensed nurses restrained residents without physician orders.During an interview on 11/1/11 at 3:18 p.m., the FMD stated facility staff restrained residents found partly out of bed, WC, or lounger and to prevent falls. The FMD stated he was not aware that staff was implementing the use of restraints without physician orders.When queried about the use of least restrictive measures, the FMD stated he was not aware facility staff should implement least restrictive measures and, "Clearly I haven't been looking at that." The FMD stated he generally took the recommendations of staff for restraint application. The FMD stated licensed nurses made recommendations about which restraints to use and when to use the restraints on residents. The FMD stated, "I'm basically very trusting of their skills, so I'm rubber stamping their recommendations." Therefore the facility violated the regulations when facility staff: 1. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 4's behavior, 2. Failed to develop a care plan for the use physical restraints that specified the behavior to be eliminated and a time limit for the use of the restraint for Resident 4 and, 3. Failed to follow policies and procedures for the use of physical restraints. These failures resulted in the potential for symptoms of withdrawal, depression, reduced social contact, decreased range of motion, contractures (abnormal, usually permanent, bending of joints which may result from immobilization), pressure ulcers (open wounds that form over bony parts of the body due to prolonged pressure, i.e. immobilization), incontinence, decreased ability to ambulate, pain, increased risk of falls, strangulation, and death. These failures had a direct or immediate relationship to patient health, safety, or security. |
| 010000951 |
Marin Convalescent & Rehabilitation Hospital |
110008870 |
B |
08-Mar-12 |
XJ2R11 |
15732 |
72319(a) Nursing Service-Restraints and Postural Support (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. 72319(i)(2)(A) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (A) Physical restraints for behavioral control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of, the behavior for which the restraint is applied. There shall be no PRN orders for behavioral restraints. 72319 (i)(2)(B) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (B) Each patient care plan which includes the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method. 72319(j)(2) Nursing Service-Restraints and Postural Support (j) When drugs are used to restrain or control behavior or to treat a disordered thought process, the following shall apply: (2) The plan of care for each patient specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions. Resident 6: The facility violated the regulation when facility staff: 1. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 6's behavior, 2. Failed to develop a care plan for the use physical restraints that specified the behavior to be eliminated and a time limit for the use of the restraint for Resident 6, 3. Failed to develop a care plan for the use psychotherapeutic medications for Resident 6, 4. Failed to follow policies and procedures for the use of physical restraints. These failures resulted in the potential for unrecognized adverse effects of psychotherapeutic medications, symptoms of withdrawal, depression, reduced social contact, decreased range of motion, contractures (abnormal, usually permanent, bending of joints which may result from immobilization), pressure ulcers (open wounds that form over bony parts of the body due to prolonged pressure, i.e. immobilization), incontinence, decreased ability to ambulate, pain, increased risk of falls, strangulation, and death. Review of the, undated facility policy, "Physical Restraints," provided by the Director of Nursing (DON) on 10/26/11, from the, "Resident Care" policy and procedure (P&P) manual, reviewed by the facility P&P committee 11/11/08, defined:1. Physical Restraints; are any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement or normal access to one's body. (Federal register 483.13) 2. Behavioral Restraints; are physical devices used to control a resident's behavior such as assaultiveness/agitation which is non-responsive to alternate means of intervention and may endanger the welfare of the resident and/or others. Behavioral restraints are used temporarily and are to lead to the elimination of the behavior for which the restraint is applied. Behavioral restraints require the denial of resident rights and necessitate the completion of appropriate paperwork for such denial. 3. Convenience; is defined as action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest. Restraints may not be used for staff convenience. If the resident needs emergency care, restraints may be used for brief periods of time to permit medical treatment to proceed unless the facility has received a notice indicating the resident has previously made a valid refusal of a treatment in question. If as resident's unanticipated violent or aggressive behavior places him/her at or other residents in imminent danger, the resident does not have right to refuse the use of restraints. In this situation, the use of restraints is a measure of last resort to protect the safety of the resident or others and must not extend beyond the immediate episode. The policy, "Physical Restraints," identified the following: 1. Waist Restraint in Bed: risks/potential risks included; decreased sense of independence, potential for agitation, potential for sense of tightness at waist, potential for decline in functional ability. Less restrictive devices included, bolster, pillows, padded side rails, self- releasing roll belt, bed alarm. 2. Wheelchair Belt Non-Release Type: risks/potential risks included; may increase weakness and loss of muscular strength in lower extremities, decrease sense of independence, potential for development of contractures of lower extremities, pressure on coccyx, potential decline in functional ability, potential for symptoms of withdrawal, depression, or social isolation, increased incidence if infection. Less restrictive devices included, self- release WC belt, cushions, wedges, or pillows, posture glide. During an interview on 11/3/11 at 9 a.m., certified nursing assistant (CNA) B stated she worked the day shift and had worked at the facility 40 years. CNA B stated "all" of the facility residents, except one (not Resident 6), had dementia and wore belts, including; webbed belts, soft tie positional support (STPS) in bed or chair/wheelchair. CNA B stated the purpose was to prevent residents from getting up and falling down. During an observation and concurrent interview with LN C on 10/25/11 at 11:07 a.m., Resident 6 was observed in the solarium, restrained to his wheelchair (WC), seated on a chair alarm (an alarm that sounds when the resident moves from the WC) with a waist restraint. LN C stated Resident 6 had the chair alarm because he often got agitated and refused to wear a waist restraint.During an observation and concurrent interview on 10/26/11 at 9:50 a.m., Resident 6 was observed in the solarium restrained in a high backed WC with a waist restraint. LN E stated Resident 6 could not release the waist restraint.Review of Resident 6's clinical record on 10/31/11 at 3 p.m., revealed Resident 6 was admitted to the facility on 1/30/10 and suffered dementia. Physician orders, dated 10/1/11 - 10/31/11, signed by the physician on 10/21/11: 1. Webbed belt (waist restraint) in WC due to dementia with ataxia (unsteadiness), dated 1/27/11. The order did not specify the duration the restraint was to be used and was not designed to lead to a less restrictive way of managing, and ultimately the elimination of the behavior for which it was applied. 2. Seroquel, 50 milligrams (mg) by mouth every day at 06:00, dated 3/10/11. 3. Seroquel, 25 mg by mouth every day at 13:00, dated 3/10/11. 4. Seroquel, 75 mg by mouth every day at hour of sleep, dated 3/30/11. 5. Seroquel, 25 mg by mouth twice a day, every day as needed for behavior symptoms, dated 8/11/10. 6. Ativan, one mg by mouth/under tongue, once a day as needed for needed excessive agitation and behavior symptoms, dated 8/11/11. Nurse's notes 12/19/10 - 4/9/11 indicated: 1. 12/26/10, Resident 6 got out of bed unattended, unclipped and removed an alarm, and went back to bed without incident. 2. 1/9/11 at 1 p.m., Resident 6 was, "Highly agitated, needing to go to the bathroom, and agitated at the presence of the belt (waist restraint in WC). Resident 6 stated, "Take this thing off," "I don't need this," and, "I'm not in prison."3. 1/9/11 at 4 p.m., Resident 6 became "furious" when a CNA tried to re-apply a waist restraint while he (Resident 6) was in his WC. 4. 1/21/11, Administrative Staff (AS) L called Resident 6's family member to obtain consent to allow Resident 6 to remain in his room without being restrained. 5. 2/4/11 at 2:45 p.m., Resident 6 removed his bed alarm and made his way down the hall, asking, "Which way out?" 6. 2/4/11 at 3 p.m., facility staff administered 12.5 mg of Seroquel to Resident 6 in addition to his 3 p.m. dose of Seroquel for behaviors. 7. 3/2/11, the facility requested a psychiatric consultation. The clinical record did not contain a care plan which specified behaviors to be eliminated, the physical restraints used and a time limit for the use of the restraints. There was no care plan related to the use of the psychotherapeutic medication, Ativan, in the clinical record.A, "Physical Restraint for Elimination Assessment" (PREA), dated 6/11, indicated Resident 6, was restrained with a waist restraint in WC and recliner, scored 23 points, and was a good candidate (21-35) for restraint reduction / elimination. During an interview and concurrent document review on 10/26/11 at 12:48 p.m., when queried about the facility policy and procedure for restraint reduction, the DON stated she was the head of the facility restraints committee (FRC). The DON stated members of the FRC included the facility Medical Director (FMD), Administrator, DON, DSD, and licensed nurses. The DON stated the FRC met quarterly. The DON stated restraint reduction assessments were done quarterly but, "we (FRC) don't always spell out who has what."Review of the, "Nursing Services Procedures Manual," provided by DON on 10/26/11, last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Use of Restraints," which indicated: 1. Physical restraints for behavior control shall only be used on the signed order of a physician, except in an emergency which threatens to bring immediate injury to the resident or others. In such an emergency an order may be received by telephone, and shall be signed by the physician within 48 hours. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time, and the name of the individual applying such measures shall be entered in the resident's medical record. 2. Physical restraints for behavior control shall only be used with a written order designed to lead to a less restrictive way of managing and ultimately the elimination of the behavior for which the restraint was applied.3. Care plans which include the use of physical restraints for behavior shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method. 4. When drugs are used to restrain or control behavior or to treat a disordered thought process, the following shall apply: a. The plan of care for each resident specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions. 5. Should a resident not be capable of making a decision, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. "Note: The surrogate/sponsor may not give permission to use restraints for the sake of disciple or staff convenience or when the restraint is not necessary to treat the resident's medical condition." Review of the, "Nursing Services Procedures Manual," last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Physical Restraint Application,? indicated: 1. Written P&P's delineate the following; ? Orders indicate the specific reason, type, and period of time for the use of restraints. Restraints may only be used as a last resort and the medical record must indicate the events leading up to the necessity of the restraint. ? The use of restraints is temporary, and the resident will not be restrained for an indefinite amount of time. ? Orders for restraints will not be enforced for longer than twelve hours, unless the resident's condition requires continued treatment. 2. The need for restraints will be reevaluated at least quarterly to determine their need. Every effort will be made to eliminate their use. 3. An interdisciplinary assessment team, in coordination with the resident and his/her family or representative (sponsor) develops and maintains a comprehensive care plan which identifies: ? The medical symptom that warranted the use of the restraint ? The symptom being treated ? The type of restraint being used ? When the restraint is to be used ? The plan for release of device for exercise and toileting every two hours ? The plan for monitoring every 30 minutes ? How the use of the restraint will assist the resident in reaching his/her highest level of physical and psychosocial well-being ? The care plan "must" indicate that the continued use of a restraint has been reevaluated and that a reorder from the physician is so noted. During an interview on 11/1/11 at 3:18 p.m., the FMD stated facility staff restrained residents found partly out of bed, WC, or lounger and to prevent falls. The FMD stated he was not aware that staff was implementing the use of restraints without physician orders.When queried about the use of least restrictive measures, the FMD stated he was not aware facility staff should implement least restrictive measures and, "Clearly I haven't been looking at that." The FMD stated he generally took the recommendations of staff for restraint application. The FMD stated licensed nurses made recommendations about which restraints to use and when to use the restraints on residents. The FMD stated, "I'm basically very trusting of their skills, so I'm rubber stamping their recommendations." Therefore the facility violated the regulations when facility staff: 1. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 6's behavior, 2. Failed to develop a care plan for the use physical restraints that specified the behavior to be eliminated and a time limit for the use of the restraint for Resident 6, 3. Failed to develop a care plan for the use psychotherapeutic medications for Resident 6 and, 4. Failed to follow policies and procedures for the use of physical restraints. These failures resulted in the potential for unrecognized adverse effects of psychotherapeutic medications, symptoms of withdrawal, depression, reduced social contact, decreased range of motion, contractures (abnormal, usually permanent, bending of joints which may result from immobilization), pressure ulcers (open wounds that form over bony parts of the body due to prolonged pressure, i.e. immobilization), incontinence, decreased ability to ambulate, pain, increased risk of falls, strangulation, and death. These failures had a direct or immediate relationship to patient health, safety, or security. |
| 010000951 |
Marin Convalescent & Rehabilitation Hospital |
110008871 |
B |
08-Mar-12 |
XJ2R11 |
12205 |
72319(a) Nursing Service-Restraints and Postural Support (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. 72319(b) Nursing Service-Restraints and Postural Support (b) Restraints shall only be used with a written order of a physician or other person lawfully authorized to prescribe care. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints. 72319(i)(2)(A) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (A) Physical restraints for behavioral control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of, the behavior for which the restraint is applied. There shall be no PRN orders for behavioral restraints. 72319 (i)(2)(B) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (B) Each patient care plan which includes the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method. Resident 7: The facility violated the regulation when facility staff: 1. Failed to obtain a physician order prior to restraining Resident 7 in a Geri-chair (a Geri-chair is a large heavily padded wheelchair with reclining positions and a foot rest), 2. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 7's behavior, 3. Failed to develop a care plan for the use physical restraints that specified the behavior to be eliminated and a time limit for the use of the restraint for Resident 7, 4. Failed to follow policies and procedures for the use of physical restraints. These failures resulted in the potential for symptoms of withdrawal, depression, reduced social contact, decreased range of motion, contractures (abnormal, usually permanent, bending of joints which may result from immobilization), pressure ulcers (open wounds that form over bony parts of the body due to prolonged pressure, i.e. immobilization), incontinence, decreased ability to ambulate, pain, increased risk of falls, strangulation, and death. Review of the, undated facility policy, "Physical Restraints," provided by the Director of Nursing (DON) on 10/26/11, from the, "Resident Care" policy and procedure (P&P) manual, reviewed by the facility P&P committee 11/11/08, defined:1. Physical Restraints; are any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement or normal access to one's body. (Federal register 483.13) 2. Behavioral Restraints; are physical devices used to control a resident's behavior such as assaultiveness/agitation which is non-responsive to alternate means of intervention and may endanger the welfare of the resident and/or others. Behavioral restraints are used temporarily and are to lead to the elimination of the behavior for which the restraint is applied. Behavioral restraints require the denial of resident rights and necessitate the completion of appropriate paperwork for such denial. The policy, "Physical Restraints," identified the following: 1. Geri-Chair in Reclined Position: risks/potential risks included; limiting the ability to propel self, difficult for resident/family/staff to move, pressure on coccyx/hips, potential circulatory impairment of lower extremities, potential for contractures, further decline in functional ability, potential for symptoms of withdrawal, depression, or social isolation, and increased incidence of infection. Less restrictive devices identified included, Geri-chair in upright position, wheelchair (WC), cushions, wedges, or pillows. During an observation on 10/25/11 at 9:05 a.m., Resident 7 was observed in the facility solarium, reclined in a Geri-chair with her feet elevated. Resident 7 did not respond to attempt to interview. During an interview on 10/25/11 at 10:25 a.m., Licensed Nurse (LN) C stated facility staff put Resident 7 in the Geri-chair because Resident 7 was, "Moving too much," and " Trying to get out of the chair." Review of Resident 7's clinical record on 11/1/11 at 11 a.m., revealed Resident 7 was admitted to the facility on 2/4/09, and suffered mild dementia. Physician orders, 10/1/11 - 10/31/11, signed by the facility medical director (FMD) on 10/4/11, revealed there was no physician order to put Resident 7 in a Geri-chair and therefore no physician order which specify the duration the restraints was to be used and were not designed to lead to a less restrictive way of managing, and ultimately the elimination of the behavior for which it was applied. A nursing care plan titled, "Mobility/Safety/Elimination,? initiated 2/4/09 and updated 8/11, identified the approach; Geri-chair, reposition every two hours. The clinical record did not contain a care plan which specified behaviors to be eliminated, the physical restraints used and a time limit for the use of the restraints, per facility policy.During interview and concurrent document review on 10/26/11 at 12:48 p.m., the DON stated facility staff restrained residents that were restless, had a previously fell, or were at risk for falling. The DON identified pain, hunger, and needing to use the restroom as situations that put residents at risk for falling. The DON stated licensed nurses filed incident reports. Review of, "Resident Incident Log," dated 10/10 - 6/11, revealed no incidents of falls for Resident 7. A,"Physical Restraint Elimination Assessment" (PREA), dated 11/1/11, indicated facility staff documented no restraints were used and did not complete PREA for Resident 7. During continued interview and concurrent document review on 10/26/11 at 12:48 p.m., when queried about the facility policy and procedure for restraint reduction, the DON stated she was the head of the facility restraints committee (FRC). The DON stated members of the FRC included the FMD, Administrator, DON, DSD, and licensed nurses. The DON stated the FRC met quarterly. The DON stated restraint reduction assessments were done quarterly but, "we (FRC) don't always spell out who has what."Review of the, "Nursing Services Procedures Manual," provided by DON on 10/26/11, last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Use of Restraints," which indicated: 1. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. 2. Physical restraints for behavior control shall only be used on the signed order of a physician, except in an emergency which threatens to bring immediate injury to the resident or others. Physical restraints for behavior control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately the elimination of, the behavior for which the restraint was applied. There shall be no PRN (as needed) orders for behavioral restraints. 3. Care plans which include the use of physical restraints for behavior shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method. Review of the, "Nursing Services Procedures Manual," last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, "Physical Restraint Application," indicated: 1. Written P&P's delineate the following; ? Orders indicate the specific reason, type, and period of time for the use of restraints.? The use of restraints is temporary, and the resident will not be restrained for an indefinite amount of time. ? Orders for restraints will not be enforced for longer than twelve hours, unless the resident's condition requires continued treatment. 2. The need for restraints will be reevaluated at least quarterly to determine their need. Every effort will be made to eliminate their use. 3. An interdisciplinary assessment team, in coordination with the resident and his/her family or representative (sponsor) develops and maintains a comprehensive care plan which identifies: ? The medical symptom that warranted the use of the restraint ? The symptom being treated ? The type of restraint being used ? When the restraint is to be used ? The plan for release of device for exercise and toileting every two hours ? The plan for monitoring every 30 minutes ? How the use of the restraint will assist the resident in reaching his/her highest level of physical and psychosocial well-being ? The care plan "must" indicate that the continued use of a restraint has been reevaluated and that a reorder from the physician is so noted. During an interview on 11/1/11 at 3:18 p.m., the FMD stated facility staff restrained residents found partly out of bed, WC, or lounger and to prevent falls. The FMD stated he was not aware that staff was implementing the use of restraints without physician orders.When queried about the use of least restrictive measures, the FMD stated he was not aware facility staff should implement least restrictive measures and, "Clearly I haven't been looking at that." The FMD stated he generally took the recommendations of staff for restraint application. The FMD stated licensed nurses made recommendations about which restraints to use and when to use the restraints on residents. The FMD stated, "I'm basically very trusting of their skills, so I'm rubber stamping their recommendations." Therefore the facility violated the regulations when facility staff: 1. Failed to obtain a physician order prior to restraining Resident 7 in a Geri-chair (a Geri-chair is a large heavily padded wheelchair with reclining positions and a foot rest), 2. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 7's behavior, 3. Failed to develop a care plan for the use physical restraints that specified the behavior to be eliminated and a time limit for the use of the restraint for Resident 7 and, 4. Failed to follow policies and procedures for the use of physical restraints. These failures resulted in the potential for symptoms of withdrawal, depression, reduced social contact, decreased range of motion, contractures (abnormal, usually permanent, bending of joints which may result from immobilization), pressure ulcers (open wounds that form over bony parts of the body due to prolonged pressure, i.e. immobilization), incontinence, decreased ability to ambulate, pain, increased risk of falls, strangulation, and death. These failures had a direct or immediate relationship to patient health, safety, or security. |
| 010000951 |
Marin Convalescent & Rehabilitation Hospital |
110008872 |
B |
08-Mar-12 |
XJ2R11 |
13685 |
72319(a) Nursing Service-Restraints and Postural Support (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. 72319(b) Nursing Service-Restraints and Postural Support (b) Restraints shall only be used with a written order of a physician or other person lawfully authorized to prescribe care. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints. 72319(i)(2)(A) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (A) Physical restraints for behavioral control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of, the behavior for which the restraint is applied. There shall be no PRN orders for behavioral restraints. 72319 (i)(2)(B) Nursing Service-Restraints and Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (B) Each patient care plan which includes the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method. Resident 8: The facility violated the regulation when facility staff: 1. Failed to obtain a physician order prior to restraining Resident 8 in a wheelchair with a waist restraint and in a Geri-chair (a Geri-chair is a large heavily padded wheelchair with reclining positions and a foot rest), 2. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 8 ' s behavior, 3. Failed to develop a care plans for the use physical restraints that specified the behavior to be eliminated and a time limit for the use of the restraint for Resident 8, 4. Failed to follow policies and procedures for the use of physical restraints. Review of the, undated facility policy, " Physical Restraints, " provided by the Director of Nursing (DON) on 10/26/11, from the " Resident Care " policy and procedure (P&P) manual, reviewed by the facility P&P committee 11/11/08, defined:1. Physical Restraints; are any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident ' s body that the resident cannot remove easily which restricts freedom of movement or normal access to one ' s body. (Federal register 483.13) 2. Behavioral Restraints; are physical devices used to control a resident ' s behavior such as assaultiveness /agitation which is non-responsive to alternate means of intervention and may endanger the welfare of the resident and/or others. Behavioral restraints are used temporarily and are to lead to the elimination of the behavior for which the restraint is applied. Behavioral restraints require the denial of resident rights and necessitate the completion of appropriate paperwork for such denial. The policy also identified, "Physical Restraints,"identified the following: 1. Wheelchair Belt Non-Release Type: risks/potential risks included; may increase weakness and loss of muscular strength in lower extremities, decrease sense of independence, potential for development of contractures of lower extremities, pressure on coccyx, potential decline in functional ability, potential for symptoms of withdrawal, depression, or social isolation, increased incidence if infection. Less restrictive devices included, self- release WC belt, cushions, wedges, or pillows, posture glide. 2. Geri-Chair in Reclined Position: risks/potential risks included; limiting the ability to propel self, difficult for resident / family / staff to move, pressure on coccyx /hips, potential circulatory impairment of lower extremities, potential for contractures, further decline in functional ability, potential for symptoms of withdrawal, depression, or social isolation, and increased incidence of infection. Less restrictive devices identified included, Geri-chair in upright position, wheelchair (WC), cushions, wedges, or pillows. During an observation on 10/25/11 at 9:05 a.m., Resident 8 was observed in the facility solarium. Resident 8 ' s arms rotated inward and the back of each hand touch the other hand as they lay in her lap. Resident 8 was restrained to a high back wheelchair (WC) in a reclined position, her feet elevated, a waist restraint crossed Resident 8 ' s waist and attached to the back of her WC. Resident 8 did not respond to attempt to interview.During an observation and concurrent interview on 10/26/11 at 9:50 a.m., Residents 8 was observed in the solarium reclined in a Geri-chair with her feet were elevated. Licensed Nurse (LN) E stated Resident 8 could not get out of the Geri-chair without assistance.During an interview on 11/3/11 at 9 a.m., Certified Nursing Assistant (CNA) B stated she worked the dayshift and had worked at the facility 40 years. CNA B stated "all " of the facility residents, except one (not Resident 8), had dementia and wore belts, including; webbed belts, soft tie positional support (STPS) in bed or chair/wheelchair or Geri-chairs. CNA B stated the purpose was to prevent residents from getting up and falling down. Review of Resident 8 ' s clinical record on 11/3/11 at 8:30 a.m., revealed Resident 8 was admitted to the facility on 7/30/10 and suffered Alzheimer's disease. Physician orders, 10/1/11 - 10/31/11, signed by the facility medical director (FMD) on 10/4/11, indicated:1. Coccyx, cleanse with wound cleanser , apply allevyn thin every three days and as needed, dislodged, or soiled, until healed, dated 1/19/11. 2. There was no physician order for use of a waist restraint while in WC. 3. There was no physician order for use of a Geri-chair in a reclined position, with elevated feet. Nurse's notes dated 12/27/10-10/14/11, did not indicate facility staff restrained Resident 8 in a WC or a Geri-chair. A nursing care plan titled, "Mobility/Safety/Elimination, "initiated 7/30/10 and updated 10/11, identified the approach; WC or Geri-chair, reposition every two hours. The clinical record did not contain a care plan which specified behaviors to be eliminated, the physical restraints used and a time limit for the use of the restraints, per facility policy.During interview and concurrent document review on 10/26/11 at 12:48 p.m., the DON stated facility staff restrained residents that were restless, had a previously fell, or were at risk for falling. The DON identified pain, hunger, and needing to use the restroom as situations that put residents at risk for falling. The DON stated licensed nurses filed incident reports. Review of, "Resident Incident Log," dated 10/10 - 6/11, revealed no incidents of falls for Resident 8. A Resident Care Conference Review (RCCR), dated 4/11 & 6/11, indicated Resident 8 was at little risk for falls and restraint reduction was not applicable, but Resident 8 ' s reoccurring coccyx (tail bone) pressure ulcer was a continued concern.A Physical Restraint Elimination Assessment (PREA), dated 8/8/11, indicated Resident 8 scored 26 on 4/11 and 6/11, indicating the resident was a good candidate for restraint elimination or reduction. However, the DON documented Resident 8 was not restrained. During continued interview and concurrent document review on 10/26/11 at 12:48 p.m., when queried about the facility policy and procedure for restraint reduction, the DON stated she was the head of the facility restraints committee (FRC). The DON stated members of the FRC included the facility Medical Director (FMD), Administrator, DON, Director of Staff Development (DSD), and licensed nurses. The DON stated the FRC met quarterly. The DON stated restraint reduction assessments were done quarterly but, "we (FRC) don't always spell out who has what."Review of the, "Nursing Services Procedures Manual, " provided by DON on 10/26/11, last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, " Use of Restraints, " which indicated: 1. Restraints shall only be used upon the written order of a physician. 2. Physical restraints for behavior control shall only be used on the signed order of a physician, except in an emergency which threatens to bring immediate injury to the resident or others.3. Physical restraints for behavior control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately the elimination of, the behavior for which the restraint was applied.4. Care plans which include the use of physical restraints for behavior shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method. Review of the, "Nursing Services Procedures Manual, " last reviewed by the facility P&P committee on 11/11/08, revealed the undated policy, " Physical Restraint Application, " indicated: 1. Restraints will only be used after other alternatives have been tried unsuccessfully. 2. Written P&P's delineate the following; * Orders indicate the specific reason, type, and period of time for the use of restraints. Restraints may only be used as a last resort. * The use of restraints is temporary, and the resident will not be restrained for an indefinite amount of time. * Orders for restraints will not be enforced for longer than twelve hours, unless the resident's condition requires continued treatment. 3. The need for restraints will be reevaluated at least quarterly to determine their need. Every effort will be made to eliminate their use. 4. An interdisciplinary assessment team, in coordination with the resident and his/her family or representative (sponsor) develops and maintains a comprehensive care plan which identifies: * The medical symptom that warranted the use of the restraint * The symptom being treated * The type of restraint being used * When the restraint is to be used * The plan for release of device for exercise and toileting every two hours * The plan for monitoring every 30 minutes * How the use of the restraint will assist the resident in reaching his/her highest level of physical and psychosocial well-being * The care plan "must "indicate that the continued use of a restraint has been reevaluated and that a reorder from the physician is so noted. During an interview on 11/1/11 at 3:18 p.m., the FMD stated facility staff restrained residents found partly out of bed, WC, or lounger and to prevent falls. The FMD stated he was not aware that staff was implementing the use of restraints without physician orders.When queried about the use of least restrictive measures, the FMD stated he was not aware facility staff should implement least restrictive measures and, "Clearly I haven't been looking at that." The FMD stated he generally took the recommendations of staff for restraint application. The FMD stated licensed nurses made recommendations about which restraints to use and when to use the restraints on residents. The FMD stated, "I ' m basically very trusting of their skills, so I ' m rubber stamping their recommendations." Therefore the facility violated the regulations when facility staff: 1. Failed to obtain a physician order prior to restraining Resident 8 in a wheelchair with a waist restraint and in a Geri-chair (a Geri-chair is a large heavily padded wheelchair with reclining positions and a foot rest), 2. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 8 ' s behavior, 3. Failed to develop a care plans for the use physical restraints that specified the behavior to be eliminated and a time limit for the use of the restraint for Resident 8 and, 4. Failed to follow policies and procedures for the use of physical restraints. These failures resulted in the potential for symptoms of withdrawal, depression, reduced social contact, decreased range of motion, contractures (abnormal, usually permanent, bending of joints which may result from immobilization), pressure ulcers (open wounds that form over bony parts of the body due to prolonged pressure, i.e. immobilization), incontinence, decreased ability to ambulate, pain, increased risk of falls, strangulation, and death. These failures had a direct or immediate relationship to patient health, safety, or security. |
| 010000951 |
Marin Convalescent & Rehabilitation Hospital |
110008873 |
B |
08-Mar-12 |
XJ2R11 |
3825 |
72349(d)(2) Dietetic Service-Equipment and Supplies (d) Food supplies shall meet the following standards: (2) All food shall be of good quality and procured from sources approved or considered satisfactory by federal, state or local authorities. Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used. 72523(a) Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility violated the regulation when: 1. Facility staff stored food for the preparation of resident meals in swelling, rusted, dented cans, and 2. Facility staff stored expired food for the preparation of resident meals in the dry storage. 3. Failed to follow policies and procedures for food storage. According to The National Institutes of Health (NIH), 12/12/11, foods can be contaminated with bacteria, parasites, and viruses. Eating contaminated food may cause foodborne illness. According to the Food and Drug Administration (FDA), 2011, the elderly and persons with weakened immune systems are at greater risk of serious consequences from most foodborne illnesses. Therefore, the listed failures had the potential to result in foodborne illness including upset stomach, abdominal cramps, nausea, vomiting, diarrhea, fever, dehydration. Additionally, these failures had the potential to result in disease from foodborne illness including; kidney failure, chronic arthritis, brain and nerve damage, or death. 1. During an observation and concurrent interview on 10/31/11 at 12:48 p.m., six dented cans of soup, nine dented cans of juice, one dented can of pureed tomatoes, and one dented can of apple rings were observed in the food storage area. The DS stated the dented cans of food should not be stored with food for resident use and should have been returned to the vendor per facility policy. The DS removed the dented cans from the food storage area. Review of the facility procedure, "Sanitation and Infection Control," from the Dietary Directions, INC. Food Service Policy and Procedure Manual, 2011, indicated food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells was not used and was stored in a separate labeled area. The undated policy, "Canned and Dry Goods Storage," indicated canned food items were routinely inspected for damage, "such as dented, bulging or leaking cans."This policy indicated damaged cans were set aside to be returned to the vendor or disposal. 2. During an observation and concurrent interview on 10/31/11 at 12:48 p.m., three swelling, undated boxes of grape drink mix, five boxes of grapefruit juice expired 10/24/09, and one box of orange juice expired 10/24/09 were observed in the food storage area. The DS stated the undated and expired drinks should have been discarded. Review of the facility policy, "Dry Storage Areas," from the Policy and Procedure Manual, dated 2005; indicated spoiled foods were disposed of promptly to, "Prevent contamination of other foods." Therefore the facility violated the regulations when: facility staff stored food for the preparation of resident meals in swelling, rusted, dented cans, and facility staff stored expired food for the preparation of resident meals in the dry storage. These failures had the potential to result in foodborne illness including upset stomach, abdominal cramps, nausea, vomiting, diarrhea, fever, dehydration. Additionally, these failures had the potential to result in disease from foodborne illness including; kidney failure, chronic arthritis, brain and nerve damage, or death. These failures had a direct or immediate relationship to patient health, safety, or security. |
| 010000951 |
Marin Convalescent & Rehabilitation Hospital |
110008874 |
B |
08-Mar-12 |
XJ2R11 |
5167 |
72349(d)(6) Dietetic Service-Equipment and Supplies (d) Food supplies shall meet the following standards: (6) Foods held in refrigerated or other storage areas shall be covered. Liquids and food which are prepared and not served shall be tightly covered, stored appropriately, clearly labeled and dated. A written procedure shall be established and followed for the safe use of leftover foods. The facility violated the regulation when: 1. Cook K failed to check and document the final cooking temperature of leftover meatloaf before serving it to two Residents (Resident 2 and Random Resident 10) , 2. Facility staff failed to monitor and document the cool down process of potentially hazardous foods. 3. Failed to follow policy and procedure related to food temperatures. According to the Food and Drug Administration (FDA), 2011, food is safely cooked when it reaches a high enough internal temperature to kill the harmful bacteria that cause foodborne illness. According to The National Institutes of Health (NIH), 12/12/11, the bacteria that cause foodborne illness multiply quickest in temperatures between 40-140 degrees Fahrenheit.Therefore, the FDA recommends the following Safe Cooking Temperatures (measured in degrees Fahrenheit): poultry 165, raw ham and egg dishes 160, fresh beef, pork, veal, lamb 145, ground beef, pork, veal, lamb 160, left overs 165. Therefore, the facility's listed failures had the potential to result in foodborne illness including upset stomach, abdominal cramps, nausea, vomiting, diarrhea, fever, dehydration. Additionally, these failures had the potential to result in disease from foodborne illness including; kidney failure, chronic arthritis, brain and nerve damage, or death. 1. During an observation and interview on 10/31/11 at 11:18 a.m., Cook K removed a left-over meatloaf, labeled 10/29/11, from the refrigerator. Cook K then pureed the meatloaf, put it in a single serving dish and placed it on the steam table. Cook K did not heat or take the temperature of the left-over meatloaf prior to placing it on the steam table. During an interview and document review on 11/1/11 at 11:15 a.m., the DS reviewed the facility menu and stated the meatloaf which was pureed and served on 10/31/11 was cooked on 10/29/11 at "about "10 a.m. During an interview on 11/1/11 at 11:20 a.m., Cook K stated the meatloaf which he (Cook K) pureed on 10/31/11, was for Resident 2 and Random Resident (RR) 10. During an interview on 11/3/11 at 10:50 a.m., Certified Nursing Assistant (CNA) B stated she cared for RR 10 on 10/31/11. CNA B stated she " clearly " remember RR 10 ate meatloaf for lunch on 10/31/11 and that RR 10 " always " ate 90-100% of her meal. During an interview on 11/3/11 at 10:40 a.m., CNA L stated she cared for Resident 2 on 10/31/11. CNA L stated Resident 2 was served pureed meatloaf for lunch and that Resident 2 ate 100% of the meatloaf. During an interview on 11/1/1 at 11:25 a.m., the DS stated Cook K should have heated the meatloaf to 155 F0 and then pureed it. Review of the facility procedure, "Proper Food Handling," from the Dietary Directions, INC. Food Service Policy and Procedure Manual, 2011, indicated food that was not prepared at the time of meal service, "must "be reheated to the proper temperature (165 F0) before serving. 2. During continued interview on 10/31/11 at 2:20 p.m., the facility cool down log for PHF was requested for review. The DS stated facility staff did not correctly document a cool down log during 9/11. The DS did not provide evidence of a cool down log for 9/11 or 10/11. During an interview and document review on 10/31/11 at 3:15 p.m., the DS reviewed the facility ' s menu cycle starting five week menu cycle and stated 19 dishes contained potentially hazardous foods which should have been cooled using the cool down process. Review of the facility procedure, "Food Preparation," from the Dietary Directions, INC. Food Service Policy and Procedure Manual, 2011, indicated food that was cooked and not immediately served was cooled to " appropriate " temperatures within an allotted time to prevent microbial growth. The policy described the following procedure: 1. Maintain a cool down log to ensure standards are met, 2. Food must be cooled to 70 F0 within two hours, and then to 41F0 within the next four hours, 3. If food does not reach 41F0 within six hours, reheat until the inner temperature reaches 165 F0 for at least 15 seconds and re-start the process. Therefore the facility violated the regulations when: Cook K failed to check and document the final cooking temperature of leftover meatloaf before serving it to two Residents (Resident 2 and RR 10), and facility staff failed to monitor and document the cool down process of PHFs. These failures had the potential to result in foodborne illness including upset stomach, abdominal cramps, nausea, vomiting, diarrhea, fever, dehydration. Additionally, these failures had the potential to result in disease from foodborne illness including; kidney failure, chronic arthritis, brain and nerve damage, or death. These failures had a direct or immediate relationship to patient health, safety, or security. |
| 010000951 |
Marin Convalescent & Rehabilitation Hospital |
110008952 |
B |
08-Mar-12 |
XJ2R11 |
3632 |
72347(a) Dietetic Service-Cleaning and Disinfection(a) All utensils used for eating, drinking and in the preparation and serving of food and drink shall be cleaned and disinfected or discarded after each usage. 72347(c) Dietetic Service-Cleaning and Disinfection (c) Utensils not washed by mechanical means shall be placed in hot water with a minimum temperature of 43 degrees C (110 degrees F), washed using soap or detergent, rinsed in hot water to remove soap or detergent and disinfected by one of the following methods or equivalent, as approved by the Department: 72523(a) Patient Care-Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility violated the regulation when: 1. Cook K removed a soiled knife from the dishwashing sink, and used the knife to slice green onions without first cleaning and disinfecting the knife or washing the onions. 2. Cook K also used a food processor to puree meatloaf and then only rinsed, rather than clean and disinfect, the food processor prior to it being used for rice preparation during a meal preparation. 3. The facility failed to follow their policy and procedure related to cleansing and disinfecting items used in food preparation.According to The National Institutes of Health (NIH), 12/12/11, foods can be contaminated with bacteria, parasites, and viruses. Eating contaminated food may cause foodborne illness. According to the Food and Drug Administration (FDA), 2011, the elderly and persons with weakened immune systems are at greater risk of serious consequences from most foodborne illnesses. Therefore, the listed failures had the potential to result in foodborne illness including upset stomach, abdominal cramps, nausea, vomiting, diarrhea, fever, dehydration. Additionally, these failures had the potential to result in disease from foodborne illness including; kidney failure, chronic arthritis, brain and nerve damage, or death. a. During an observation on 10/31/11 at 11:03 a.m., Cook K removed green onions from the refrigerator and a knife from a dirty sink. Cook K did not wash the knife or the green onions prior to slicing the green onions.b. During an observation on 10/31/11 at 11:25 a.m., Cook K rinsed the food processor, used to puree meatloaf, in the dishwashing sink, rinsed it a second time in the rinse sink, and then placed the food processor back on the counter in its original place for use. Cook K did not use soap or sanitizer to wash the food processor. During an observation on 10/31/11 at 11:30 a.m., Cook K used the food processor to puree rice; Cook K did not wash or sanitize the food processor before pureeing the rice. During an interview on 10/31/11 at 12:45 p.m., the DS stated Cook K should have sanitized the knife before cutting the green onions, and washed or sanitized the food processor in between uses. Review of the facility procedure, "Proper Food Handling," from the Dietary Directions, INC. Food Service Policy and Procedure Manual, 2011, indicated it was the facility policy to Wash "all "raw fruits and vegetables thoroughly to remove soil and other contaminants. These failures had the potential to result in foodborne illness including upset stomach, abdominal cramps, nausea, vomiting, diarrhea, fever, dehydration. Additionally, these failures had the potential to result in disease from foodborne illness including; kidney failure, chronic arthritis, brain and nerve damage, or death. These failures had a direct or immediate relationship to patient health, safety, or security. |
| 010000951 |
Marin Convalescent & Rehabilitation Hospital |
110008953 |
B |
08-Mar-12 |
XJ2R11 |
3969 |
72551(a) External Disaster and Mass Casualty Program (a) A written external disaster and mass casualty program plan shall be adopted and followed. The plan shall be developed with the advice and assistance of county or regional and local planning offices and shall not conflict with county and community disaster plans. A copy of the plan shall be available on the premises for review by the Department. The facility violated the regulation when staff failed to follow policies and procedures for the maintenance and storage of emergency food and water supplies which indicated the facility: 1. Maintain a three - seven day emergency food supply on the premises, and 2. Store three gallons of drinking water per person per three days. These failures resulted in the potential for illness, subsequent disease and death due to inadequate food and water supply in the event of emergency or disaster. 1. During an observation and concurrent interview on 10/31/11 at 12:20 p.m., the Dietary Supervisor (DS) said she was responsible for the facility' emergency food and water supply. The DS stated the emergency food and water supply was meant to furnish enough food for 50 people for three days. The DS stated the facility didn't currently have an adequate emergency food supply. Observation of the three day emergency food supply for 50 people consisted of: a. Two number 10 size cans of pork and beans, b. Two number 10 size cans of three bean salad, c. One number 10 size cans of apple sauce, d. Two number 10 size cans of pineapple, e. One number 10 size cans of fruit cocktail, f. 24, 12 ounce cans of evaporated milk, g. 72, 1.52 ounce boxes of Raisin Bran, h. One flat of 4 pound, 2.5 ounce cans of tuna. i. Eight, 60 ounce bottles of cranberry juice, The following rusted, dented, and/ or swelling cans were observed in the emergency food supply: a. 14, 29.5 ounce cans of tuna, b. One Number 10 size can of tapioca pudding. 2. When queried about the lack of emergency food supply, the DS stated, "All the cans exploded". Observation of the bottled emergency water supply on 10/31/11 at 12:45 p.m., revealed a total of 141 gallons (less than one gallon of water per person per day), including water which was labeled "sell by" 2008. According to the manufacturer's recommendations, the water should be used "Before the 'Sell By Date' expires (which is two years after production)."When queried about the deficient and expired supply of water, on 10/31/11 at 12:45 p.m.,the DS stated the Maintenance Supervisor (MS) had an additional water supply in a storage shed. Joint observation and concurrent interview on 10/31/11 at 1:30 p.m., in the storage shed with the MS and the DS, revealed two large blue canisters with a raised label which read, "Do not use for food and drink, container subject to government regulation." When queried if the MS or the DS had read the label, neither staff member responded. Review of facility procedure, "Emergency and Disaster Procedures," dated 2011, revealed it was the facility policy to, "Maintain an emergency food supply on the premises to last for a three to seven day period and ensure water is available in essential areas when there is a loss of normal water supply." The procedure further indicated one gallon of water per resident per day, "must" be stored at the facility. Therefore the facility violated the regulation when staff failed to follow policies and procedures for the maintenance and storage of emergency food and water supplies which indicated the: 1. Maintain a three - seven day emergency food supply on the premises, and 2. Stored three gallons of drinking water per person per three days according to the facility emergency and disaster procedure. These failures resulted in the potential for illness, subsequent disease and death due to inadequate food and water supply in the event of emergency or disaster. These failures had a direct or immediate relationship to patient health, safety, or security. |
| 110001250 |
MEADOWOOD NURSING CENTER |
110009335 |
B |
13-Jun-12 |
W3YO11 |
3144 |
72311(a)(3)(B) Nursing Service General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. Based on observation, interview, and record review, the facility failed to notify the physician promptly after Resident 1 fell. The failure resulted in Resident 1 experiencing pain from a broken bone and delay in treatment. Resident 1 was admitted to the facility on 7/6/09 for the 4th time with diagnoses including:status/post left arm fracture, dementia, and history of falls. Resident 1 was admitted to the facility for the 5th time on 7/6/11 with diagnoses including: acute kidney failure, hypertension, dementia, and hypokalemia. Resident 1 had an unwitnessed fall the morning of 7/16/11. On 8/15/11 at 12:05 p.m. during an interview, Staff C stated that she did not know who notified the physician after Resident 1 fell but that typically " everyone comes to me". Staff C stated that she made the decision to medicate Resident 1 with Tylenol, an over the counter medication for pain. Staff C stated it was" pretty obvious" that the headache Resident 1 complained of after the fall was the result of the fall. Staff C stated that she thought the belly ache that Resident 1 complained of after the fall was the result of not having a bowel movement for a couple of days. Staff C stated she did not advise anyone to notify the physician of Resident's headache or belly pain. On 8/15/11 at 12:35 p.m. during an interview, Staff B stated she did not notify the physician after assessing Resident 1 after the fall. On 8/15/11 at 2:00 p.m. during an interview, Staff A stated that she expected the licensed vocational nurses( LVNs) to notify the physician when a resident had pain or " when they believe there is real acute pain going on." Staff A stated that Staff C did not notify the physician of Resident 1's headache after the fall because it was "obvious" that Resident 1 had a headache from the fall. Review of records on 10/19/11 indicated that the Nursing Notes dated 7/16/11 at 10:15 a.m. indicated that Resident 1 was found on the floor on 7/16/11 at approximately 10:05 a.m. The Nursing Notes indicated that "Res(resident)denies any pain or HA(headache)." The Nursing Note indicated "MD(medical doctor) &RP(responsible party) aware." There is no indication of the time of notification of the physician or responsible party. Review of records on 10/19/11 indicated that the Nursing Notes dated 7/16/11 at 13:30 (1:30 p.m) stated that " Dr. Shepherd on call for medical director paged X 2. awaiting call-back." Review of records on 10/19/11 indicated that the physician gave a telephone order for an X-ray to the pelvis, L hip, and L elbow on 7/17/11 at 11:30 a.m. The failure of the facility to notify the physician promptly after Resident 1 was found on the floor after an unwitnessed fall caused Resident 1 to experience pain from a broken bone and a delay in treatment. This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 010000161 |
MILESTONES OF DEVELOPMENT #2 |
110010848 |
A |
25-May-17 |
GP4N11 |
11125 |
Health & Safety 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 1 of 6 clients (Client 1) was free from harm when:
1. Water temperature was not checked for safety;
2. Direct observation and supervision of Client 1 during a sitz bath was not maintained by Direct Care Staff;
3. Train staff sufficiently to the task of safely giving sitz baths;
4. Nursing advice was inadequate (per physician interview) when nursing advised staff to apply ice, and put to bed rather than send immediately to the emergency room for professional treatment and assessment; and
5. Immediate treatment (per physician interview) was inappropriate, when ice had been applied to a second degree burn, instead of dry bandages, staff did not reposition Client 1 off the wound, and professional licensed personnel did not immediately assess the wound.
These failures resulted in a second-degree burn covering Client 1's left buttock, including the underside of his scrotum.
The facility is a six-bed, Intermediate Care Facility (ICF) for the developmentally disabled. The facility is Habilitative licensed (health care services that help keep individuals learning, or improving, skills and functioning for daily living) to provide care and services to individuals with developmental disability, and intellectual disabilities. Client 1 was dependent on the facility for all basic health and safety needs.
Client 1 had a diagnosis which included intellectual disabilities. Client 1 was described as cognitively engaged and conversant. Client 1 required full assistance with repositioning and transporting.
A review of the facility's "Incident Report," dated 4/22/14, signed by Nurse C, indicated the following:
A. Client 1 had a history of constipation that occasionally caused anal fissures (a cut or tear in the skin tissue around the anus);
B. Physician-ordered treatment included sitz bath soaks in warm water, for up to 10 minutes, three times daily;
C. On 4/9/14, Direct Care Staff (DCS) A informed Nurse C, by telephone,
Client 1 had developed a blister on his left buttocks after the sitz bath;
D. Nurse C instructed DCS-A to keep Client 1 off his left side and notify the facility's House Manager/Registered Nurse, HM-B, if the condition worsened;
E. On 4/10/14 at 8:30 a.m., HM-B informed Nurse C that Client 1's buttocks did not look very good, assessing the blister to be approximately 3" x 4" on left buttocks, and circular area approximated 1/2" x 1/2" on scrotum;
F. Water temperature from the kitchen tap was 130? Fahrenheit (25? F over advised water temperature), and;
G. At 1:50 p.m., Physician D prescribed Silvadene dressing, covered with Xeroform and abdominal pads, with a condom catheter order to be used until Client 1's scrotum healed.
During an observation on 4/24/14 at 3:50 p.m., Client 1 lay prone (on his stomach) on his bed. Licensed Staff F prepared to administer treatment to a second-degree burn which covered Client 1's left buttock and the underside of his scrotum. The exposed area of the buttock, covered the entire radius of the left buttock, and was red, with pockets of exposed fat and blood capillaries. The scrotum looked similar, with an area approximately 1" x 3/4." Treatment included cleansing with normal saline, application of Silver Sulfadiazine Cream, two Xeroform, and then 2 abdominal pads with 2" paper tape across the middle of the bandaging and across from thigh-to-thigh to hold it in place. An external condom catheter had been placed in order to prevent urine from contaminating the wound.
In an interview on 4/24/17 at 4:19 p.m., Client 1's family member stated she called Nurse C, on 4/10/14 at 8:30 a.m., about an appointment scheduled for Client 1, at which point Nurse C informed Client 1's family about the previous night's incident. Client 1's family member arrived at the Day Program at 9:10 a.m., and saw Client 1 upon his stomach on a floor mat. Client 1's family member reported Client 1 had, "tears in his eyes" and she saw a, "devastating" burn on his left buttocks. Client 1's family member recalled asking Nurse C, "What happened to this man?" The family member stated concern that the facility had not: a. properly assessed Client 1 and called emergency; b. not given Client 1 pain medication, and; c. notified the family member more timely.
During an interview on 4/24/14 at 5 p.m., DCS-A stated that on 4/9/14 at 3 p.m., he prepared and administered a physician-ordered, sitz bath treatment to Client 1. DCS-A stated it was the first time he had administered a sitz bath entirely alone. DCS-A had assisted once before, but had not been involved in setting up the water, saying he had been told the water needed to be hot enough for steam to rise. When asked to describe his process, DCS-A described the following:
A. Client 1 had a private room and bath. DCS-A stated that he sat Client 1 on the toilet with a basin underneath the toilet seat. DCS-A filled a bag to the designated line with hot tap water, returned to Client 1's bathroom, hung the bag above head level so that it would drain by a long hose into the basin beneath Client 1. Client 1 was not to be immersed into the water, but rather seated above the water so that the steam could effectively relieve the inflammation from an anal tear.
B. DCS-A demonstrated he had left Client 1's bathroom door open, between the bedroom and bath, and sat on a couch within auditory range, but out of direct sight of Client 1. DCS-A stated he wanted to give Client 1 'his privacy.' DCS-A stated Client 1 called out that the water was hot. DCS-A entered the bathroom and saw Client 1 leaning to the left, his head resting on the sink, and his left buttock immersed into the water basin beneath the toilet seat.
C. DCS-A called House Manager (HM) B for assistance and together they transferred Client 1 to his bed. Upon inspection, DCS-A and HM-B stated they saw a thumb-sized, blister on Client 1's left buttock.
D. DCS-A stated HM-B called Nurse C for nursing guidance. DCS-A stated Nurse C instructed them to place a towel on Client 1's buttock, and then place a bag of ice for 15 minutes. DCS-A stated he followed Nurse C's instructions.
E. DCS-A placed a dry depends on Client 1, placed him back into his wheelchair, and took him into dinner.
F. After dinner, DCS-A put Client 1 to bed, placing him on his back, "because that is how he always sleeps."
G. The next morning, 4/10/13, at approximately 6:30 a.m., DCS-A changed Client 1's depends, which were, "wet but not soaked," and described the blister as, "basketball size, looked filled with water."
H. DCS-A and another staff transferred Client 1 to a shower chair, after which DCS-A placed a dry depends on Client 1, and placed Client 1 in his wheelchair for breakfast.
I. DCS-A reported to HM B that the blister had popped. HM-B called Nurse C and asked that Client 1's buttock be assessed when he arrived at the Day Program.
A review of the facility's document, "Administering a Sitz Bath," dated 4/11/14, included the following:
A. Staff should take the water temperature, which should be between 100-105? F, and;
B. Staff should stay with the client throughout the sitz bath treatment.
A review of the facility's Daily Temperature Log, April 2014, indicated staff had not recorded daily water temperatures from 4/2/14 to 4/9/14 (inclusive). The water log indicated staff recorded a water temperature of 130? F, on 4/10/14.
In an interview on 4/24/14 at 5:21 p.m., HM-B stated she had been cooking, and DCS-A had transferred Client 1 into his bed without her assistance, although he was a two-person transfer assist. HM-B stated she saw Client 1 in his bed, and he had a blister on his back that looked, "like a small one bubble water blister." HM-B stated Client 1 did not complain of pain. HM-B stated she called Nurse C at approximately 4 p.m. and was instructed to ice the blister, with a bag of ice and a towel between. HM-B stated she did not know for how long, but thought it was for less than five minutes. HM-B stated the blister did not look much different after it had been iced. HM-B stated she and DCS-A got Client 1 up into his wheelchair for dinner, and he went to bed between 6-6:30 p.m., and was placed on his back. HM-B stated staff did not change Client 1's depends at night because he did not typically wet during the night. HM-B stated morning staff changed Client 1's depend at 6 a.m., but she did not recall the aides telling her anything, except DCS-A told her the blister had popped. HM-B stated she called Nurse C and asked that she look at Client 1's blister when he arrived at Day Program.
When interviewed on 6/5/14 at 2:28 p.m., Physician D stated being shocked by Client 1's condition and surprised the facility had not sent Client 1 to emergency immediately: "It was pretty bad." Physician D stated ice would not be helpful, as moisture could be a source for infection. Physician D's clinical Progress Notes, dated 4/10/14, page 2 of 4, confirmed a diagnosis of 2nd degree burn to the buttocks and scrotum, for which Physician D prescribed treatment.
An interview, on 6/5/14 at 2:40 p.m., with a home health wound treatment nurse, confirmed the following: Licensed Staff E stated ice would not have been helpful, but rather keeping the blister dry and covered to avoid infection and then seeing a physician immediately would have been the best course of action after Client 1 had been immersed in hot water during his sitz bath.
Therefore, the facility failed to:
1. Check water temperature for safety;
2. Directly observe and supervise Client 1 during a sitz bath;
3. Train staff sufficiently to the task of safely giving sitz baths;
4. Provide appropriate nursing advise (per physician interview), when nursing advised staff to apply ice and put Client 1 to bed rather than keep the wound dry and send Client 1 immediately to the Emergency Room for professional treatment and assessment; and
5. Provide appropriate immediate emergency treatment (per physician interview) by applying dry bandages, rather than ice, positioning Client 1 off the affected area, and getting immediate licensed professional assessment of the wound.
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. |
| 050000056 |
MAYWOOD ACRES HEALTHCARE |
120009100 |
A |
20-Jul-12 |
XZWG11 |
9451 |
Title 22 - 72311 (a) (1) (A) (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. Title 22 - 72311 (a) (3) (B) (a) Nursing service shall include, but not be limited to the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.The facility did not comply with the above regulations by failing to assess Patient A and promptly notify her physician when the patient exhibited a change in mental status and adverse changes , including increased somnolence and refusing meals and medications. Between 12/14/11 and 12/17/11 nursing identified that Patient A was sleeping more than usual, did not receive medication she routinely took for chronic pain due to increased drowsiness and sedation, and was refusing meals and medication. Despite adverse changes documented by nursing as early as 12/14/11, the patient was not assessed and the physician was not notified of the change in the Patient A's condition until the afternoon of 12/17/11. Following notification of the physician, Patient A was transferred to the hospital, evaluated in the emergency room for an altered level of consciousness, diagnosed with a urinary tract infection and a subarachnoid hemorrhage, and admitted to the hospital.Patient A was a 50 year old female who was admitted to the facility on 1/21/11 with diagnoses including muscle weakness, acute respiratory failure, chronic airway obstruction, congestive heart failure, coronary artery disease, chronic kidney disease, diabetes, anemia, high blood pressure, and neuropathy (nerve damage with symptoms that include pain, burning, tingling, loss of sensation, or loss of sensation). The patient's comprehensive assessment dated 10/05/11, noted that Patient A was alert and oriented, capable of making decisions regarding her care, and able to communicate her needs. The patient had bilateral above the knee amputations, was continent, was able to eat independently, and required limited assistance to transfer between her bed and wheelchair, and to bathe, dress and use the toilet. The patient used a wheelchair for mobility, was able to schedule her own appointments and used public transportation for community access.Patient A had a history of chronic pain and was on a pain management program. Physician orders for December 2011 included an order for MS Contin (a long acting narcotic pain medication) two times a day for chronic pain, and Vicodin 7.5/750 mg (a narcotic pain medication) every 4 hours prn (if needed) for chronic pain. The orders included instructions to hold (not administer) MS Contin if the patient was sedated, and instructions that Patient A was not to receive more than 4 tablets of Vicodin in 24 hours.In an interview on 1/24/12, Patient A's sister indicated that she went to see Patient A on 12/14/11, and the patient was mumbling and seemed overmedicated. She saw the patient again on 12/15/11, and the patient was speaking, but was very disoriented. She also indicated that Patient A asked to use the bathroom, was very unsteady, it took her a long time to get up, and she had to call for help. Patient A's sister stated she was concerned about the change in Patient A's condition, spoke to the Social Service Designee (SSD) and asked about her sister's medications. The SSD told her, however, that she could not discuss the patient's medications with her.The patient's record was reviewed and a note by the SSD on 12/14/11, verified that Patient A's sisters came to her office , were concerned about the patient's medications and asked what she was taking. The note also indicated that the sisters said they had been calling the patient but she did not answer her phone, and they did not like seeing her like this. A late entry by nursing at 10:30 pm on 12/14/11, also noted that Patient A's sisters had stopped by the SSD's office and said they were concerned the patient was taking too many medications. Despite the concern regarding Patient A's condition reported by her sisters, no assessment of the patient was documented by nursing. On 12/15/11 between 8 am and 1:30 pm, nursing documented that Patient A was in bed, had no complaints of pain or discomfort and was sleeping soundly. Nursing notes indicated the patient did not take her breakfast and lunch meals stating "not now", and refused her medications, stating, "Not now, I still want to sleep." Nursing also noted that Patient A was found by a certified nursing assistant (CNA) sitting on the commode, but mostly leaning on the right side. The nurse indicated Patient A was repositioned, was put back to bed, and was still drowsy. There were no nursing progress notes documented on 12/16/11. Patient A's medication administration record and her meal intake record were reviewed, however, and noted that Patient A did not receive any of her medications on 12/16/11 and refused all three meals. On 12/17/11 at 7:30 am, nursing documented that Patient A was awake, in bed; had no complaints of pain or discomfort, and her respirations were even and unlabored. At 8 am, the nurse noted that Patient A refused breakfast, and at 8:30 am, that Patient A refused breakfast and said she was not ready to take her medications. At 9:30 am, Patient A's vital signs and oxygen saturation were taken, were within normal range, and the nurse noted that Patient A had no complaints of pain or discomfort, and was not short of breath or congested. The nurse indicated that Patient A was asked again if she was ready for her medication, said "not yet," and closed her eyes.At 11:30 am on 12/17/11, nursing noted that Patient A refused to have her blood sugar checked, and did not answer when she was asked to get up for a shower. Between 12:30 pm and 1:15 pm, nursing noted a change in Patient A' level of consciousness and documented that she was barely talking, but able to respond to simple questions.The patient's vital signs, blood sugar and oxygen saturation were taken, and she was given some orange juice. At 1:25 pm nursing documented that the patient's physician was notified, new orders were received, and at 1:50 pm, Patient A transported to emergency room by ambulance for further evaluation.The hospital Emergency Room Report dated 12/17/11, noted Patient A's chief complaint as altered level of consciousness. The physician documented that Patient A had multiple medical problems, appeared very confused, was slow to respond, and did not know why she was in the emergency department. The physician examined the patient, her vital signs and oxygen saturation were normal, and the physician documented that Patient A was awake, alert, appeared in no acute distress, answered questions slowly, and followed commands appropriately. The physician also noted, however, that he had personally seen Patient A in the emergency room before, and there was a definite change in her normal level of consciousness.Laboratory and diagnostic studies were performed in the emergency room. The patient's urinalysis was positive for a urinary tract infection, and a computerized axial tomography (CT) scan of the patient's head, revealed a small subarachnoid hemorrhage (bleeding in the area between the brain and the tissues that cover the brain),described by the radiologist as an atraumatic hemorrhage. The scan was evaluated by a neurosurgeon, it was determined no acute intervention was needed, and Patient A was admitted to the hospital with diagnoses including urinary tract infection and subarachnoid hemorrhage. Patient A's record, including her medication administration records and daily flow sheets were reviewed, and revealed that from 12/1/11 through 12/13/11, Patient A routinely received MS Contin twice a day, as ordered, for chronic pain, and also received from 1 to 4 doses of Vicodin daily. During this time period Patient A refused 10 of the 39 meals offered and usually ate 80-100% at breakfast, 50-80% at lunch, and 100% at dinner. Between 12/14/11 and 12/17/11, however, Patient A refused 9 of 11 meals, received only one dose of Vicodin on 12/14/11 at 10 pm, and nursing held all scheduled doses of the MS Contin Patient A routinely took for chronic pain, because she was sedated and/or sleeping soundly. On 12/14/11, Patient A refused her 9 am medications; on 12/15/11 she refused her 9 am, 1 pm and 2 pm medications, and on 12/16 and 12/17/11 she refused all medications.The facility violated the above regulations by failing to assess Patient A and promptly notify her physician, when Patient A exhibited a change in her mental status and adverse changes including increased somnolence and refusing meals and medications. Adverse changes in Patient A's condition were reported by her family and documented by nursing as early as 12/14/11, however, Patient A was not assessed, her physician was not notified , and she did not receive medical attention until the afternoon of 12/17/11, when she was transferred to the emergency room and admitted to the hospital. 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. |
| 120001505 |
MORGAN'S TLC - LINDLEY |
120011920 |
B |
06-Jan-16 |
938N11 |
2843 |
Welfare and Institution Code 4502 (b)(8)- A right to be free from harm, including unnecessary physical, restraint, or isolation, excessive medication, abuse, or neglect. On 12/10/15, at 11:40 AM, an unannounced visit was made to the facility to investigate an entity reported incident of alleged employee to client verbal abuse. Based on interview and record review, the facility failed to ensure Client 1 was treated with respect and not subject to verbal abuse. This had the potential to cause emotional trauma. Client 1 is a 32 year old male with a diagnosis of Profound Mental Retardation due to head trauma incurred during a motor vehicle accident and seizure disorder.During a review of the clinical record for Client 1, the "SEMI-ANNUAL PROGRESS REVIEW" dated 9/21/15, indicated under Behavior: "...Golfer's type glove would be utilized to keep his skin intact as he will not stop the behavior of rubbing his skin." During an interview with the Qualified Individual Intellectual Disability Professional (QIIDP), on 12/10/15, at 12:30 PM, she stated Client 1 is non-verbal and has episodes of moaning. On 11/22/15, at approximately 6 AM, while Direct Care Assistant (DCA) 2 was in the dining room, she heard DCA 1 screaming at Client 1 in the bathroom while DCA 1 was giving Client 1 a shower. DCA 1 told the client "Stop moaning, shut up."During an interview with DCA 2, on 12/14/15, at 8:43 AM, she stated at approximately 6 AM, she was in the dining room, when she heard DCA 1 screaming at Client 1 in the bathroom. DCA 1 was in the shower room with Client 1 for approximately fifteen to twenty minutes and during this time DCA 1 was screaming at Client 1 telling him to "Shut up, stop moaning, I don't want to hear you moaning, I hate you when you're moaning." She also stated after DCA 1 gave the client a shower and after dressing him, DCA 1 pushed the client's wheelchair to the dining room. However, DCA 1 was still screaming at Client 1. DCA 2 also stated DCA 1 attempted to apply the golfer's gloves on the client's hands, but DCA 1 had a difficult time placing the golfer's gloves on the client's hand. Since DCA 1 was still screaming at the client, DCA 2 told DCA 1 to just sit and relax and she would do it. DCA 2 also stated she talked to Client 1 in Spanish because the client appeared so "sad."The undated facility policy and procedure titled "CLIENT ABUSE AND NEGLECT" indicated under "I. GENERAL: The intermediate care facilities in our group prohibit both client abuse and neglect, whether perpetrated by staff, volunteers, family members, friends, other clients, associates of outside agencies, or the general public."Therefore, the facility failed to protect Client 1 from verbal abuse and has a direct or immediate relationship to the patient's health, safety, and security. This violation is a class "B" violation. |
| 120001505 |
MORGAN'S TLC - LINDLEY |
120011921 |
B |
06-Jan-16 |
938N11 |
3089 |
Health and Safety Code 1418.91 (a) - A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. Health and Safety Code 1418.91 (b) - A failure to comply with the requirements of this section shall be a class "B" violation. On 12/10/15, at 11:40 AM, an unannounced visit was made to the facility to investigate an entity reported incident of alleged employee to client verbal abuse. Based on interview and record review, the facility failed to report an allegation of employee to client verbal abuse within the required time frame. During a review of the clinical record for Client 1, diagnoses include Profound Mental Retardation due to head trauma incurred during a motor vehicle accident and seizure disorder. The "SEMI-ANNUAL PROGRESS REVIEW" dated 9/21/15, indicated under Behavior: "...Golfer's type glove would be utilized to keep his skin intact as he will not stop the behavior of rubbing his skin." During an interview with the Qualified Individual Intellectual Disability Professional (QIIDP), on 12/10/15, at 12:30 PM, she stated Client 1 is non-verbal and had episodes of moaning. On 11/22/15, at approximately 6 AM, while Direct Care Assistant (DCA) 2 was in the Dining room, she heard DCA 1 screaming at Client 1 in the bathroom while DCA 1 was giving Client 1 a shower. DCA 1 told the client "Stop moaning, shut up."During an interview with DCA 2, on 12/14/15, at 8:43 AM, she stated at approximately 6 AM, she was in the Dining room, when she heard DCA 1 screaming at Client 1 in the bathroom. DCA 1 was in the shower room with Client 1for approximately fifteen to twenty minutes (15-20) and all this time DCA 1 was screaming at Client 1 telling him to "Shut up, stop moaning, I don't want to hear you moaning, I hate you when you're moaning." She also stated after DCA 1 gave the client a shower and after dressing him, DCA 1 pushed the client's wheelchair in the Dining room. However, DCA 1 was still screaming at Client 1. DCA 2 also stated, DCA 1 attempted to provide the client his golfer's gloves, but DCA 1 had a difficult time placing the golfer's gloves on the client's hand.Since DCA 1 was still screaming at the client, DCA 2 told DCA 1 to just sit and relax and she would do it. DCA 2 also stated she talked to Client 1 in Spanish because the client appeared so "sad." The undated facility policy and procedure titled "CLIENT ABUSE AND NEGLECT" indicated under "V. REPORTING: All employees, visitors, and volunteers are required to report abuse of any kind detailed above, real or suspected...D. For all clients a report shall be telephoned within 24 hours to: Department of Public Health..." Therefore, the facility failed to notify the department timely of an allegation of employee to client verbal abuse.In accordance with Health and Safety Code 1418.91 (b), this violation is a class "B" violation. This violation caused or occurred under circumstances likely to have a direct relationship to the health, safety or security of the client. |
| 120001495 |
MORGAN'S TLC - MEMORY |
120011939 |
A |
29-Feb-16 |
NKD611 |
3780 |
Welfare and Institution Code 4502 (b)(8) - A right to be free from harm, including unnecessary physical, restraint, or isolation, excessive medication, abuse, or neglect. On 12/23/15, at 9:04 AM, an unannounced visit was made to the facility to investigate an entity reported incident of alleged employee to client sexual abuse. Based on interview and record review, the facility failed to ensure Client 1 was treated with respect and not subject to sexual abuse. This had the potential to cause emotional and physical trauma. Client 1 is a 25 year old female, who was admitted to the facility on 11/12/14, with diagnoses of Cerebral Palsy (a congenital disorder of movement, muscle tone, or posture) and Depression (a mood disorder causing a persistent feeling of sadness and loss of interest). During a review of the clinical record for Client 1, the "Annual ISP (Individual Service Plan) and QMRP (Qualified Mental Retardation Professional) Progress Review" dated 7/15, indicated under Behavioral Response: "...She gives good eye contact when speaking to others and she really enjoys interaction..." Indicated under Rights: "Client utilizes a motorized wheelchair with a seatbelt for translocation. She is able to operate the wheelchair herself to get where she wants to go. She is offered choices and will verbally indicate her wants and needs, likes and dislikes." During an interview with Direct Care Staff (DCS) 1, on 12/23/15, at 9:12 AM, she stated on 12/22/15, at approximately 8 AM, DCS 2 was observed sitting on the couch in the living room while Client 1 was sitting in her motorized wheelchair in the dining area finishing her breakfast. DCS 1 went upstairs for about two minutes. When DCS 1 came downstairs, she saw DCS 2 sitting on Client 1's lap in her motorized wheelchair with DCS 2's legs straddling Client 1. DCS 2 was kissing the client's neck and hugging her. The client's head was titled backward. DCS 1 stated she heard the kissing and stated, "He (DCS 2) was on top of her (Client 1)." DCS 1 immediately asked DCS 2, "What are you doing?" DCS 2 suddenly jumped off Client 1 and stepped away. The client looked like she was in shock. DCS 1 immediately called her House Manager (HM) and informed her of the incident. During an interview with the Qualified Individual Intellectual Disability Professional (QIIDP), on 12/23/15, at 10:10 AM, she stated when she asked Client 1 what happened, Client 1 showed the QIIDP how DCS 2 exposed her left breast and touched her. DCS 2 sat on the client's lap; his legs were on each side of the client's wheelchair, so the client could not move. The client was telling DCS 2 to get off her. During an interview with the HM, on 12/23/15, at 10:20 AM, she stated she immediately went to the facility and when she arrived, she talked to DCS 2. DCS 2 told the HM, he had a problem, he was sick and he could not control himself. HM also stated DCS 2 admitted the sexual abuse incident and stated "Yes, I did it."The undated facility policy and procedures titled "CLIENT ABUSE AND NEGLECT" indicated under I. GENERAL: Steele's Quality Living facilities prohibit both client abuse and neglect, whether perpetrated by staff, volunteers, family members, friends, other clients, associates of outside agencies, or the general public. II. DEFINITIONS: "...C. Sexual Abuse: Sexual abuse is defined as acts of sexual assault on and/or sexual exploitation of an individual. Sexual assault includes rape, rape in concert, incest, sodomy, lewd or lascivious acts, fondling, oral copulation, penetration of a genital or anal opening by a foreign object and molestation..." These violations presented either imminent danger that serious harm would result or a substantial probability that serious emotional and physical harm would result. |
| 120001495 |
MORGAN'S TLC - MEMORY |
120011996 |
A |
29-Feb-16 |
Y1EA11 |
11598 |
W 127 The facility must ensure the rights of all clients. Therefore, the facility must ensure that clients are not subjected to physical, verbal, sexual or psychological abuse or punishment.Based on interview and record review, the facility failed to have a mechanism in place for client protection to prevent unauthorized removal of one of four sampled clients (1) from the day program. This resulted in: 1. Client 1 being allowed to go with an unknown, unauthorized person, from 12/24/15 to 12/26/15, from the day program. The unknown, unauthorized person was not asked to provide proper identification when picking up the client from the day program. This resulted in the facility being unaware of the location of Client 1.2. Client 1 not receiving any of his medications including antidiabetic medication for two days which resulted in Client 1 being sent to the clinic for an elevated blood sugar level of 442 milligrams per deciliter (mg/dl) (acceptable blood sugar levels are less than 100 mg/dl after not eating for at least 8 hours and less than 140 mg/dl two hours after eating). According to the Mayo Clinic if high blood sugar (hyperglycemia) levels go untreated it can result in ketoacidosis (buildup of ketones [toxic acids] in the blood and urine) signs and symptoms of such a condition includes: nausea, vomiting, shortness of breath, weakness, confusion, abdominal pain, and coma. These failures had the potential for an immediate threat to all the clients residing in the facility.Findings: Client 1 is a 30 year old deaf male who is intellectually disabled (brain does not function within the normal range) and who has episodes of confusion. He is nonverbal and communicates with gestures and signs. His diagnoses include Diabetes (a group of diseases which affects how your body uses blood sugars resulting in elevated blood sugar levels) with erratic blood sugars and a special diet to help in controlling the blood sugar levels. He also is diagnosed with Peripheral Vascular Disease ([PVD] is a common circulatory problem in which narrowed arteries reduce blood flow to the limbs) and Cerebral Palsy (disorders that affect body movement and coordination). He does require minimal assistance with his activities of daily living (ADLs) and ambulates with a walker. 1. During a review of the facility's "SPECIAL INCIDENT REPORT" dated 12/27/15, the report indicated, "Description of the Incident: On December 24, 2015 at approximately (4 PM), (Client 1) had not yet arrived home from the...day program...Facility staff called the day program and there was no answer...Program Manager (PM) went to the...day program to find it closed...police department contacted (day program supervisor) who said the client was picked up by a relative from the (day program) at the time of release. No further information regarding the relative's name or how the relative was related to the client. No contact information for the client's family was current at the facility...During a review of the clinical record for Client 1, the "Shift Notes" dated 12/24/15 at 5 PM to 5:45 PM, indicated in part "...Client (1) had not arrived home from the (day program)...The police department got a hold of the supervisor of (day program)...". The "Shift Notes" dated 12/24/15, at 6 PM to 6:30 PM, indicated in part "...The Police Department got a hold of the supervisor of (day program). The officer reported...the staff at (day program) let (Client 1) leave with...a man, woman, and a younger boy...". The "Shift Notes" dated 12/24/15 at 7 PM, indicated "...the officer from the (police department)... relayed the message that (day program) staff let (Client 1) leave with what they believed to be family members...". The "Shift Notes" dated 12/24/15, at 7 PM to 10 PM, indicated in part "...facility (staff) went to restaurants in the...area to see if we could find (Client 1)...(case worker from the regional office) went to restaurants, hotels to see if she could find him...(facility staff) that worked the AM shift this morning...said, a woman, man and a young boy (Spanish speaking) came by to see (Client 1 at the facility)...Staff told them he was at the workshop (day program). They took the phone number, the person on the phone said they just (wanted) to see him (Client 1). They didn't say anything about taking (Client 1) to (their) home..." The "Shift Notes" dated 12/26/15, at 8 AM, indicated "Call to check if staff heard anything about (Client 1). They reported that they have not heard anything..." The "Shift Notes" dated 12/26/15, at 11 AM to 11:30 AM, indicated "...I was on the phone with staff...to check if they had heard anything about (Client 1)...as we were (talking), staff...said...(Client 1) is here. They are outside right now..." The "Unusual Incident/Injury Report" from the day program dated 12/24/15, indicated "...On 12/24/15, at approximately 2:30 PM, (Client 1) was picked up from the (day program)...In the car were: a man, a woman and two children...I tried calling the telephone numbers in the file for the family, but none of the numbers worked..."The "Functional Assessment" dated 9/14, indicated Client 1 had episodes of confusion associated with erratic (unpredictable) blood sugar levels, had limited safety awareness, required a special diet for Diabetes and required blood sugar levels to be monitored. The "Mental Status" indicated Client 1 had intellectual disability (a brain does not function within the normal range). During an interview with the Day Program Supervisor (DPS), on 12/30/15, at 12:20 PM, DPS stated, an unidentified Spanish speaking individual called the day program on 12/24/15, and spoke to a Spanish speaking staff at the day program. The unidentified Spanish speaking individual asked for directions to get to the day program to see Client 1. DPS stated she was not aware who gave the telephone number of the day program to the unidentified Spanish speaking individuals who picked up Client 1 from the day program. She stated when the unidentified individuals came to the day program on 12/24/15, they picked up Client 1. She was asked if the day program staff recognized the individuals who picked up the client from the day program and if the day program staff had asked for any information to identify the unidentified individuals. DPS stated the day program staff stated they never saw these unidentified Spanish speaking individuals before and they did not ask for any information nor identification from the unidentified individuals. DPS was asked if they had a policy and procedure in place for picking up clients from the day program. She stated, "...We should have called the home and not assumed. We don't have a policy specifically with this situation." During an interview with the QIIDP, on 12/30/15, at 2:15 PM, she was asked about the facility contact information for Client 1. QIIDP stated, the person listed as the contact person, the telephone number is disconnected. She stated the facility did not have any updated information for any family contact. QIIDP added "Family didn't come (to see Client 1) for a long time. They had not been here and had not called in the last two years."During an interview with Direct Care Assistant (DCA), on 12/20/15, at 2:30 PM, she was asked about the incident on 12/24/15, when Client 1 went missing. DCA stated an unidentified woman told her she was the aunt. She stated, "I was not able to obtain her name and the unidentified woman's phone number...They asked for the (day program's) phone number...This is the first time I saw this family." She was asked if the facility had a policy and procedure in place for providing client information to persons. She stated, "We did not have a policy in place at that time for staff to ask family and give (their) identification." During an interview with the QIIDP, on 12/30/15, at 4:20 PM, she was asked about the mental status and communication skills of Client 1. She stated, "He (Client 1) smiles to everybody and he will go with anybody he did not see before...He uses sign language...can't demonstrate mastery of sign language to be able to communicate...He's deaf..." During an interview with the QIIDP and the Program Manager (PM), on 12/30/15, at 2 PM, they were asked for their policy and procedure for "Missing Person" and "Unusual Incidents". The QIIDP and the PM were unable to provide policies and procedures for the "Missing Person" and "Unusual Incidents" to direct staff on their duties when such a situation occurred.2. During a review of the clinical record for Client 1, "Special Incident Report" dated 12/27/15, indicated in part "...On December 26, 2015 at approximately 11:30 AM, Client 1 was returned to the facility by his aunt (unknown individual not listed in Client 1's contact information)...When the facility staff checked the client's blood sugar, it was 442 (normal blood sugar level-100 mg/dl[milligrams/deciliter]). Client 1 had not been administered any of his medications, including medication for diabetes, since the morning of 12/24/15 at the facility, before going to the day program..." The document "(Facility) Medication and Treatment Record" dated 12/15 indicated "...Check Blood Glucose (as needed) if not feeling well...". The blood sugar on 12/26/15 at 12 Noon indicated "...Fingerstick (as needed secondary) to shaking (blood sugar) 442 mg/dl." During a review of the clinical record, the "(Facility) Medication and Treatment Record" dated 12/15 indicated the following medications were not given on the following dates and time: 1. Metformin (medication for diabetes) 1000 mg (milligram) one tablet twice a day - 12/24/15 at 8 PM, on 12/25/15 at 6 AM and 8 PM. 2. Onglyza 2.5 (medication for diabetes) mg one tablet twice a day for diabetes - 12/24/15 at 8 PM, on 12/25/15 at 6 AM and 8 PM. 3. Nitroglycerin paste (used to treat peripheral vascular disease [a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs]) 1/4 inch on each foot twice daily - 12/24/15, at 6 AM and 8 PM. 4. Atarax (for itching) 10 mg one tablet twice daily - 12/24/15 at 8 PM, on 12/25/15 at 6 AM and 8 PM. 5. Aspirin (medication to prevent clotting of blood) 325 mg one tablet at bedtime - 12/24/15 at 8 PM, and on 12/25/15 at 8 PM. 6. Coumadin (blood thinner to treat and prevent blood clots) 10 mg one tablet at bedtime - 12/24/15 at 8 PM and 12/25/15 at 8 PM. 7. Keppra (used to treat involuntary movements of the tongue, lips, face, trunk, and extremities) 500 mg one tablet twice a day - 12/24/15 at 8 PM, 12/25/15 at 6 AM and 8 PM. 8. Benadryl (used to treat symptoms of allergy and for involuntary movements) 25 mg one capsule three times a day - 12/24/15 at 4 PM, and 8 PM, 12/25/15 at 6 AM, 4 PM and 8 PM.During a review of the clinical record for Client 1, the "Nursing Notes" dated 12/26/15, at 11:30 AM, the notes indicated, "...Was on home visit and family did not give (medications) while he was at home..." During an interview with the QIIDP, on 12/30/15, at 3 PM, she stated, Client 1 was sent to the clinic for an elevated blood sugar of 442 mg/dl on 12/26/15, when Client 1 was brought back to the facility.During a review of the clinical record for Client, the clinic record dated 12/26/15, indicated "...Reason for visit...Regarding (medication)...Patient was with family (unidentified individual not listed in Client 1's contact information) away from group home without his (medication) for 2 days...Today's Diagnoses Include...Type 2 diabetes mellitus..." The above violation presented a substantial probability of death or physical harm to the patient. |
| 220001016 |
MOUNTAIN VIEW HEALTHCARE CENTER |
220009846 |
B |
23-Apr-13 |
PLEY11 |
7708 |
F 333 -- 483.25(m)(2) RESIDENTS FREE OF SIGNIFICANT MED ERRORS The facility must ensure that residents are free of any significant medication errors. This regulation was not met as evidenced by Based on interview and record review, the facility failed to ensure medication was administered as prescribed for one (Resident A) of one sampled resident. For Resident A, an excessive amount of diabetic medication (insulin) were received, resulting in a clinically evident overdose of the diabetic medications, and Resident A was transferred to a hospital emergency department service.Findings: Resident A was admitted on 01/11/12 with diagnoses including diabetes and diabetic kidney and eye problems. The 01/23/12 Minimum Data Set (MDS, a resident assessment) indicated Resident A was able to understand others and to express his ideas and needs; Resident A needed extensive assistance for transfer from a bed to a chair, dressing, toilet use, and bathing; Resident A used a walker with total dependence of the staff assistance or a wheelchair for mobility. On 03/15/12 at 7:10 a.m., Resident A received a clinically evident overdose of diabetic medications [Insulin NPH (Novolin N) and Insulin Aspart (Novolog)]. Nurse A had administered 100 units (u) of a diabetic medication [Insulin NPH] instead of 14 units. Nurse A also administered 100 units of another diabetic medication [Insulin Aspart] instead of six (6) units. Resident A was treated with orange juice (OJ) and one milligram (1 mg) injection of a sugar substance [glucagon] intramuscularly (IM, into the muscle) to raise blood sugars. Resident A was then sent to an acute care hospital emergency department (ED) and then later transferred to the hospital intensive care unit (ICU) for another day.During an interview on 03/07/13 at 12:08 p.m., Nurse A stated she had administered 100 units of a diabetic medication [Insulin Aspart] instead of six units; and 100 units of another diabetic medication [Insulin NPH] instead of 14 units. Nurse A also stated that she had confused the concentration (100 u/ml (milliliter) with the dose. She said that it was the first week she had worked by herself and she had two weeks training after taking over a year off. During an interview on 03/07/13 at 1:00 p.m., Director of Nursing (DON) stated she had no documentation on a policy and procedures (P&P) for administration of the diabetic medication (insulin) and/or training and evaluation of the staff member's ability to administer the diabetic medication.Record review of Resident A's physician's orders, dated 01/11/12, indicated, "Insulin Aspart (Novolog) 100 unit/ml, inject 6 units SC [subcutaneously, beneath the skin] two times a day before meals; and Insulin NPH (Novolin N) 100 units/ml inject 14 units subcutaneously twice daily in the morning and at bedtime (HS)." Record review of Resident A's Medication Administration Record (MAR) for March, 2012, indicated Resident A received the diabetic medication [Insulin Aspart and Insulin NPH]. The MAR indicated that Resident A was to receive diabetic medication [Insulin Aspart] 100 unit/ml inject six units subcutaneously twice daily before meals; and a second diabetic medication [Insulin NPH] 100 units/ml inject 14 units subcutaneously every morning. The MAR also indicated that they [Insulin Aspart and Insulin NPH] were to be given at 6:00 a.m. The MAR did not document Resident A received 100 units of the diabetic medication [Insulin Aspart] and 100 units of the second diabetic medication [Insulin NPH] on 3/15/12. Review of Resident A's Nurses Progress Notes, dated 03/15/12 at 9:50 a.m., Nurse A documented, "I gave patient 100 units of Novolin N 100 u/ml instead of 14 units and 100 units of Aspart 100 u/ml instead of 6 units at 7:10 a.m. Patient given 2 cups of OJ (orange juice) blood glucose at 7:30 a.m. was 106 (Reference value was 70-110 mg/dL (deciliter or 100 ml). Given 1 cup OJ with sugar. Blood glucose at 7:55 a.m. was 82. Given 1 cup OJ with sugar. Blood glucose at 8:30 a.m. was 101. Given 1 cup of sugar. Blood glucose at 9 a.m. was 101. Blood glucose at 9:30 a.m. was 112. Pt Alert, verbally responsive, says he feels wheezy from drinking so much OJ ...will continue to monitor patient." Review of Resident A's nurses progress notes, dated 03/15/12 at 11:00 a.m., indicated, "Ambulance came and transported resident to Kaiser hospital at Santa Clara, via gurney accompanied by staff member, at 10:19 a.m. IM Glucotrol given to pt as ordered to L (left) upper arm ...says he feels "wheezy" from drinking orange juice ..." Review of Resident A's telephone contact summary (documented calls to physician or nurse practitioner [NP]), dated 03/15/12 at 10:24 a.m., indicated, "Please call...ED to arrange for Transfer ...Reason for Transfer: Was to get Novolin N 14 units and Asparte 6 units-was given 100 units of each-FS (finger stick) at 10:00 am 90 ...SNF (skilled nursing facility) nurse ...will monitor closely till ambulance arrives...03/15/12 10:09 AM ...Spoke with NP and patient also to be given 1 mg of glucagon IM stat (immediately) and will send patient in to the hospital for frequent monitoring of blood sugars ...03/15/12 at 9:41 AM ...SNF nurse ...states pt should get Novolin N 14 units and Asparte 6 units-she gave 100 units of each ...NP give 3 glasses of OJ with sugar now-then 1 glass with sugar q (every) 1 hr x 4 hrs-give pt hard candy ...Call 911 with acute changes." Review of Lexicomponline.com:(; copyright (c ) Lexi-Comp, inc. 2013) information for insulin indicated concerns for adverse effects included: Hypoglycemia (low blood sugar): The most common adverse effect of insulin is hypoglycemia. The timing of hypoglycemia differs among various insulin formulations. Hypoglycemia may result from increased work or exercise without eating ...Profound and prolonged episodes of hypoglycemia (adverse effects of low blood sugar) may result in convulsions, unconsciousness, temporary or permanent brain damage, or even death. ..The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.Review of Resident A's hospital history and physical note in the emergency department (ED), dated 03/15/12 at 12:03 p.m., indicated, "Accidentally getting 100 units of NPH and 100 units of regular insulin at ...SNF ...insulin overdose, accidental/major ...FSG (finger stick glucose) 60s (low blood sugar)...discharge diagnosis: insulin overdose." Review of Resident A's hospital history and physical note in ICU, dated 03/15/12 at 2:00 p.m., indicated, "Accidentally given 100 u of insulin NPH ...blood sugar checks are around 48-66 at this time in the ED. One Mg (milligram) glucagon given at SNF ...monitor FSBG (finger stick blood glucose) every hour, continue at D10gtt (10% dextrose drip, a sugar liquid) at 75/hr. If consistently BS (blood sugar) over 150 start Aspart sliding scale. Expect NPH to act for at least 18 hours." Review of Resident A's hospital critical lab values on 03/15/12 and 03/16/13 indicated the following: On 03/15/13 at 2:30 p.m., FS=63 (low blood sugar); at 5:00 p.m., FS=49 (low blood sugar); at 5:21 p.m., FS=112 (excessive blood sugar); on 03/16/13 at 11:47 a.m., FS=409 (excessive blood sugar). Review of Resident A's hospital discharge summary, dated 03/23/12 at 9:47 a.m., indicated "Date of admission..03/15/12 ...Date of discharge 03/23/12 ...Hospital course and significant findings...was given per report 100 units of NPH & 100 Aspart at SNF and found to have sugars 40-60s (low blood sugar)."The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 220000087 |
Millbrae Skilled Care |
220012396 |
B |
15-Jul-16 |
VTZT11 |
8022 |
F205 483.12(b)(1)&(2) NOTICE OF BED-HOLD POLICY BEFORE/UPON TRANSFER Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility, and the nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section. This Requirement is not met as evidenced by: Based on interview and record review the facility failed to implement its policy and procedure for one sample resident, Resident 1, when: 1. The facility failed to provide Resident 1 and her family member, written information of its bedhold policy that specified the duration of the bedhold period when the resident was transferred to the general acute care hospital on 4/14/16. 2. The facility refused to readmit Resident 1 during the bedhold period when she was discharged from the general acute care hospital on 4/14/16. These failures presented potential harm from undue stress when Resident 1 had the potential to lose her right to return to the facility and be displaced from her residence for over ten years. Findings: Resident 1 was admitted on 11/09/09 with diagnoses including hypothyroidism, anxiety disorder and major depressive disorder. Review of the Minimum Data Set (MDS, an assessment tool) dated 3/06/16 showed Resident 1 had a Brief Interview of Mental Status (BIMS) score of 13, indicating she was cognitvely intact. BIMS is a brief screener that aids in detecting cogntive impairment. Review of the Interdisciplinary Team (IDT) notes dated 4/14/16 at 1:30 p.m. indicated Resident 1 "...Verbalized to CNA she wants to kill herself... she claimed she will hurt herself with a small scissor... MD ordered to transfer the resident to the ER (Emergency Room) for evaluation...". During record review the IDT meeting notes dated 4/14/16 and 4/19/16 did not contain documentation that a bedhold notice was given to Resident 1 and her daughter prior to transfer to the acute care hospital. During an interview on 4/20/16 at 9:00 a.m., Resident Care Coordinator stated Resident 1 and her daughter were not given a bedhold notice when Resident 1 was transferred to the acute care hospital emergency room on 4/14/16. During a telephone interview on 4/21/16 at 8:20 a.m., Resident 1's daughter stated she did not receive a bedhold letter for the resident's transfer to the General Acute Care Hospital emergency room on 4/14/16. Review of an undated and unsigned Discharge of Resident to Acute Hospital policy and procedure indicated, "Procedures: #11. After discharge to the acute hospital, licensed nurse shall document in the resident's clinical record the following information: .... Notification of resident or responsible party of right to request for any bedhold". Review of the California Code of Regulations Section 72520, Bedhold, indicated, "(a) If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the nursing facility shall afford the patient a bedhold of seven days, which may be exercised by the patient or the patient's representative". 2. Review of the Emergency Room (ER) Summary signed and dated by Medical Doctor (MD)1 on 4/14/16 at 11:25 a.m. indicated, "... Per caregivers they are concerned that patient is suicidal. Patient denies this, states she is fine... Patient with a history of dementia denies cutting herself. Per facility they cannot take her back due to danger to self.... Disposition: Home (1:43 p.m.). Disposition: Admit to 2 AB (2:06 p.m.) Disposition Type: Inpatient. Condition: Stable..." Review of the acute care facility's Psychiatric consultation notes by MD 1 dated 04/14/16 at 2:54 p.m. indicated, "Recommendations: At this time, the patient would not meet criteria for hospitalization in the psychiatric unit, and in fact, this would be detrimental. I spoke with Administrator by phone and informed them the patient was reevaluated for the second time and was determined to lack the capacity to hurt herself or others. If not given the instrument she cannot hurt herself. She needs to return to her home for 7 years (the SNF). However, Administrator stated they cannot care for the resident because she now requires a higher level of care they cannot provide, and the family gives her (patient) stuff to hurt herself. Administrator was adamant about not readmitting the patient". Review of the ER summary documentation dated 04/14/16 at 3:11 p.m. indicated, "Patient endorsed to me by MD 8. Will admit to medicine...". Review of the ER Summary documentation dated 04/14/16 at 3:13 p.m. indicated, Resident 1 was admitted with the following diagnoses: Primary diagnosis: cellulitis unspecified; Additional diagnoses: dementia, hypertension, r/o (rule out) suicidal intent, SOCIAL ADMIT". During interview on 6/30/16 at 2:00 p.m. Social Worker (SW) stated, "Social admit means the person is not acutely ill but is admitted for social placement because she does not have a place to go". Review of the acute care hospital History and Physical dated 04/14/16 at 17:32 p.m. by MD 1, indicated, "The patient is mainly being admitted for social placement since the social worker was not able to get her to an assisted living or nursing home while in the ER (emergency room)". Review of MD 3's Psychiatric Consultation documentation dated 4/15/16 at 14:35 p.m. indicated, "There is no need for the patient to be placed on hold at this time. She has been cooperative with her care and is willing to take medications, and again, I think her ability to do any harm to herself is minimal, if nonexistent". Review of MD 4's Hospitalist Progress Notes dated 4/19/16 at 10:50 a.m. indicated, "Demented female presents due to suicidal ideation. Medically and psychiatrically cleared. Waiting for placement. Her facility of 14 years refused to take her back for unjustified reasons". During interview on 4/20/16 at 9:20 a.m., the facility Director of Nursing (DON) stated, "Per our assessment the resident was suicidal. Per the facility assessment, she is not fit in this environment because she has the potential to attempt suicide again". During interview on 4/21/16 at 8:30 a.m., County Ombudsman stated, "I saw the resident at the hospital. All she said was she wanted to go back to her room". Review of MD 4's Hospitalist Progress Notes documentation dated 4/21/16 at 2:32 p.m. and on 4/22/16 at 1:03 p.m. indicated, "...Medically and psychiatrically cleared. Waiting for placement. Her facility of 14 years refused to take her back for unjustified reasons...". Review of MD 6's Hospitalist Progress Notes dated 4/25/16 at 5:45 p.m. and on 4/26/16 at 10:21 a.m. indicated, "... Medically and psychiatrically cleared but awaiting placement. Her facility of 14 years refused to take her back". Review of the readmission appeal decision from the Department of Health Care Services Office of Administrative Hearings and Appeal dated April 25, 2016, indicated that a hearing convened on 4/22/16 at the General Acute Care Hospital. The subsequent Summary of Findings indicated, "Facility failed to substantially comply with the bed-hold and readmission requirements of 22 C.C.R. Section 72520 and 42 CFR Section 483.12 (b) as follows: - Failed to issue a written bed-hold notice; - Failed to readmit Resident during the bed-hold period; and - Failed to readmit Resident to the first available bed following the bed-hold period." |
| 230000389 |
Modoc Medical Center D/P SNF |
230008708 |
A |
19-Jun-12 |
F0NN11 |
11582 |
A 169 T22 DIV5 CH3 ART3-72311(a)(3)(B) Nursing Services--General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. The following citation was written as a result of an unannounced visit to the facility on 03/30/11 for the investigation of complaint #CA00262413. The Department determined that the facility failed to promptly notify the attending physician when Patient 1 developed complications while receiving Coumadin (a blood-thinning medication, used for preventing blood clots). Excessive thinning of the blood can lead to major bleeding. Nursing service did not inform the physician when Patient 1 first vomited bloody fluid (a potential indication that there was too much thinning of the patient's blood), or when Patient 1's blood pressure dramatically dropped, she was less responsive and eventually became unconscious. These failures resulted in a delay of care and treatment for Patient 1. She was eventually transferred to an acute care hospital on 3/6/11 at 9:40 pm, and died on 3/8/11 of complications from too much Coumadin (blood thinning).Patient 1, a 78 year old female, was admitted to the facility on 1/31/11 for physical therapy following a knee injury. Her diagnoses included leg pain, lung disease, heart disease, and a history of a blood clot in her leg. She chose to have all life sustaining treatments, except for CPR (cardiopulmonary resuscitation, a method to restore breathing and/or heartbeat), if needed. Her Minimum Data Set (MDS - a standardized assessment tool), dated 2/11/11, indicated that Patient 1 was alert and oriented and capable of making her own decisions.On 2/1/11, Patient 1's physician did a history and physical examination, and ordered a complete blood count (a test that counts the number of blood cells). The test results showed that Patient 1's hemoglobin (HGB - a protein in red blood cells that carries oxygen) was 11.9 (normal range 12 - 16) and hematocrit (HCT - a test to measure red blood cell concentration) was 36.1 (normal range 35 - 55). Red blood cells and the hemoglobin contained within them are necessary for the transport and delivery of oxygen from the lungs to the rest of the body. Without a sufficient supply of oxygen, organs throughout the body (brain, heart, lungs) can be adversely affected. On that same day, the physician wrote orders for Coumadin 7.5 milligram (mg) on day one, then 5 mg daily, to be started in order to prevent the patient from getting another blood clot in her leg. And, to recheck Patient 1's Prothrombin Time (PT) on Friday (2/4/11). Prothrombin Time is a blood test for anticoagulation monitoring essential in ensuring the dose of Coumadin is high enough to prevent the development of blood clots, and low enough so that the patient is not at risk for serious bleeding. On 2/4/11, Patient 1's PT/INR (prothrombin time/international normalized ratio, a blood test used to help determine the level of blood thinning from Coumadin) was 15.6 (Normal 10-13) and flagged as "high." The INR was 1.72 (normal 0-5). There was no documentation, in the record, that the physician was notified of the of the high PT result. Patient 1 continued to receive 5 mg of Coumadin daily. When Patient 1's PT/INR was checked again, on 2/14/11, the PT was flagged as "high" at 22.3, and the INR was 3.22. That same day, Patient 1's HGB/HCT were within normal range at 13.2 and 39.3 respectively. The physician's progress note, dated 2/15/11, acknowledged the INR test result of 3.2, however, the physician did not order any further PT/INR tests. Patient 1's Coumadin dosage was not changed; it remained at 5 mg daily until her decline on 3/6/11. On 4/6/11 at 2:40 pm, during an interview, Certified Nurse Assistant (CNA) A stated that on 3/6/11 between 12 am and 6:30 am, Patient 1 became lethargic and unresponsive at times. She further stated that at about 2 or 3 am, Patient 1 complained of stomach pain and vomited liquid which tested positive for the presence of blood. According to CNA A, she reported the positive test immediately to Licensed Nurse (LN) B and kept LN B informed of the patient's status during the night.In an interview on 4/6/11 at 3:05 pm, LN B recalled that on 3/6/11 at 3 am, she notified Physician D that Patient 1 vomited, but did not remember if she told the physician that it tested positive for blood. She stated that Physician D ordered Patient 1 to be given Compazine (a medication to suppress nausea), which she gave at 3:15 am. LN B stated that Patient 1 had no further vomiting, and was "doing well" when she left work at 6:30 am.In an interview on 4/7/11 at 8:30 am, Physician D stated that the facility had called him on 3/6/11 at 3 am to report that Patient 1 had vomited, but that the caller had not mentioned that it tested positive for blood. He further stated that he was not notified that the patient had any change in her level of consciousness.During an interview on 4/7/11 at 5:15 pm, CNA E stated that on 3/6/11 at about 7:30 am, Patient 1 vomited red liquid, which tested positive for blood. She notified LN C, who said to let her know if it happened again. CNA E stated that Patient 1 had a red-colored bowel movement later that morning, which also tested positive for blood. She again notified LN C. CNA E recalled that Patient 1 was acting "sluggish," and by 1 pm, Patient 1 was becoming "unresponsive." She notified LN C, who told her to encourage Patient 1 to drink fluids. In an interview on 4/7/11 at 11:15 am, LN C stated that on 3/6/11 at about 11 am, Patient 1 had a large, "bloody" bowel movement and that the patient's blood pressure was "lower than normal."She called Physician D at 11:45 am, who ordered a PT/INR, a complete blood count and basal metabolic panel (tests that count the number of blood cells, and measure the blood chemistry), and to give 4 milligrams of Zofran (a medication for nausea) sublingual (under the tongue).On 3/6/11 at 11:55 am, Physician D arrived at the facility.During an interview on 4/7/11 at 8:30 am, Physician D stated that he visited Patient 1 in the late morning, around noon, on 3/6/11. And, at that time Patient 1 was alert and oriented, though she didn't feel very good.During an interview on 4/7/11 at 9:40 am, LN C recalled that Patient 1 was alert when Physician D visited at 12 pm, but was otherwise quite lethargic throughout the day, only opening her eyes briefly in response to voice or touch.The laboratory tests were run on 3/6/11 at 1:08 pm, and revealed a PT of 55.7 and an INR of 16.03. The laboratory report flagged both results as "critical high," indicating too much thinning of the blood. Patient 1's HGB and HCT dropped to 9.6 and 29.3 and were flagged as "Low." LN C notified Physician D of the results at 1:20 pm; he ordered Vitamin K (a medication used to counteract the effects of Coumadin) to be given to Patient 1. LN C stated that at about 4 pm, Patient 1's blood pressure was 69/40; she called Physician D, who ordered a 500 ml (milliliters) bolus of intravenous (IV) fluid (rapidly giving fluid directly into the blood stream), then decrease the IV rate to 150 cc per hour. According to LN C, Patient 1's blood pressure went up to 142/69 after 500 ml of intravenous fluid was administered. This information was also documented in the nurses note dated 3/6/11 at 4 pm. LN C stated that by 6:30 pm, Patient 1 was moaning and "moving a bit" when spoken to or touched.Physician D stated that on 3/6/11 at 4 pm, when Patient 1's blood pressure dropped, he had the nurses give her intravenous fluids, which raised her blood pressure back to normal. He recalled that at that point he felt that Patient 1 was stable.LN B stated that when she arrived at work on 3/6/11 at 6:30 pm, Patient 1 was receiving intravenous fluids and was unresponsive, with a blood pressure of 91/64. She recalled that according to the report she received from LN C, the day shift nurse, Patient 1 was stable, and there were orders to call the physician if there were any further changes in Patient 1's condition.LN B stated that she called Physician D at 9:30 pm (three hours later) when Patient 1's blood pressure dropped to 38/10.The nurses note dated 3/6/11 at 6 pm read, "No vomiting or diarrhea." There was no documentation that Patient 1's blood pressure was rechecked during the two hour period after the IV rate was decreased to 150 cc per hour. The next nurses note, made at 7 pm read, "Remains unresponsive, B/P (blood pressure) 91/40..." There was no documentation that the physician was notified that Patient 1's blood pressure had decreased from 142/69 to 91/40 or that she was unresponsive. Patient 1's vital sign record contained an entry dated 3/6/11 "Sunday PMs" (untimed) noting that Patient 1's blood pressure was 78/42. There was no documentation that the nurse or the physician was notified of this blood pressure reading. Physician D stated that he was unaware of any changes in Patient 1's level of consciousness until 9:30 pm that night, when a nurse called to tell him that Patient 1's blood pressure dropped again, and that she was unresponsive. He ordered that she be transferred to the hospital emergency department immediately. The emergency department nursing record, dated 3/6/11 at 10:15 pm, indicated that upon arrival, Patient 1 was unresponsive, and her pupils were dilated and did not react to light (a possible indication of brain damage). Patient 1 received one unit (200 milliliters) of O negative blood before being transferred to a larger acute care hospital by medical air ambulance at 11:40 pm. Patient 1's history and physical, dated 3/7/11, done by Physician F, a consulting doctor at the acute care hospital where she was transferred, noted that Patient 1 had "Acute gastrointestinal bleeding" due to "Marked coagulopathy" (too much blood thinning), "She has suffered substantial end-organ damage (irreversible), and "The patient's overall prognosis is quite grim." Patient 1's death summary, dated 3/8/11, by Physician G, a consulting doctor at the acute care hospital, indicated that after aggressive treatment in the intensive care unit with intravenous fluids, maximum doses of medications to support blood pressure (phenylephrine, epinephrine, vasopressin, and dopamine), and CPR, she was pronounced dead on 3/8/11 at 9:17 am. Patient 1's death certificate indicated that the cause of death was gastrointestinal hemorrhage (bleeding) due to, or as a consequence of warfarin (Coumadin) use. The Department determined that the facility failed to promptly notify the attending physician when Patient 1 developed complications after receiving Coumadin (a blood-thinning medication, used for preventing blood clots). Excessive thinning of the blood can lead to major bleeding. Nursing service did not inform the physician when Patient 1 first vomited bloody fluid (a potential indication that there was too much thinning of the patient's blood), or when Patient 1's blood pressure declined and she was experiencing a decreased level of consciousness on 3/6/11 after 4 pm until 9:30 pm.These failures resulted in a delay of care and treatment for Patient 1. She was eventually transferred to an acute care hospital on 3/6/11 at 9:40 pm, and died on 3/8/11 of complications from too much Coumadin (blood thinning).The above violation presented an imminent either danger that death or serious harm would result, or a substantial probability that death or serious physical harm would result." |
| 230000038 |
Marquis Care at Shasta |
230008862 |
B |
23-Oct-12 |
H7LI11 |
7328 |
Citation # 23-2486-0008862-F F242 483.15(b) SELF-DETERMINATION - RIGHT TO MAKE CHOICES The facility failed to ensure Patient 1 was afforded the right to choose activities that were important to her, when the facility chose to be non-smoking.In April 2011, the facility announced that they were no longer going to allow smoking. An exception to the new no smoking policy was that those patients who smoked, and were currently living in the facility, would be allowed to continue smoking. The facility identified those patients as "Grandfathered." However, patients admitted after April 2011, would not be allowed to smoke.Patient 1 was admitted to the facility on 7/21/11 with diagnoses that included obsessive compulsive disorder (an anxiety disorder that involves repetitive rituals), post traumatic stress disorder, depression, and insomnia. The facility Admission Record reflected that Patient 1's sister was her responsible party (RP) and decision maker.On 12/27/11 at 11:50 am, during a telephone interview, Patient 1's sister stated that when Patient 1 was admitted to the facility, the Administrator had informed RP that there were still some patients in the facility that smoked. RP stated that the Administrator told her that Patient 1 would be included in that group of "Grandfathered" patients still smoking and would be allowed to smoke as well.In December 2011, the facility changed their smoking policy again, prohibiting even the "Grandfathered" smokers from smoking on the facility grounds. The facility offered two choices to those existing patients who smoked; quit smoking or transfer to a facility that allowed smoking.On 12/27/11 at 11 am, during an observation and concurrent interview, Patient 1 stated that she did not like not being able to smoke, "I want to smoke, it's my social time with my friends." Patient 1 stated, with a saddened facial expression, that she missed socializing with the other patients that she used to smoke with. Patient 1 stated that since the facility banned smoking, she has no longer socialized with one of her closest friends, "I never see her anymore" and that two others from the "group" had left the facility. Patient 1's voice was trembling as she described how the facility had allowed her to smoke, from the time she was admitted in 7/2011 through 11/2011, and then told her, "no more." Patient 1 stated that she had felt intimidated and that she had, "no choices or rights."During the phone interview on 12/27/11 at 11:50 am, RP stated, "I wish they had not let her smoke in the first place, now it's like taking candy away. It's was all she had left." RP stated that Patient 1 had greatly improved her socialization skills, and was happy when she was out smoking with the "group." RP said that she now feared that Patient 1 would become "reclusive." RP stated that the facility offered to find another place for Patient 1 to live that allowed smoking, but she did not feel that the choices that the facility presented were acceptable. RP stated that her sister, Patient 1, only had two choices, "quit smoking or move out."On 12/27/11 Patient 1's record was reviewed. The Social Service Director (SSD) documented in her notes on 8/19/11, four months after the no smoking policy had been in effect, that Patient 1, "has made friends with another smoker, [Patient 1] and her new friend converse during smoke breaks." Social Service staff member (SS) B documented on 9/9/11, "She [Patient 1] enjoys smoking and the company of some of the other patients."An Activities Admission Assessment, dated 8/5/11, four months after the no smoking policy had been in effect, documented that Patient 1 was an "Independent lady likes to go outdoors to smoke..." Patient 1's "Activities" care plan, developed on 7/21/11, identified that Patient 1 needed independent and self-directed activities. The goal was that Patient 1 would participate in activities that she had chosen, which included, "...small social group during smoking activity..."On 12/27/11, the Assistant Administrator (AA) provided a memo that was given to the patients of the facility. The "Memo" read, "We are now a "Smoke Free" campus. There are specific patients who have been grand-fathered in to allow them to continue to smoke." A list of patients then followed. Patient 1's name was not on the list because she did not reside in the facility in 5/2011, Patient 1 was admitted on 7/21/11 and grand-fathered in at that time. The memo continued, "Due to concerns of staying in compliance with the California Law of NOT smoking within 20 feet of a door or window, the smoking area will be moved immediately." "The new smoking area will be in the grassy area by the Main Dining Room...Patients are allowed to sit on the sidewalk...The smoking times are 9:30 am, 1:30 pm, 4:30 pm, and 7:30 pm." On 12/27/11, the AA provided another letter that had been issued to the patients of the facility. On 11/9/11, seven months after the "Smoking Policy" was in effect, the Administrator created a letter that contained the following information: "...earlier this year [the facility name] took great strides to become a smoke free environment. At that time, exceptions to our policy were made to try and accommodate patients with a history of smoking. The harmful effects of secondhand smoke and the fire dangers caused by the presence of smoking in our community are simply too great to ignore...decided to go completely smoke free as of December 1, 2011."On 12/27/11 at 2:35 pm, an interview was conducted with both the SSD and SS B. SS B stated, "we let her [Patient 1] smoke because she saw the others smoking," and confirmed that the facility had not followed their own newly adopted no smoking policy, when they allowed Patient 1 to smoke with the others. The SSD confirmed that the facility had not prepared Patient 1 for mandatory smoking cessation. The SSD stated that in November 2011, Patient 1was offered nicotine patches, which were not ordered by the physician until December 2011, or to be transferred to a facility that allowed smoking.On 12/27/11 at 1 pm and 3:30 pm, interviews were conducted with the AA. AA stated that although Patient 1 had been admitted after the no smoking policy went into effect they let her smoke as part of the grand-fathered patients. AA confirmed that Patient 1 was not happy when the facility revoked her smoking activity.AA stated, "It was not their [the patients] choice to quit smoking." AA stated that the facility moved the original, fairly secluded, smoking area for the patients to a lawn area just outside of the main dining room in May 2011. AA stated that caused numerous complaints from the other patients and staff, "the staff began bringing notes in from their doctors stating they could not work around second hand smoke." AA stated that during that same time frame, the staff smoking area had caught on fire and the Administrator, "was fed up with smokers."Therefore, the facility failed to ensure Patient 1 was afforded the right to choose activities that she felt were important to her quality of life, when the facility chose to be non-smoking and gave Patient 1 two alternatives, quit smoking or move.The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to patients. |
| 230000389 |
Modoc Medical Center D/P SNF |
230008965 |
B |
08-Feb-12 |
1LZQ11 |
2308 |
A 064 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 incident of mental and verbal abuse to the California Department of Public Health within 24 hours. On 10/7/11 at 11:30 am, Resident 2's visiting daughter told Resident 1 to "Get the f*** out of here, you smelling, gross, old woman; go to your own room." The facility notified the Department via fax, on 10/13/11 at 2:20 pm, six days after the incident occurred. The late reporting delayed the investigation, and placed Resident 1, and other residents in the facility, at risk for further verbal abuse, fearfulness, and emotional distress.During an interview on 10/19/11 at 2 pm, Certified Nursing Assistant B (CNA B) stated that on 10/7/11 at 11:30 am, she heard loud voices coming from Resident 2's room. When CNA B went into the room she saw that Resident 2's daughter and another facility resident, Resident 1, were in the room visiting Resident 2. CNA B stated that Resident 2's daughter was walking close to Resident 1, directing her towards the door, and saying "Get the f*** out of here you smelly gross old woman; go to your own room." CNA B stated that she immediately reported the incident to the Social Services Coordinator (SSC). A social services entry, dated 10/7/11 (no time), noted that Resident 2's daughter told the SSC, "That d*** old woman will not leave my mother alone and I am sick and tired of her standing there when my mom needs to go to the bathroom, and when I tell her to leave she doesn't, it's gross and I am sick and tired of it!" The next entry documented that CNA B reported the incident of abuse to the SSC.On 10/19/11 at 8:30 am, an interview and concurrent document review was conducted with the Director of Nurses (DON). He provided a document titled, Timeline for Elder Abuse report, filed 10/13/11, that showed the DON was notified of the abuse incident on 10/7/11 at 11:45 am, 15 minutes after the abuse occurred. When was asked why the incident was not reported to the Department until 10/13/11, one week later, the DON stated, he and the Social Services Coordinator were not sure if it was a reportable issue. |
| 230000389 |
Modoc Medical Center D/P SNF |
230008970 |
B |
08-Feb-12 |
1LZQ11 |
2792 |
A 880 T22 DIV5 CH3 ART5-72527(a)(9) 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. The facility failed to keep Patient 1 free from mental and verbal abuse when Patients 2's visiting daughter told Patient 1 to, "Get the f*** out of here, you smelling, gross, old woman; go to your own room." This failure resulted in Patient 1 experiencing fear as well as verbal and emotional abuse, and allowed the potential for all facility patients to be subjected to abusive behavior. Patient 1 was admitted to the facility on 1/15/10 with diagnoses that included vascular dementia and a foul smelling abscess on her back. A review of her Minimum Data Set (MDS - an assessment tool), dated 10/12/11, showed Patient 1 had cognitive difficulties, forgetfulness, and wandered in the facility. During an interview on 10/19/11 at 2 pm, Certified Nursing Assistant B (CNA B) stated that on 10/7/11 at 11:30 am, she heard loud voices coming from Patient 2's room. When CNA B went into the room she saw that Patient 2's daughter and another facility resident, Patient 1, were in the room visiting Patient 2. CNA B stated that Patient 2's daughter was walking close to Patient 1, directing her towards the door, and saying "Get the f*** out of here you smelly gross old woman; go to your own room."During an interview on 10/19/11 at 9 am, Patient 1 stated that she did not remember the exact incident of 10/7/11, however, she stated that her friend (Patient 2) had a visitor that wasn't very nice, and she tried to stay away from her. When Patient 1 was asked if she was afraid of Patient 2's visitor, she said, "A little." In a phone interview on 10/19/11 at 1 pm, Patient 2's daughter stated, "When that bitch comes into my mom's room, she smells it up." Patient 2's daughter refused to further discuss the event and hung up.Therefore, the facility failed to keep Patient 1 free from mental and verbal abuse when Patients 2's visiting daughter yelled, "Get the f*** out of here, you smelling, gross, old woman; go to your own room." This failure resulted in Patient 1 experiencing fear as well as verbal and emotional abuse, and allowed the potential for all facility patients to be subjected to abusive behavior. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 230000389 |
Modoc Medical Center D/P SNF |
230009021 |
B |
04-Apr-12 |
4W3Q11 |
2857 |
A 880 T22 DIV5 CH3 ART5-72527(a)(9) 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. The facility failed to ensure Patient 1 was not subjected to abuse when Visitor 3 yelled at Patient 1 and pulled on her arm. This physical and verbal abuse had the potential to result in physical and psychological harm to Patient 1. A review of Patient 1's record disclosed that she was admitted to the facility on 1/15/10 with diagnoses that included dementia. The Social Service Note, dated 10/7/11, gave details of an incident of verbal abuse directed at Patient 1 by Visitor 3, who was the daughter of Patient 2. No care plan could be found that contained interventions to prevent Patient 1 from experiencing a similar incident again in the future. On 12/14/11, the facility notified the California Department of Public Health that Visitor 3 yelled at Patient 1 and grabbed her arm on 12/13/11. In a written statement, Certified Nursing Assistant (CNA) B wrote that she heard Visitor 3 yell at Patient 1 and saw her pull on Patient 1's right upper arm.During an interview on 2/2/12 at 12:10 pm, CNA B stated that as she came up to Patient 2's room she heard Visitor 3 yell at Patient 1, "you can't do that." CNA B stated that as she entered Patient 2's room she saw Visitor 3 holding Patient 1's right upper arm and turning her around towards the door.During an interview on 2/2/12 at 11:35 am, Visitor 3 admitted that she put her hands on Patient 1's shoulders and turned her towards the door on 12/13/11. She also admitted to yelling at Patient 1 in a prior incident.During an interview on 2/2/12 at 1:30 pm, Administrative Nurse (Admin) A confirmed that a specific care plan was not developed, following the incident that occurred on 10/7/11 between Visitor 3 and Patient 1. Admin A reviewed Patient 1's care plan for wandering, dated 10/20/11, and stated that the care plan did not address the altercation issue, and should have contained specific interventions to prevent further incidents between Visitor 3 and Patient 1.Patient 1 was not treated with dignity and respect and was subjected to abuse when Visitor 3 yelled at Patient 1 and pulled on her arm. This physical and verbal abuse had the potential to result in physical and psychological harm to Patient 1. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 230000038 |
Marquis Care at Shasta |
230009130 |
B |
23-Oct-12 |
H7LI11 |
4055 |
F242 483.15(b) SELF-DETERMINATION - RIGHT TO MAKE CHOICES The facility failed to ensure Patient 4 was afforded the right to choose activities that were important to him, when the facility chose to be non-smoking. In April 2011, the facility announced that they were no longer going to allow smoking. An exception to the new no smoking policy was that those patients who smoked, and were currently living in the facility, would be allowed to continue smoking. The facility identified those patients as "Grandfathered." However, patients admitted after April 2011, would not be allowed to smoke. In December 2011, the facility changed their smoking policy again, prohibiting even the "Grandfathered" smokers from smoking on the facility grounds. The facility offered two choices to those existing patients who smoked; quit smoking or transfer to a facility that allowed smoking.Patient 4 was admitted to the facility on 1/6/11 with diagnoses that included dementia. On 12/27/11 at 11:30 am, Patient 4 was interviewed. Although diagnosed with senile dementia, he stated, "Hell yeah, I want to smoke, they won't let me, and I tore those damn patches off." On 12/27/11, Patient 4's record was reviewed. An "Elopement Assessment," dated 12/7/11 at 2:31 pm, documented that Patient 4 had attempted to "go out the side door." The assessment included documentation by a nurse that, "Patient was accustomed to smoking multiple times a day. The facility went smoke free on 12/1/11; it appears that Patient 1 may have been following his typical routine of going outside around this time." As a result an alarm was applied to Patient 4 on 12/8/11. On 12/27/11, the Assistant Administrator (AA) provided a memo that was given to the patients of the facility. The "Memo" read, "We are now a "Smoke Free" campus. There are specific patients who have been Grand-fathered in to allow them to continue to smoke." A list of patients then followed, which included Patient 4. The memo continued, "Due to concerns of staying in compliance with the California Law of NOT smoking within 20 feet of a door or window, the smoking area will be moved immediately." "The new smoking area will be in the grassy area by the Main Dining Room...Patients are allowed to sit on the sidewalk...The smoking times are 9:30 am, 1:30 pm, 4:30 pm, and 7:30 pm." On 12/27/11, the AA provided a letter that had been issued to the patients of the facility. On 11/9/11, seven months after the "Smoking Policy" was in effect, the Administrator created a letter that contained the following information: "...earlier this year [the facility name] took great strides to become a smoke free environment. At that time, exceptions to our policy were made to try and accommodate patients with a history of smoking. The harmful effects of secondhand smoke and the fire dangers caused by the presence of smoking in our community are simply too great to ignore...decided to go completely smoke free as of December 1, 2011."On 12/27/11 at 1 pm and 3:30 pm, interviews were conducted with the AA. Patient 4 had begun to wander, looking for a place to smoke. AA stated, "It was not their [the patients] choice to quit smoking." AA stated that the facility moved the original, fairly secluded, smoking area for the patients to a lawn area just outside of the main dining room in May 2011. AA stated that caused numerous complaints from the other patients and staff, "the staff began bringing notes in from their doctors stating they could not work around second hand smoke." AA stated that during that same time frame, the staff smoking area had caught on fire and the Administrator, "was fed up with smokers."Therefore, the facility failed to ensure Patient 4 was afforded the right to choose activities that she felt were important to her quality of life, when the facility chose to be non-smoking and gave Patient 4 two alternatives, quit smoking or move.The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to patients. |
| 230000038 |
Marquis Care at Shasta |
230009131 |
B |
23-Oct-12 |
H7LI11 |
4085 |
F 242 483.15(b) SELF-DETERMINATION - RIGHT TO MAKE CHOICES The facility failed to ensure Patient 2 was afforded the right to choose activities that were important to her when the facility chose to be non-smoking.In April 2011, the facility announced that they were no longer going to allow smoking. An exception to the new no smoking policy was that those patients who smoked, and were currently living in the facility, would be allowed to continue smoking. The facility identified those patients as "Grandfathered." However, patients admitted after April 2011, would not be allowed to smoke. In December 2011, the facility changed their smoking policy again, prohibiting even the "Grandfathered" smokers from smoking on the facility grounds. The facility offered two choices to those existing patients who smoked; quit smoking or transfer to a facility that allowed smoking.Patient 2 was admitted to the facility on 9/16/08 with diagnoses that included dementia with behavior disturbances and a bipolar disorder (a type of depression with anxiety).On 12/12/11 at 1:10 pm, Patient 2 was interviewed at the new facility where she was currently living. Patient 2 stated that she was very upset that she had to move from the facility where she had lived for more than three years. Patient 2 stated that her choices were either quit smoking or move out. Patient 2 stated that because she wanted to continue to smoke, she reluctantly moved to another facility on 11/23/11. Patient 2 stated, "I don't know why they changed the rules." Patient 2 expressed that she enjoyed smoking and that it calmed her nerves and was an important part of her daily routine.On 12/27/11, the Assistant Administrator (AA) provided a memo that was given to the patients of the facility. The "Memo" read, "We are now a "Smoke Free" campus. There are specific patients who have been grand-fathered in to allow them to continue to smoke." A list of patients then followed, which included Patient 2. The memo continued, "Due to concerns of staying in compliance with the California Law of NOT smoking within 20 feet of a door or window, the smoking area will be moved immediately." "The new smoking area will be in the grassy area by the Main Dining Room...Patients are allowed to sit on the sidewalk...The smoking times are 9:30 am, 1:30 pm, 4:30 pm, and 7:30 pm." On 12/27/11, the AA provided a letter that had been issued to the patients of the facility. On 11/9/11, seven months after the "Smoking Policy" was in effect, the Administrator created a letter that contained the following information: "...earlier this year [the facility name] took great strides to become a smoke free environment. At that time, exceptions to our policy were made to try and accommodate patients with a history of smoking. The harmful effects of secondhand smoke and the fire dangers caused by the presence of smoking in our community are simply too great to ignore...decided to go completely smoke free as of December 1, 2011."On 12/27/11 at 1 pm and 3:30 pm, interviews were conducted with the AA. AA confirmed that Patient 2 transferred to a facility that allowed smoking.AA stated, "It was not their [the patients] choice to quit smoking." AA stated that the facility moved the original, fairly secluded, smoking area for the patients to a lawn area just outside of the main dining room in May 2011. AA stated that caused numerous complaints from the other patients and staff, "the staff began bringing notes in from their doctors stating they could not work around second hand smoke." AA stated that during that same time frame, the staff smoking area had caught on fire and the Administrator, "was fed up with smokers."Therefore, the facility failed to ensure Patient 2 was afforded the right to choose activities that she felt were important to her quality of life, when the facility chose to be non-smoking and gave Patient 2 two alternatives, quit smoking or move.The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to patients. |
| 230000038 |
Marquis Care at Shasta |
230009132 |
B |
23-Oct-12 |
H7LI11 |
3998 |
F 242 483.15(b) SELF-DETERMINATION - RIGHT TO MAKE CHOICES The facility failed to ensure Patient 3 was afforded the right to choose activities that were important to him, when the facility chose to be non-smoking. In April 2011, the facility announced that they were no longer going to allow smoking. An exception to the new no smoking policy was that those patients who smoked, and were currently living in the facility, would be allowed to continue smoking. The facility identified those patients as "Grandfathered." However, patients admitted after April 2011, would not be allowed to smoke. In December 2011, the facility changed their smoking policy again, prohibiting even the "Grandfathered" smokers from smoking on the facility grounds. The facility offered two choices to those existing patients who smoked; quit smoking or transfer to a facility that allowed smoking.Patient 3 was admitted to the facility on 7/19/10 with diagnoses that included a stroke with left sided weakness and depression. On 12/12/11 at 1:40 pm, Patient 3 was interviewed at the new facility where he was currently living. Patient 3 stated that he was very upset and, "still is," over having to leave his "home of two years." Patient 3 stated, "They made me move," and explained that he was offered two choices, neither of which, he was happy with, either quit smoking or be moved to another facility where smoking was allowed. Patient 3 stated that he liked to smoke, it was important to him, and he was not going to quit, so he transferred to another facility on 11/28/11.On 12/27/11, the Assistant Administrator (AA) provided a memo that was given to the patients of the facility. The "Memo" read, "We are now a "Smoke Free" campus. There are specific patients who have been grand-fathered in to allow them to continue to smoke." A list of patients then followed, which included Patient 3. The memo continued, "Due to concerns of staying in compliance with the California Law of NOT smoking within 20 feet of a door or window, the smoking area will be moved immediately." "The new smoking area will be in the grassy area by the Main Dining Room...Patients are allowed to sit on the sidewalk...The smoking times are 9:30 am, 1:30 pm, 4:30 pm, and 7:30 pm." On 12/27/11, the AA provided another letter that had been issued to the patients of the facility. On 11/9/11, seven months after the "Smoking Policy" was in effect, the Administrator created a letter that contained the following information: "...earlier this year [the facility name] took great strides to become a smoke free environment. At that time, exceptions to our policy were made to try and accommodate Patients with a history of smoking. The harmful effects of secondhand smoke and the fire dangers caused by the presence of smoking in our community are simply too great to ignore...decided to go completely smoke free as of December 1, 2011."On 12/27/11 at 1 pm and 3:30 pm, interviews were conducted with the AA.AA confirmed that Patient 3 transferred to a facility that allowed smoking. AA stated, "It was not their [the patients] choice to quit smoking." AA stated that the facility moved the original, fairly secluded, smoking area for the patients to a lawn area just outside of the main dining room in May 2011. AA stated that caused numerous complaints from the other patients and staff, "the staff began bringing notes in from their doctors stating they could not work around second hand smoke." AA stated that during that same time frame, the staff smoking area had caught on fire and the Administrator, "was fed up with smokers."Therefore, the facility failed to ensure Patient 3 was afforded the right to choose activities that she felt were important to his quality of life, when the facility chose to be non-smoking and gave Patient 3 two alternatives, quit smoking or move.The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to patients. |
| 230000038 |
Marquis Care at Shasta |
230009133 |
B |
25-Apr-12 |
ERRL11 |
4734 |
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. Based on interview, and record review, the facility failed to assess, plan, and implement interventions to reduce Resident 1's risk of accidents. Resident 1 fell twice in a period of four days; the second fall resulted in a broken left hip and wrist. Resident 1 was admitted to the facility on 1/18/11 for physical therapy and strengthening following a stroke that left her with muscle weakness, and an unsteady gait. A fall risk assessment, completed on admission, identified that Resident 1 was at risk for falls due to her recent stroke, cognitive impairment, unsteady gait, and the inability to stand. Additionally, Resident 1 exhibited the behavior of wandering and exit seeking, and received psychotropic medications that could affect her motor abilities. Resident 1 had a fall risk care plan initiated 1/20/11. Interventions included encouraging Resident 1 to call for assist and to check frequently for care and toileting needs.A fall Care Area Assessment (CAA), dated 2/7/11, noted that Resident 1 had impaired balance while walking and transferring due to a recent stroke.Resident 1's fall risk care plan was not updated when additional risk factors were identified, and the use of an assistive device was not incorporated in the plan to assist in preventing falls. On 2/8/11 at 1:40 pm, Resident 1 stood up from her wheel chair without staff assistance and fell. There were no nurse's notes regarding the fall or Resident 1's condition written in the record at that time. A nurse's note written on 2/9/11 at 1:45 pm read, "Late entry for 2/8/11 at 1:45 pm." The note reflected that Resident 1's family was notified of a fall that occurred on 2/8/11, that Resident 1 had a cut on the bridge of her nose, and that she initially complained of hip pain. The next nurse's note, written on 2/9/11 at 3:15 pm read, "Late entry for 2/8/11 at 1:40 pm. Called to main dining room by housekeeper, (told) that resident had just fallen to floor."A post fall assessment, dated 2/8/11, described the fall as witnessed and that it occurred when Resident 1 attempted to stand without assistance. The portion of the form used to document the resident status (vital signs, positional blood pressures, and presence and intensity of pain was blank. The nurse noted that there was no change in Resident 1's cognitive status, she was described as "Alert," and when asked to describe the event, Resident 1 stated "She was just going to the Rose Queen Tea Party." Environmental factors that may have contributed to the fall were not assessed. Preventative measures, such as safety alarm, and call light, were marked not applicable, and the use of a seatbelt was not addressed. The nurse placed an x in the box indicating that Resident 1's care plan was reviewed and updated. Resident 1's follow-up fall risk assessment was incomplete. The "Functional" section that listed contributing factors of: impaired mobility, weakness, balance, activity intolerance, bowel and bladder issues, and unsteady gait was not addressed. Instead, "Ambulates in hall" was written in the section. The facility identified anti-depressants as a contributing risk, medical/clinical risk factors were not evaluated.Dementia and diminished awareness were identified as cognitive factors, and environmental and sensory risks were marked zero. The summary statement read, "..."Appears to be an isolated incident."Resident 1's care plan was not updated with a higher level of interventions after her first fall. There were no assistive devices or interventions, such as a chair alarm or diversional activities, recommended based on the investigation. The facility's plan was to "Encourage rest periods" and "Monitor for safety," however, the frequency and duration of the rest periods and supervision were not defined. On 2/12/11 at 8:55 am, Resident 1 had a second, un-witnessed, fall in her room. She was assessed and found to be complaining of pain in her left leg and arm. A facility ordered portable x-ray identified a fracture of Resident 1's left hip. She was transferred to an acute care facility for treatment and assessed to also have sustained a fracture of her left wrist. Therefore, the facility failed to assess, plan, and implement interventions to reduce Resident 1's risk of accidents. Resident 1 fell twice in a period of four days; the second fall resulted in a broken left hip and wrist. The violation of this regulation had a direct relationship to the health, safety, or security of residents. |
| 230000389 |
Modoc Medical Center D/P SNF |
230009201 |
B |
04-Apr-12 |
Z9D411 |
1423 |
A 064 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 to the California Department of Public Health (CDPH), immediately or within 24 hours. This placed residents at risk of continued abuse. On 1/3/12 at 10 am, while investigating an incident of alleged abuse that occurred on 1/26/11, between Residents 1 and 2, the surveyor noted a report describing another alleged abuse incident that involved Resident 1.On 12/25/11 at 12:25 pm, Resident 1 and 3 were sitting next to each other in the dining room, waiting for lunch to be served, when for no apparent reason, Resident 1 hit Resident 3 in the arm. The incident was witnessed by CNA 1. The 12/25/11 report did not show evidence that the facility had reported the incident to the CDPH immediately, or within 24 hours. On 1/3/12 at 2 pm, the CDPH was contacted and verified that the alleged abuse that had occurred on 12/25/11, involving Resident 1 and 3, had not been reported to CDPH.During an interview on 1/3/11 at 5 pm, the Director of Nurses confirmed that the facility had not reported the 12/25/11 incident to the CDPH.Therefore, the facility did not report an allegation of abuse within 24 hours to the California Department of Public Health. |
| 230000187 |
Mayers Memorial Hospital D/P SNF |
230009377 |
B |
16-Oct-12 |
2J5211 |
5045 |
F223 483.13(b), 483.13(c)(1)(i) Free from abuse/involuntary seclusionThe resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to ensure Patient 1 was not verbally, physically, or mentally abused when Certified Nurse Assistants (CNA) A and B used profane language, pulled the patient's arm, and spoke to her in a demeaning manner. CNA A and B then pulled the call light cord from the wall, so that Patient 1 could not call for help. This verbal, physical, and mental abuse caused Patient 1 mental and emotional distress. The facility's Patient Abuse Policy, revised 10/19/11, defined abuse as "The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation of an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being." The policy further defined verbal abuse as, "Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients......" and mental abuse as "Humiliation, harassment, threats of punishment or deprivation." On 4/22/12 at approximately 5:30 am, Patient 1 reported to CNA C that the two night shift CNAs (CNA A and B) were mean to her. CNA C reported the alleged abuse to Licensed Vocational Nurse (LVN) D. LVN D spoke to Patient 1 and documented the incident as follows. Patient 1 stated that during the night CNA A and B woke her up and told her to get up and walk to the bathroom, to which, Patient 1 replied, "I can't walk." Patient 1 said that CNA A and B pulled her arm to walk to the bathroom and that's when Patient 1 began yelling because she was scared. Patient 1 said that CNA A and B referred to her bed linen as a "F--ing sheet" then "Told me to take my stinking shirt off because it stinks. They pulled the call light and put it where I couldn't reach it." Patient 1 said that she told CNA A and B that they broke the light and they said, "Big deal." Patient 1 was admitted to the facility on 2/9/12 with diagnoses that included congestive heart failure, previous total knee replacement and morbid obesity. The minimum data set (an assessment tool), dated 2/21/12, identified that Patient 1 had no memory problems, could make her own decisions, could not walk, and needed assistance with transfers. On 5/1/12 at 1:30 pm, Patient 1 was observed sitting in a wheel chair with her left leg elevated on an extended wheel chair riser. In a concurrent interview, Patient 1 stated that she had surgery on her left knee four years ago and as a result, she was unable to walk. Patient 1 was reluctant to discuss the 4/22/12 incident.During an interview on 5/21/12 at 11:30 am, LN D stated that on 4/22/12, CNA C reported that Patient 1 had told her that the two CNA's on the night shift had abused her. LN D stated that she interviewed Patient 1 on 4/22/12 and was told that CNA's A and B used the "F" word while caring for her, and told her that she "stunk" and that she had to walk to the bathroom. LN D further stated that CNA C mentioned that Patient 1 could not use the nurse call light because it was on the floor at the foot of the bed. LN C stated that Patient 1 was docile for the rest of the day, which was not her usual behavior, and that she was scared to say anything, for fear of how she would be treated by CNA A and B. During an interview with Patient 1's roommate, Patient 2, on 6/22/12 at 10:45 am, she stated that CNA's A and B were caring for Patient 1 on the night shift, when she heard them use profane language and tell Patient 1 that "she stunk." Patient 2 further stated that CNA's A and B told Patient 1 to "walk to the bathroom, and Patient 1 told them she couldn't walk," and was crying while lying in bed.In an interview on 6/22/12 at 11:05 am, CNA C stated that she went into Patient 1's room on 4/22/12 at approximately 5:30 am for morning rounds. CNA C stated that she saw Patient 1 crying and saw the nurse call light cord unplugged from the wall, lying on the floor and out of Patient 1's reach. Patient 1 told CNA C that CNA's A and B had pulled it out of the wall, told her she "stunk," and to walk to the bathroom. CNA C stated she reported this to Licensed Nurse (LN) D on 4/22/12. CNA C stated, "The thing that really bothered me was that Patient 1's roommate said the same thing," "The CNAs were mean." CNA C also said that CNA A told her, at a later date, that CNA B had pulled the nurse call light cord out of the wall. Therefore, the facility failed to ensure Patient 1 was free from verbal and mental abuse when CNA A and CNA B used profane language and pulled the call light cord from the wall, so Patient 1 could not call for help.This violation had a direct relationship to the health, safety, or security of patients. |
| 230000038 |
Marquis Care at Shasta |
230009575 |
B |
26-Apr-13 |
LU3011 |
9895 |
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 ensure an environment free of accident hazards/injury by failing to ensure that Resident 1 was transferred, according to the care plan, using the correct assistive device (a Medcare Stand) and to prevent a skin tear during transfer. The facility failed to ensure that Resident 1's signs and symptoms of right upper extremity injury (redness, swelling, verbalized complaints of pain, guarding and grimacing [physical signs of pain]) were assessed by a registered nurse and reported to the physician promptly, and to provide sufficient care and treatment to Resident 1, in a timely manner.These failures resulted in a skin tear and bruising, and delayed treatment and identification of a fractured right upper extremity, which caused Resident 1 moderate to severe pain, compromised her ability to feed herself, and negatively affected her ability to maintain and/or reach her highest practicable level of well-being, comfort, and quality of life.On 10/12/12 at 11:40 am, during an interview with the Administrator and Director of Nursing (DON), the DON stated that a nursing assistant (CNA A) had used the wrong assistive device while transferring Resident 1 on 8/8/12. The DON stated that, per the facility's investigation of the incident, the Resident's injury (right shoulder fracture discovered on 8/11/12) was believed to be directly related to the transfer on 8/8/12. Resident 1 was admitted on 12/2/10 with diagnoses that included a seizure disorder, bipolar (manic depression), and obesity. The Minimum Data Set, (MDS- a resident assessment tool), dated 8/10/12, showed that Resident 1's cognitive abilities lacked memory, recall, and understanding of conversation. Resident 1 was non-ambulatory and required two staff to physically assist her during transfers because her balance was unsteady and she could only be stabilized with staff assistance. On 10/12/12 at 12:15 pm, Resident 1 was observed and interviewed. Resident 1's right arm was moderately swollen and in a sling. There was purple and green discoloration of her right arm from the shoulder to the hand. Resident 1 stated, "my arm broke when they lifted me and it hurts." Resident 1's spouse was present and stated that he was informed by the facility that Resident 1's injury happened "when they got her out of bed." Resident 1's record was reviewed 10/12/12. A care plan titled, "Dependent with transfer with mechanical lift, non-ambulatory related to lower extremity weakness" was initiated on 7/21/11. The care plan directed, "TRANSFERS: Use total lift for transfers two staff member assist..." On 10/25/12 at 2:15 pm, an interview and concurrent review of the assistive devices used in the facility was conducted with the Director of Nursing (DON). The instructions to use the "Medcare Stand" directed that the assistive device was specifically designed for assisting residents to a standing position and should only be used on residents that had been assessed as able to bear weight and who possessed advanced motor skills. The Medcare Lift was a sling chair device. The instructions directed that it was intended for residents who are non-weight bearing and require total lifting.On 10/12/12, the facility's "Investigation Report Form," dated 8/12/12, was reviewed. The investigation had been conducted by Social Worker (SW) C. SW C documented in the investigative report, "due to increased complaint of pain [by Resident 1] and swelling an x-ray was ordered." SW C's report included, "[CNA A] did not follow resident [Resident 1] care plan during a patient transfer; and this may have resulted in an injury sustained by the resident" and Resident 1 stated, "the nurse that was lifting me drop me." On 10/12/12 at 3:07 pm, CNA A was interviewed. CNA A stated that on 8/6, 8/7, and 8/8/12, she used the Medcare Stand to get Resident 1 out of bed and into her wheelchair for supper. CNA A stated that she "always" used the Medcare Stand alone, when she transferred Resident 1, but on 8/8/12, at approximately 3:30 pm, she asked CNA B to help her. CNA A stated that a couple of hours later, during supper, around 5:30 pm, Resident 1 complained of right arm pain. Resident 1 was unable to lift her spoon to her mouth and CNA A had to feed her. CNA A stated, "I told the charge nurse that Resident 1 couldn't move her right arm and it was hurting her." CNA A also stated that when she and CNA B put Resident 1 back to bed, they used the Medcare Lift. CNA A stated that she knew how to access Resident 1's care plans and acknowledged the importance of implementing the resident care plans to ensure that the resident's needs were properly being met. CNA A then stated, "but I don't look at them." On 10/12/12 at 3:30 pm, CNA B was interviewed. CNA B confirmed that she had helped CNA A transfer Resident 1 using the Medcare Stand on 8/8/12. CNA B stated that she was aware that Resident 1 required a total lift (Medcare Lift) with two staff, but CNA A already had the Medcare Stand in Resident 1's room, "I didn't say anything, I thought she knew what she was doing." CNA B stated, "We tried three times to get her [Resident 1] up, she wouldn't hang on, she couldn't do it, I had to go get the total lift," which contradicted what CNA A had stated. CNA B stated that she had observed Resident 1 during dinner on 8/8/12, and stated that Resident 1 had complained of right arm pain and could not lift her arm to feed herself, "We told the charge nurse."There was no documentation in the nursing progress notes on 8/8/12, that Resident 1 had complained of right arm pain which had affected her ability to feed herself. On 8/9/12, a nurse documented that Resident 1 had a bruise and a skin tear to the right arm, from a transfer at 7:47 am. On 8/10/12, a nurse documented that Resident 1 complained of right shoulder pain "9/10" (10 being the most severe) and stated, "my shoulder hurts real bad-that's why I didn't get up for dinner." The nurses noted that Resident 1 had limited range of motion and slight swelling and redness to the right arm. There was no documentation that the physician was notified of the Resident's change of condition.On 8/11/12, a nurse documented that Resident 1, "guards and grimaces" during care. And, on 8/11/12 at 7:17 am, a nurse documented, "Right shoulder and arm bruised and swelling, limited range of motion, resident is requesting to go to the hospital." Resident 1's physician was then notified and orders were obtained for an x-ray of Resident 1's right arm. The three view x-ray of Resident 1's right shoulder, dated 8/11/12, reported that Resident 1 had an acute-appearing impacted fracture through the surgical neck of the humerus with a displaced bone fragment measuring 11 x 4 mm (millimeters) with possible comminution through the base of the greater tuberosity (meaning that the top of Resident 1's right upper arm bone, that connects with the shoulder, was broken and wedged into the shoulder bone, with a couple of pieces of splintered or crushed bone adjacent to the break). On 10/24/12 at 11:30 am, during interview and record review, the DON confirmed that CNA A had not followed Resident 1's care plan and used an incorrect assistive device, the Medcare Stand, on Resident 1. The DON stated that CNA A should have used the "total" assistive device, the Medcare Lift, each time she transferred Resident 1. The DON stated that she expected CNA A to review Resident 1's care plans, prior to assuming her care, so that she would know which assistive device was appropriate to use. The DON stated that the charge nurse had not documented an assessment or note related to Resident 1's complaint of right shoulder pain and confirmed that both CNAs A and B stated that they had told the charge nurse. The DON stated that the facility's policy for Change in Resident Condition required physician notification and a nurses progress note and care plan update. On 10/25/12 at 2:15 pm, during an interview and review of the August 2012 Activities of Daily Living (ADL) documentation, the DON stated, per CNA A's documentation, CNA A transferred Resident 1 using the wrong assistive device on three separate occasions. Review of Resident 1's July and August 2012 Medication Administration Records (MARs) showed Resident 1 experienced increased pain and required more pain medication in August (after being transferred with the wrong assistive device three times 8/6, 8/7, and 8/8/12, suffering the skin tear during transfer on 8/9/12, and her change of condition with symptoms of acute right upper extremity injury on 8/10/12).Therefore, the facility failed to ensure an environment free of accident hazards/injury by failing to ensure that Resident 1 was transferred, according to the care plan, using the correct assistive device (a Medcare Stand) and to prevent a skin tear during transfer. The facility failed to ensure that Resident 1's signs and symptoms of right upper extremity injury (redness, swelling, verbalized complaints of pain, guarding and grimacing [physical signs of pain]) were assessed by a registered nurse and reported to the physician promptly, and to provide sufficient care and treatment to Resident 1, in a timely manner.These failures resulted in a skin tear and bruising, and delayed treatment and identification of a fractured right upper extremity, which caused Resident 1 moderate to severe pain, compromised her ability to feed herself, and negatively affected her ability to maintain and/or reach her highest practicable level of well-being, comfort, and quality of life.These failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 230000187 |
Mayers Memorial Hospital D/P SNF |
230010288 |
B |
05-Mar-14 |
ZKE611 |
5049 |
F223 483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to protect one resident from abuse when Certified Nursing Assistant (CNA) A forcefully pushed a resident down onto his bed (Resident 1) and repeatedly told him to sit down. This resulted in anxiety and agitation as evidenced by the resident becoming more agitated, requiring additional reassurance from the staff following the incident.On 11/13/13 at 7:47 am, the Department of Public Health received a fax notification from the facility reporting a witnessed inappropriate staff to resident interaction. The report indicated that on 11/12/13, CNA A was witnessed by CNA B to physically push Resident 1 down onto his bed. The facility's records indicated that on 11/12/13, the local law enforcement agency was also notified regarding this incident. Resident 1, a 60 year old male, was admitted to the facility on 11/18/09, with diagnoses which included dementia, brain cancer and depression. The facility's Minimum Data Set (MDS, an assessment tool) for Resident 1 dated, 10/1/13, indicated that Resident 1 had both short and long term memory deficits and severe impairments in regards to his daily decision making abilities.Resident 1's care plan titled, "Impaired Cognition/Communication," dated 10/1/13 indicated that due to his condition, he experienced intermittent difficulty verbalizing needs, had impairments with processing information and had frustration with articulating needs. Staff interventions to assist Resident 1 in coping were to allow him adequate time to communicate his needs, and if he becomes frustrated take a break and re-approach at a later time. During an interview and observation, on 11/26/13 at 10:15 am, with Resident 1 in his room it was noted that he was extremely hard of hearing, partially blind and had obvious cognitive deficits making communication extremely difficult.During a telephone interview, with CNA B on 11/26/13 at 3:15 pm, she reported that on the night of 11/12/13 at about 11 pm, she responded to Resident 1's bed alarm. CNA A was already present in the room and she could hear CNA A repeatedly telling Resident 1 to "sit down." CNA B reported that Resident 1 had difficulty processing information and could become frustrated easily. CNA B stated that upon entering the room she observed CNA A place his hands on Resident 1's chest and forcefully push him down onto his bed "very hard". CNA A then left the room with no explanation provided as to his actions. CNA B stated that she had to reassure Resident 1 because he became extremely agitated following this interaction and being shoved onto his bed. CNA B stated that she felt that CNA A's actions were abusive and represented inappropriate patient care. The facility's abuse policy dated, 12/2011, read, "It is this facility's intent to ensure that each patient has the right to be free from abuse (verbal, physical and mental) including corporal punishment and involuntary seclusion. Patients must not be subjected to any of the above by anyone, including, but not limited to, facility staff, other patients, consultants, volunteers and other agencies that service the patient, family members, legal guardians, friends or other individuals... Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish..." CNA A's employee file was reviewed on 11/26/13. CNA A had received the following training on 12/25/12; Communication with Cognitively Impaired Clients, Elder Abuse and Resident Rights. According to CNA A's 2012 Employee Evaluation; CNA A was written up on 2/18/12 for having a bad attitude with a co-worker. CNA A was written up on 5/10/12 after a verbal confrontation with co-workers at the nurse's station. CNA A was written up on 10/1/12 for patient care issues which resulted in a three day suspension. CNA A's 2013 Employee Evaluation dated, 11/18/13, read, "CNA A has to be told what to do daily. Fellow co-workers would prefer not to be assigned with him due to his work performance." During an interview and record review, with Charge Nurse (CN) C on 11/26/13 at 9:10 am, she confirmed CNA A had been immediately sent home after she was made aware of the incident on 11/12/13. CN C reported that her investigation had substantiated the allegation of abuse and that combined with a history of "unflattering" job performances, resulted in CNA A's termination from the facility.Therefore the facility failed to ensure that Resident 1 was free from verbal and physical abuse when CNA A repeadly told him to sit down and shoved him on to his bed. This caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 230000278 |
Marysville Post-Acute |
230011643 |
B |
07-Aug-15 |
VIR811 |
5129 |
A064 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 staff to resident mistreatment that occurred on 7/19/14, when Certified Nursing Assistant (CNA) B spoke rudely toward Resident 1, resulting in Resident 1 feeling angry, dumb, and demeaned, and had the potential to have a negative impact on the well-being of residents. An undated Administrative Manual, titled, "Elder/ Dependent Adult Abuse" indicated, each employee is a mandated reporter, and has the duty as an individual to report any actual, known, alleged, or suspected incident of physical, verbal, financial abuse, neglect, abandonment or isolation. The manual indicated all alleged, known or suspected abuse would be reported to CDPH as soon as practicable, but no later than 24 hours of having knowledge of the incident. On 7/23/14 at 4:34 pm, four days after the alleged incident, the facility sent a faxed notification to CDPH of a verbal confrontation by CNA B toward Resident 1.Review of Resident 1's record indicated Resident 1 was admitted to the facility on 7/8/13 with diagnoses that included dementia and high blood pressure.Review of the facility's Minimum Data Set (MDS, a standardized assessment), dated 8/10/14, indicated Resident 1 was mentally alert and able to recall the correct day and year, having no delusions (misconceptions/beliefs contrary to reality) or hallucinations (false perceptual experiences).Review of nurse's notes indicated there was no documentation of the incident on 7/19/14. Nurses notes, dated 7/20/14 at 12 pm, indicated a CNA reported to Licensed Nurse (LN) D that Resident 1 reported a CNA and a nurse were rude to her, and the Administrator (Admin) and the Director of Nurses (DON) were notified, via telephone. LN D documented she spoke to Resident 1 on 7/20/14, and the resident said she had asked CNA B on the previous pm shift for an alternative meal (egg salad sandwich) because she did not want seafood for dinner. The nurse's notes indicated Resident 1 stated CNA B was rude to her, arguing about what was on the menu. Resident 1 was interviewed on 7/25/14 at 4:10 pm. She recalled asking CNA B for an egg salad sandwich because she stated she did not want seafood for dinner. She stated CNA B was "rude and snotty" toward her, questioning her how she would know what was on the menu. Resident 1 stated CNA B made her feel dumb, as if she did not know what she was talking about. On 9/3/14 at 2:50 pm, CNA B was interviewed. CNA B stated she answered Resident 1's call light on 7/19/14, on the pm shift, and Resident 1 requested an egg salad sandwich. She stated she asked her if she knew what was for dinner, and Resident 1 then replied, of course she knew and started cursing at her. CNA B stated she then went to go get her charge nurse (LN C). A review of the facility's investigation disclosed a phone interview with LN C on 7/21/14 indicating she went into Resident 1's room because CNA B informed her that Resident 1 was yelling at her because she asked her "do you know what's on the menu?"On 3/3/15 at 10:55 am, LN D was interviewed. She confirmed that LN C did not document the incident on 7/19/14, and that she worked the previous am shift. She stated Resident 1 was still upset about the incident the next day and she had told her that CNA B was rude to her. Review of a "Notice of Disciplinary Action" taken for CNA B, dated 7/23/14, indicated, Resident 1 asked CNA B for an egg salad sandwich for dinner and CNA B implied the resident did not know what she was talking about which caused a potential abuse investigation and left the resident angry and demeaned.On 3/3/15 at 3:15 pm, Resident 2 was interviewed. Resident 2 was alert and oriented, able to state her name, date, year, and the President of the United States. She stated she recalled an incident with Resident 1, who was her roommate at the time. She stated Resident 1 requested an egg salad sandwich and CNA B answered her in a "real snotty tone...'and how would you know what was on the menu?'" Resident 2 stated this altercation upset her roommate for several days. During an interview with Medical Records Staff (MRS) on 3/3/15 at 9 am, she confirmed the SOC 341 (a suspected dependent adult/elder abuse report) was addressed without a date to the Ombudsman. MRS confirmed there was no documentation in Resident 1's record that CDPH was notified of the incident, within 24 hours. MRS stated she called the Administrator during about needing documentation of when CDPH was notified, but there was no documentation.Therefore, the facility failed to report staff to resident mistreatment that occurred on 7/19/14, when Certified Nursing Assistant (CNA) B spoke rudely toward Resident 1 to CDPH, within 24 hours, resulting in Resident 1 feeling angry, dumb, and demeaned, and had the potential to have a negative impact on the well-being of residents. This violation had a direct relationship to the health, safety, or security of patients. |
| 230000038 |
Marquis Care at Shasta |
230012151 |
B |
01-Apr-16 |
6UUW11 |
6222 |
F223 Free from Abuse/Involuntary SeclusionThe resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.The facility failed to ensure Resident 2's right to be free from abuse and to protect Resident 2 from physical and mental abuse when Certified Nursing Assistant (CNA) 1 was excessively rough and rude toward Resident 2, rushed and shoved Resident 2 into the bathroom during toileting, refused to clean feces off of the toilet, pried Resident 2's fingers from a grab bar and forced Resident 2 down onto the toilet, and after leaving the bathroom, CNA 1 wadded up and threw a blanket at Resident 2.This resulted in physical and mental abuse by CNA 1 toward Resident 2. Resident 2 expressed feeling pain that felt like "scalding hot water" to his buttocks, helpless and unable to defend himself, and fearful of CNA 1, and had the potential to continue to adversely affect Resident 2's physical and psychosocial well-being. According to the faxed report received by CDPH (California Department of Public Health) from the facility on 11/6/15, an allegation of physical abuse by CNA 1 toward Resident 2, Resident 2 reported receiving rough personal care from CNA 1. Resident 2 reported that he was afraid of CNA 1 and did not feel safe with him providing his care.Resident 2's record was reviewed. Resident 2 was originally admitted to the facility on 9/26/14, with diagnoses which included chronic pain and Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors). According to the facility's Minimum Data Set (MDS, a resident assessment), dated 10/7/15, Resident 2 was alert, oriented and required assistance to use the bathroom.Review of a written statement made by the Social Services Director (SSD) on 11/6/15 (no time), the SSD indicated, in a conversation she had with Resident 2, Resident 2 told her that CNA 1 "has been rough with me before, but this was the first time that he had tried to man handle me. I was scared of him...but I'm 80 years old so what am I supposed to do."Review of an IDT (interdisciplinary team of various facility staff who meet to discuss resident care needs) progress note, dated 11/6/15 at 1:59 pm, indicated Resident 2 expressed feeling upset and was described to appear to be "down" and more quiet than usual.Review of a Behavior Note, written by the SSD on 11/9/15 at 8:32 am, Resident 2 stated, "I'm still upset, but I'm not scared anymore." Review of a document titled, "Disciplinary Action," dated 7/26/15, indicated that another resident had complained that CNA 1 had held her arm too tight while providing personal care. CNA 1 had received corrective retraining following this complaint.During an interview on 11/13/15 at 8:20 am, the Administrator (Admin) reported that Resident 2 had reported that CNA 1 had provided rough and rude care to him around 4 am on 11/6/15. The Admin reported that Resident 2 was alert and oriented. The Admin reported that CNA 1 was terminated following his initial suspension during this investigation, due to job performance concerns, which included a previous report of rough care being provided to a different resident.During an observation and interview with Resident 2 on 11/13/15 at 9:40 am, Resident 2 reported that on 11/6/15 at 4 am, CNA 1 seemed annoyed from the moment that he entered his room to answer his call light for assistance to the bathroom. Resident 2 stated that CNA 1 "roughly pushed and rushed me" into the bathroom. Upon entering the bathroom, Resident 2 noticed that there was feces left on the toilet seat and asked CNA 1 to please clean it off prior to being placed on the toilet. Resident 2 stated that CNA 1 refused to clean it. Resident 2 stated that he grabbed the bar in the bathroom, but CNA 1 roughly pried his fingers off and forced him down onto the toilet. Resident 2 stated that this movement hurt his arm and his bottom. Resident 2 stated, "This hurt a lot. It made me feel terrible" and described the pain on his bottom when it made contact with the toilet seat as feeling like "scalding hot water." After leaving the bathroom and returning to his recliner, Resident 2 stated that CNA 1 wadded it up and threw a blanket at him. Resident 2 stated that he felt that CNA 1 was excessively rough and rude. Resident 2 stated that he felt helpless and unable to defend himself. Resident 2 became extremely emotional and upset when recounting this episode.During an interview with the Resident Care Manager (RCM, a licensed nurse) on 11/13/15 at 10:10 am, she reported that Resident 2 is alert and oriented and not the type of person to make a big fuss over nothing. The RCM stated that she was absolutely appalled by the care that Resident 2 described receiving from CNA 1, and that this behavior was completely not acceptable. The RCM acknowledged that CNA 1 had been previously written up for providing rough care to a different resident.The facility's policy titled, "Abuse Prevention Program," dated 5/2014, indicated that all residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. This facility is committed to protecting their residents from abuse by anyone including, but not necessarily limited to; facility staff, other residents, consultants, volunteers, staff from other agencies providing services, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individuals.Therefore, the facility failed to ensure Resident 2's right to be free from abuse and to protect Resident 2 from physical and mental abuse when CNA 1 was excessively rough and rude toward Resident 2, rushed and shoved Resident 2 into the bathroom during toileting, refused to clean feces off of the toilet, pried Resident 2's fingers from a grab bar and forced Resident 2 down onto the toilet, and after leaving the bathroom, CNA 1 wadded up and threw a blanket at Resident 2.These failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 230000187 |
Mayers Memorial Hospital D/P SNF |
230012276 |
B |
31-May-16 |
4B3J11 |
7748 |
F223 483.13(b) 483.13(c)(1)(i) Free from abuse/involuntary seclusionThe resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.The facility failed to protect Resident 1 from verbal and physical abuse by Resident 2 when: On 2/16/15, Resident 2 grabbed Resident 1's wheel chair, shaking Resident 1 back and forth, hitting Resident 1 in the head.On 3/18/15, Resident 2 had grabbed Resident 1's wheel chair (while he was in the wheel chair) and pushed it against a wall.On 3/25/15, Resident 2 yelled at and hit Resident 1 resulting in a large goose egg (protruding soft tissue impact injury) to Resident 1's left eye with bruising. These failures resulted in Resident 1 being abused by Resident 2 on three occasions leaving Resident 1 feeling anxious and fearful about Resident 2 assaulting him and causing a large goose egg with bruising on his left eye, and has the potential for Resident 1 to continue to abused by Resident 2 and places other residents at risk for mistreatment, neglect and/or abuse.The facilities policy titled, "Abuse, Resident," dated 10/19/11, indicated the resident has the right to be free from abuse including abuse from other residents. The staff will assess, care plan and monitor residents with needs and behaviors which might lead to conflict or neglect. The facility will protect resident and will take steps to prevent other opportunities of abuse from occurring which includes resident to resident altercations. Resident 1's record was reviewed. Resident 1 was admitted to the facility on 1/14/14 with diagnoses that included dementia, agitation, and history of stroke with weakness. Resident 1's Minimum Data Set (MDS, a resident assessment), dated 1/31/15, indicated that Resident 1 was moderately cognitively impaired, had difficulty with communication, and used a wheel chair for mobility. Resident 1 was Spanish speaking only.A Nursing Care Plan (CP), dated 1/27/15, titled, "Alteration in Behavior" indicated Resident 1 was restless and had anxiety, agitation, and depression. The CP approach included to give medications, smile and use a calm approach, monitor triggers and provide intervention, allow verbalizations and listen, and communicate using short sentences.A facility document titled, "Investigation Tool Form (ITF)," dated 2/16/15, indicated, it was witnessed by a the Activity Staff (AS) that Resident 2 had shook and hit Resident 1 from behind while he was seated in his wheelchair. There were no injuries. Resident 1's Nurse's Progress Note (NPN), dated 2/16/15, indicated, that Resident 2 had followed Resident 1, and it was witnessed that Resident 2 grabbed Resident 1's wheel chair, shaking Resident 1 back and forth, hitting Resident 1 in the head. Resident 1 took his hat off and attempted to hit Resident 2, who was behind him, with his hat. Resident 2's record was reviewed. Resident 2 was admitted to the facility on 2/2/15, with diagnosis that included depression, anxiety, and attention deficit hyperactive disorder (disorder with hyperactive or impulsive behaviors).Resident 2's CP titled, "Alteration in Mood and Behavior," dated 2/16/15, indicated, "agitation with Resident 1." An update to the CP on 3/18/15 indicated, Abusing other resident, keep these residents apart as much as possible.Resident 1's NPN and an ITF, both dated 3/18/15, indicated in an unwitnessed event, Resident 2 had grabbed Resident 1's wheel chair (while he was in the wheel chair) and pushed it against a wall. The event was reported to Certified Nurses Aide (CNA) C by Resident 1. Resident 2 (who was alert and oriented) confirmed the above and stated, that he had "made me mad, then I reached and lifted him up, and said the next time I will rip your head out. So he knows not to come around." The ITF indicated the CP was revised, and included to protect the resident and indicated, "...do not leave these residents alone together."Resident 1's Physician's Progress Note, dated 3/19/15, indicated Resident 1 has been anxious about another resident who had been physically assaulting him.The plan indicated, "Victim of abuse by another nursing home resident. The other nursing home resident's (Resident 2) medications have been adjusted. He (Resident 2) has had multiple discussions with nursing staff as well as his physician and if he continues with this behavior, he will be leaving the facility." A form titled, "SOC 341 (report of suspected abuse)," dated 3/25/15, was completed by the facility and indicated, "Alarm sounding, CNA responded, heard yelling, Resident 2 was saying, I'm going to kill you mother f---er. CNA asked Resident 2 if he hit Resident 1 and he stated yes. Large goose egg to Resident 1's left eye with bruising." The IFT, dated 3/25/15, indicated the facility had determined resident to resident abuse occurred because Resident 2 does not like Resident 1 and confirmed Resident 1 had a left eye bruise with a big goose egg bump on his head. Number nine on the form indicated, "Was Care Plan followed? and the answer was marked "Yes". Number 11 on the form indicated "Resident 1 was afraid of Resident 2, Resident 2 is always looking for Resident 1. Interview of Resident 2, admits hitting Resident 1." Number 24 on the form indicated, "Continue to keep these residents separated."Resident 1's NPN, dated 3/26/15, indicated that Resident 1 has a large goose egg on the "right side" of his head and has black eyes. Resident will no longer have altercation with Resident 2. Resident 1 will be safe from this resident abuse.On 4/8/15 at 3:15 pm, Resident 2 stated in an interview that he had hit Resident 1 and if he "had the chance, he would beat his head in."On 4/29/15 at 2:50 pm, an interview with Charge Nurse (CN) A and CN B, and a concurrent record review of the three resident to resident altercations that involved both Residents 1 and 2 on 2/16, 3/18, and 3/25/15 was conducted. Both CN A and B stated that Resident 2 was "out to get Resident 1" and confirmed that Resident 1 had not been kept safe from Resident 2. CN A acknowledged and stated the care plan for Resident 1 had not been followed to keep the residents separated from each other, in accordance with the facility's "Abuse, Resident" policy which indicates the resident has the right to be free from abuse including abuse from other residents, the staff will assess, care plan and monitor residents with needs and behaviors which might lead to conflict or neglect, and protect the resident, taking steps to prevent other opportunities of abuse from occurring which includes resident to resident altercations. Therefore, the facility failed to implement its abuse prevention policy to protect Resident 1 from verbal and physical abuse when: On 2/16/15, Resident 2 grabbed Resident 1's wheel chair, shaking Resident 1 back and forth, hitting Resident 1 in the head.On 3/18/15, Resident 2 had grabbed Resident 1's wheel chair (while he was in the wheel chair) and pushed it against a wall.On 3/25/15, Resident 2 yelled at and hit Resident 1 resulting in a large goose egg (protruding soft tissue impact injury) to Resident 1's left eye with bruising. These failures resulted in Resident 1 being abused by Resident 2 on three occasions leaving Resident 1 feeling anxious and fearful about Resident 2 assaulting him and causing a large goose egg with bruising on his left eye, and has the potential for Resident 1 to continue to abused by Resident 2 and places other residents at risk for mistreatment, neglect and/or abuse.This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 230000278 |
Marysville Post-Acute |
230012786 |
B |
4-Jan-17 |
5X4F11 |
27600 |
F204 Preparation For Safe/orderly Transfer/discharge A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency the State LTC ombudsman, residents of the facility, and the legal representatives of the residents or other responsible parties, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.75(r). The facility failed to ensure a safe and orderly discharge for Resident 1 when Resident 1 was inappropriately discharged to a room and board (unlicensed living arrangement where lodging and food are furnished for a set price, non-medical, landlord tenant situation where resident does not need 24 hour supervision) where his physical and psychosocial needs could not be met, and without proper assessment, evaluation, preparation, ancillary healthcare services referrals (home health nursing and physical and occupational therapies), and follow up physician appointments. This failure resulted in Resident 1 being discharged to a place that could not provide adequate care for his needs, such as supervision, behavior monitoring, medication administration, and wound care, jeopardizing his health and welfare, placing him at risk for harm. The room and board owners called 9-1-1 and the police responded and transported Resident 1 to a hospital for further evaluation and treatment, where he required constant hospital staff supervision and psychiatric evaluation and treatment. Review of a nursing progress note, dated 7/29/16 at 10:13 pm, indicated Resident 1 was newly admitted to the facility with diagnoses of dementia (loss of brain function affecting memory, thinking, and behavior) and bipolar disorder (mental problem characterized by mood swings with emotional highs and lows), that Resident 1 was having behaviors of not letting staff assess his leg wound or help him change his urine-soaked clothes, yelling and swinging at staff, and moving about in the hallway and his room naked. The Director of Nursing (DON) was notified of these behaviors, and due to the facility not being able to care for Resident 1 safely, he was sent back to the hospital. A review of Resident 1's record indicated Resident 1 was re-admitted to the facility on 7/30/16 with diagnoses of left leg cellulitis (painful, inflamed, infected skin) requiring wound vacuum (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds), cognitive memory deficit (defined as a conditional state between normal aging and dementia), anxiety disorder (worry that interferes with ability to lead a normal life), morbid obesity (100 pounds over ideal body weight), chronic obstructive pulmonary disease (COPD, lung condition that makes it difficult to breathe that is not curable), and atrial fibrillation (afib, irregular heartbeat), and on Coumadin (blood thinning medication used to prevent blood clots caused by afib). Resident 1's record indicated he was not his own decision maker and he had a payee (a person who manages finances for an individual who cannot manage their own benefits) in place. Resident 1 was a full code (all resuscitative efforts are to be made in the event of cardiopulmonary arrest). Review of a nursing progress note, dated XXXXXXX at 5:17 pm, indicated Resident 1 was re-admitted from the hospital, and did not include a diagnosis of bipolar disorder or dementia. The facility notified Resident 1's daughter of his admission and she informed the facility that Resident 1 had a history of behaviors including urinating in public, stripping, and "running away" from the facility, when he lived at a board and care facility (a licensed 4 to 16 bed non-medical facility that provided room, meals, housekeeping, supervision, storage and distribution of medication, and personal care assistance with basic activities like hygiene, dressing, eating, bathing and transferring) prior to hospitalization. Resident 1's daughter was informed by hospital staff that Resident 1 needed to be in a "locked down facility." A review of the facility's Interdisciplinary Team (IDT, a team of facility staff who meet to review and plan for resident care needs) progress notes, for Resident 1, dated 8/1/16 at 1:10 pm, included the attendees: Director of Staff Development, the Admin, and DON. The IDT note indicated Resident 1's discharge plan was to return to the community, closer to his sister. Resident 1's family, social services, and physician did not attend the IDT meeting. A review of an IDT conference note, dated 8/2/16, conducted by the Social Services Director (SSD) with therapy staff present, attended by Resident 1 and Resident 1's sister (via telephone), indicated the family wanted Resident 1 to stay at the facility as a long-term resident. Resident 1's sister stated she wanted Resident 1 to be conserved by the County (a legally appointed decision maker), and that he already had a payee. A social services progress note, dated 8/9/16 at 6:47 pm, indicated Resident 1 refused wound care and would not wear a wound vacuum. The progress note indicated Resident 1 wanted to return to his previous board and care. According to California Advocates for Nursing Home Reform (CANHR), board and care and assisted living facilities are for care and supervision of people who are unable to live by themselves, but who do not need 24 hour nursing care. They are considered non-medical facilities and are not required to have nurses, certified nursing assistants, or physicians on staff. Review of a nursing progress note, dated 8/15/16, indicated Resident 1 required skilled nursing care related to his COPD and cellulitis of left lower extremity (LLE). Resident 1 had a LLE open wound and prescribed wound care treatments, was forgetful, required supervision for all transfers, and received narcotic pain medication for leg pain. Resident 1 was prescribed Coumadin and the dosage was being adjusted due to abnormal laboratory values per an international normalized ratio (INR, a lab measurement to determine the effects of Coumadin on the body's blood clotting) results. Resident 1 required frequent monitoring and redirection by nursing staff for inappropriate behaviors. A review of the facility's minimum data set (MDS, a resident assessment), dated 8/16/16, indicated Resident 1 had a BIMS (a mental capacity test that determines the ability to think and reason) score of 13 out of 15, no identified mood disorder, required limited assistance with bed mobility, transfers, walking, dressing and toileting, required limited to extensive assistance with bathing and hygiene, was independent for eating, continent of bowel and bladder (able to control), and experienced pain daily. A social services progress note, dated 8/17/16 at 10:17 am, indicated Resident 1 could not be re-admitted to his previous board and care. The owner of the board and care stated Resident 1 could not return "due to family issues." Review of a Nurse Practitioner (NP) progress note, dated 8/22/16 at 10:34 am, indicated Resident 1 attempted to elope (leave the facility, undetected) several times. Resident 1 was only oriented to person (himself). Resident 1 was unable to return to previous board and care due to family problems. NP stated that his wound vacuum was discontinued due to the resident removing it. A review of the facility's nurses notes, dated from 7/31/16 through 8/31/16, indicated the following: Resident removed his wound vacuum which had to be replaced by nursing. Laboratory values for Protime and INR were abnormal, requiring blood thinning medication (Coumadin) dosage adjustments. Resident 1 occasionally refused care but was noted to be mostly cooperative, pleasant, alert, confused, forgetful, required redirection and supervision for all transfers. Resident 1's diet included added nutritional supplements, vitamins and snacks twice daily for wound healing. Due to the resident removing the wound vacuum twice in 24 hours, it was discontinued, and new orders were received for an absorbent dressing to be applied and covered with kerlix and ace wrap. Resident required supervision for all transfers and toileting. Resident 1 had orders for ear drops and lavage (washing out of ears) and antibiotics for the LLE wound. Resident 1 was occasionally noncompliant with LLE wound dressing changes. Resident 1 exhibited behaviors of repeating himself verbally several times after spoken to and taking his clothes off several times throughout the day and required supervision for basic activities of daily living (ADLs, routine activities that people tend to every day), bed mobility, and transferring. Resident 1 expressed having pain by removing LLE wound dressing and picking at his wound to left medial ankle described to have purulent (containing pus) drainage and reddened tissue surrounding the wound, and pain was treated with narcotic medication. Resident 1 required skilled care for his chronic lung disease and LLE cellulitis/wound. Resident 1's LLE wound was open and had deteriorated. Resident 1 had many verbal outbursts daily, pulled his pants down and urinated on a tree outside the facility in the presence of residents and visitors. Became verbally loud and aggressive with staff (treated with Ativan, a medication used to reduce anxiety). Required limited one person assistance required with transfers, dressing and hygiene, had multiple anger outbursts, and required supervision for all transfers and toileting. Occasionally refused medications. Required redirection for aggressive behaviors and many inappropriate verbal outbursts. A review of the facility's Discharge and Transfer-Notice of proposed transfer discharge, dated 9/6/16 at 2:46 pm, indicated Resident 1 was to be discharged on 9/8/16 to a board and care, due to his health improving, no longer needing services provided by the facility. The document was not signed by Resident 1's responsible party or physician. There were no physician progress notes or assessments to indicate Resident 1 was improving mentally, rather there was documentation of his inappropriate behaviors. Resident 1 was still requiring wound care to his LLE and INR monitoring for his Coumadin dosage, which was being changed frequently due to his INR not being in a therapeutic range. Review of a NP progress note, dated 9/7/16 at 10:26 am, indicated Resident 1 was only oriented to himself and on Coumadin requiring INR monitoring. Resident 1 was started on Risperdal (an antipsychotic medication used to decrease mood instability) for elopement attempts and aggressive behavior toward staff. Resident 1 was to be discharged to an assisted living facility (a licensed 16+ bed, non-medical facility that provides room, meals, housekeeping, supervision, storage and distribution of medication, and personal care assistance with basic activities like hygiene, dressing, eating, bathing and transferring). The NP recommended Resident 1's Coumadin be discontinued because INR monitoring could not be done at an independent living facility, and Xarelto (another medication used to prevent blood clots) was to be started. A social services progress note, dated 9/8/16 at 12:05 pm, indicated Resident 1 was not accepted to the "retirement home" because the owners of the home stated resident was "unstable to go there." Despite receiving denials from two different board and care homes, due to Resident 1's inappropriate behaviors, declining orientation status, inability to make decisions on his own, per a social services progress note dated 9/12/16 at 10:37 pm, the facility's plan continued to be "look for lower level placement," for Resident 1. A review of Resident 1's record indicated he continued to have inappropriate behaviors from 9/9/16 through discharge on 9/27/16, despite the start of Risperdal. Review of a Physician's Report for Residential Care Facilities for the Elderly, signed by the physician (MD A) on 9/23/16, indicated residential care level includes primarily non-medical care and supervision to meet the needs of the person and "DO NOT PROVIDE SKILLED NURSING CARE." The document indicated Resident 1 was examined on 9/23/16, was 6'1" tall and weighed 253 pounds, could not manage his own treatment/medication/equipment, and had mild cognitive impairment (defined as a conditional state between normal aging and dementia). The document indicated Resident 1 did not have confusion or inappropriate, aggressive, or wandering behaviors and was not able to leave the facility unassisted. The document indicated Resident 1 was not able to administer his own medications or oxygen. Physical health status was "Good." A review of the facility's nurses notes, dated from 9/1/16 through 9/27/16, indicated the following: Resident 1 occasionally refused medications, was found walking outside nude, was uncooperative with care, continued to require Coumadin dosage adjustments for abnormal INR levels, his LLE wound measured 2.5 x 5.6 x 0.3 cm (increase in size) and was draining fluid. Required one person assistance for ADLs and daily skilled nursing care related to chronic lung disease and LLE cellulitis/wound and medicated for pain and anxiety, continued to require daily dressing changes performed by a treatment nurse, exhibited episodes of being verbally aggressive and inappropriate, requiring redirection for inappropriate behaviors and Ativan for increased anxiety, and was started on a new antipsychotic medication, Risperdal 0.5 milligrams (mg) every bedtime for mood instability. Coumadin was stopped and a new medication, Xarelto, was started. Resident 1 was educated by the speech therapist to "stop verbal inappropriateness and behavior with the new facility." On 9/7/16 at 5:40 pm, "new order received from NP for OK to discharge to... Retirement Home with meds, HH/PT/OT (home health/physical therapy/occupational therapy) for strengthening when arrangements made." On 9/8/16, [Retirement Home] owners refused to take Resident 1. On 9/9/16, Ativan medication was increased to 0.5 mg bid (twice daily) and bid prn (as needed). On 9/10/16, Resident 1 required one person assist with ADLs and minimal assistance with transfers, and was alert and oriented to himself only. Resident 1 continued to require daily skilled nursing care for COPD and LLE cellulitis/wound. Resident 1 went outside unattended for about 5 minutes, and after unsuccessful attempts to redirect, exhibited verbal outbursts towards staff. Resident 1 continued to receive narcotic pain medication for leg pain, Ativan for anxiety, and wound dressing changes [cleanse with normal saline, pat dry, cover with calcium alginate rope and dry dressing]. On 9/19/16, Resident 1 required redirection for angry outbursts. Review of the facility's September 2016 medication administration record indicated Resident 1 was administered Ativan for inability to relax on 9/1, 9/2, 9/3, 9/4, 9/9, 9/15, 9/16, 9/18, and 9/21/16. A review of the facility's Discharge/Transfer Report indicated Resident 1 was "Discharged home" on XXXXXXX. Resident 1's records indicated he was discharged from the facility on XXXXXXX to a room and board establishment. There was no indication of a plan or orientation process in place to smooth Resident 1's transition from one facility to another. The record showed no discharge summary with medications list that provided important information for the new accepting facility to adequately care for Resident 1. During Resident 1's entire stay at the facility there was no IDT note indicating resident was adequately assessed for appropriate discharge to a lower level of care. A written Right of Appeal of Discharge was not in his record for discharge on XXXXXXX. During an interview with room and board owner (RB) on 10/11/16 at 1:34 pm and continued on 10/13/16 at 1:00 pm, he stated "We are a room and board, not a board and care." RB stated the facility told him Resident 1 was independent, high functioning and did not need help with his medications. RB stated the plan was to provide Resident 1 with three meals a day, a room to sleep in, and for him to be independent and compliant with normal landlord/tenant rules. The owner stated Resident 1 arrived at 3:15 pm on 9/27/16, with a large bag of medications, and no instructions. He did not know anything about Resident 1's wound on his left leg. RB described Resident 1 as having aggressive behaviors toward the other room and board tenants. RB stated Resident 1 was stealing food from others, threatening to hurt them, and shoved his roommate and said "I'll kick your ass... pour this soda in your face." Resident 1 arranged the stolen food in a line and told his roommate not to touch "my food." RB's wife attempted to speak with Resident 1 about his behaviors, he threatened to hurt her. RB stated the resident had been at his room and board for less than 24 hours when they had to call 9-1-1 for assistance with Resident 1. The police arrived and Resident 1 threatened his roommate in front of the police, they arrested him and stated he was not appropriate to stay at the room and board establishment. On 10/13/16 at 2 pm, Resident 1's room and board roommate was interviewed. He stated "It was hell" explaining that Resident 1 was as "big as a house" and pushed him, stole his food, and said he was going to "kick my (his) ass." During an interview with SSD on 10/11/16 at 2:55 pm, she stated she was not involved in Resident 1's discharge, the Admin was involved with arrangement of the discharge. SSD indicated Resident 1 wanted to go back to his original board and care, but they would not take him back due to issues surrounding resident and family. She stated he was originally accepted to another local board and care, but was denied admittance due to his behaviors. SSD stated Resident 1's family wanted resident to go to a locked facility due to his behaviors. SSD described Resident 1 to be loud and stated he would get in people's faces, he liked to "sunbathe" and would get naked outside. SSD stated Resident 1 had improved physically while at the facility because he was able to walk on his own, however, mentally and psychosocially he declined and was not a good candidate for a board and care. During an interview with Resident 1's daughter on 10/12/16 at 8:45 am, she stated the only information given to her in regard to Resident 1's discharge was that he was being transferred to an assisted living place in Sacramento. She stated the facility gave her the name and address and she was not notified in writing or given discharge appeal rights. She stated that Resident 1 had a history of a mental disorder and while at the facility, he stripped his clothes off in public and urinated on cars. She stated that Resident 1 needed constant supervision due to his behaviors and she was under the impression that the assisted living would be able to provide constant supervision to her father. During an interview with the Admin on 10/12/16 at 10:25 am, he stated Resident 1 was desperate to leave the facility and his daughter was excited for him to go. The Admin stated, "I didn't give them anything in writing," and indicated he texted the name and address of the accepting facility to the daughter, further stating, "There was no reason to give them the right to appeal." A review of the facility's Observation Report: Discharge and Transfer-Discharge plan of care, originally created by the SSD on 9/6/16 at 2:40 pm, indicated Resident 1 was to be discharged on 9/8/16. The 9/8/16 date was lined out and replaced with a different hand written discharge date of 9/27/16, and timed 2:00 pm. A new observation report was never generated for Resident 1's actual discharge that occurred on 9/27/16. The report stated the NHA (nursing home administrator, Admin) personally transported Resident 1 to his new living arrangement via car. During an interview with medical records staff (MR) on 10/12/16 at 11 am, she indicated there was no leave of absence form on file for Resident 1 because the only time he left the facility with a staff member was when the Admin drove him to the board and care, when he was discharged. During an interview with NP on 10/12/16 at 12:35 pm, she stated she will never forget Resident 1; he had loud, inappropriate behaviors. When asked about the facility's discharge and IDT processes, NP stated she was not part of the IDT. She referenced a facility-provided binder that included the facility's recommendations for residents who should be discharged, and wrote the order to discharge Resident 1 to a board and care facility. She indicated that a board and care facility should be able to provide care to Resident 1 because they give him his medications and meals. In regards to Resident 1's orientation status and confusion, NP stated resident was alert and oriented to person and place depending on his level of agitation. Concurrent record review of her progress note, dated 9/27/16 at 2:10 pm, indicated Resident 1 was alert and oriented to self only. NP stated Resident 1 had good days and bad days and his orientation depended on his level of agitation. NP stated she thought a psychiatrist had seen Resident 1 during his stay at the facility and had ordered medication for him. A concurrent record review showed no evidence that Resident 1 had ever been seen by a psychiatrist at the facility. NP asserted that Resident 1 was a candidate to be transferred to the board and care despite his leg wound requiring wound care, stating, "his wound was healing, his dressing was clean, dry and intact." A concurrent record review of an order, dated 9/22/16, indicated "cleanse....ankle with normal saline, pat dry, apply Maxorb calcium alginate rope, cover with kerlix and ace wrap, change every other day for 14 days and then re-assess." NP stated she was under the impression assisted living staff could help with wound treatments. A review of physician orders written by NP, dated 9/27/16, included: discharge to board and care with medications and narcotics, home health (HH), physical therapy/occupational therapy (PT/OT) when arrangements are made and follow up with primary care provider in 7-10 days. During an interview with SSD on 10/11/16 at 2:55 pm, she stated she had not made the ordered referrals for HH/PT/OT prior to or on the day of Resident 1's discharge. During an interview with Resident 1's daughter on 10/12/16 at 8:45 am, she stated she did not know Resident 1 was being admitted to a room and board and that she was under the impression the facility was an assisted living. During an interview with NP on 10/12/16 at 12:35 pm, she indicated Resident 1 was going to a board and care. A record review conducted on 10/13/16 indicated there was no discharge summary with medication list for Resident 1. The facility's Observation Report: Discharge and Transfer-Discharge plan of care form, originally dated on 9/6/16, with date lined out and new date of 9/27/16 hand written next to it, indicated, "medications upon discharge: see physician orders." A review of the Physician Order Report, dated from 7/29/16 through 9/27/16, indicated Resident 1 was taking medications which included: 1. Carvedilol (a medication that lowers blood pressure, adverse reactions include low blood pressure and low heart rate) 3.125 mg twice a day-hold if systolic blood pressure is less than 110. 2. Potassium Chloride (medication used to replace potassium loss with use of furosemide, needs to be taken with food and water to prevent upset stomach) 10 milliequivalents (mEq) daily. 3. Aspirin (used to prevent blood clots in people who have atrial fibrillation, increased risk of bleeding can occur when taking this medication) 81 mg daily. 4. Digoxin (slows heart rate in people with afib, side effects include dizziness and nausea and vomiting, severe toxicity can occur if Digoxin levels not monitored) 125 micrograms (mcg) daily - hold for apical pulse less than 60. 5. Famotidine (treats and prevents irritations in the stomach) 20 mg daily. 6. Furosemide (used to decrease fluid in the body, adverse reactions include severe dehydration and potassium depletion) 20 mg daily. 7. Xarelto (thins the blood to decrease blood clots from forming, adverse reactions include increased chances of bleeding including bleeding into an important organ resulting in death) 20 mg daily. 8. Cranberry extract (supplement to help prevent urinary tract infections) 425 mg daily. 9. Ativan (medication that decreases anxiety, increased sleepiness can occur when taking this medication and potential for overdose if not taken correctly can lead to injury and death) 0.5 mg twice a day, and Ativan 0.5 mg twice a day, as needed for anxiety. 10. Risperdal (medication used to decrease mood instability, manufacturer warning states use in elderly people with dementia can increase risk of death) 0.5 mg at bedtime. 11. Meclizine (used to treat and prevent dizziness) 25 mg three times a day as needed for vertigo (dizziness). 12. Norco (used to treat pain, side effects include nausea, vomiting, constipation and potential for overdose if not taken correctly) 5-325 mg 1 tab every six hours as needed for pain. Review of a physician's order, dated 9/27/16, included, "medications and narcotics" were to go with Resident 1 when discharged. During an interview with hospital staff A (a registered nurse) on 10/11/16 at 10:30 am, she stated Resident 1 was brought to the hospital by police officers after he was arrested at a room and board establishment. She stated that Resident 1 had a history of bipolar disorder, a diagnosis of dementia with behaviors, and was not competent to make his own decisions. Resident 1 made multiple attempts to elope from the hospital and numerous threats to kill staff, requiring a one to one sitter (medical professional designated to directly supervise resident at all times). Hospital staff A stated the facility was called about the status of Resident 1 and they refused to take the resident back. Hospital staff A stated Resident 1 was "dumped" by the facility, resulting in an inappropriate discharge. During a follow up interview with hospital staff A on 11/3/16 at 3:30 pm, she stated Resident 1 was sent to another skilled nursing facility on 11/1/16, with one to one 24 hour supervision and psychiatric care. Hospital staff A stated there were no locked facilities who could take Resident 1. A review of hospital records indicated Resident 1 was treated with antibiotics at the hospital for LLE cellulitis. The facility failed to ensure a safe and orderly discharge for Resident 1 when Resident 1 was inappropriately discharged to a room and board where his physical and psychosocial needs could not be met, and without proper assessment, evaluation, preparation, ancillary healthcare services referrals, and follow up physician appointments. This failure resulted in Resident 1 being discharged to a place that could not provide adequate care for his needs, such as supervision, behavior monitoring, medication administration, and wound care, jeopardizing his health and welfare, placing him at risk for harm. The room and board owners called 9-1-1 and the police responded and transported Resident 1 to a hospital for further evaluation and treatment, where he required constant hospital staff supervision and psychiatric evaluation and treatment. This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 240000029 |
Mill Creek Manor |
240010904 |
B |
04-Aug-14 |
L9TE11 |
6085 |
REGULATION VIOLATION: 72315 Nursing Service-Patient Care (b) Each patient shall be treated with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The facility failed to keep one out of a universe of 50 cognitively impaired (reduced thinking skills, including language use) patient (Patient 1) free from physical and verbal abuse. This failure resulted in Patient 1 sustaining a skin tear to the left knee and had the potential to cause Patient 1 physical pain and mental anguish. Patient 1 was readmitted to the facility on July 2, 2013, with diagnoses that included: Alzheimer's disease (an irreversible, progressive brain disease that slowly destroys memory and thinking skills) and schizophrenia (a mental disorder that makes it hard to tell the difference between what is real and not real and to think clearly). On March 27, 2014, at 2:40 PM, an interview with the Administrator was conducted. She stated that on March 25, 2014, at approximately 6:15 AM, Licensed Vocational Nurse 1 (LVN 1) was asked by CNA (Certified Nurse Assistant) 1 to assist Patient 1 to transfer to a shower chair (A plastic and mesh chair on wheels that patients sit in while bathing). With CNA 1 and LVN 1 both at the bedside, CNA 1 was overheard by LVN 1 saying, "I don't have time for this," and proceeded to "Roughly yank Patient 1's legs apart, rip off his diaper, and roughly push Patient 1 onto his left side." The Administrator stated that Patient 1 sustained a skin tear (traumatic injuries which can result in partial or full separation of the outer layers of the skin) to his left knee. The Administrator stated that after witnessing the verbal and physical abuse, LVN 1 allowed CNA 1 to complete her shift. An observation and interview was conducted with CNA 2, on March 27, 2014, at 2:15 PM. Patient 1 was observed lying in bed. The bed was adjacent to a wall on Patient 1's left side. There were no side rails on the bed. CNA 2 stated, "He cannot turn over by himself, he needs help." After obtaining permission from Patient 1, CNA 2 lifted the bottom bedcovers and exposed Patient 1's left knee. A one inch skin tear was noted on the outer aspect of the left knee. An attempt was made to interview Patient 1, but he only mumbled. CNA 2 stated, "He can only answer in one or two words."On March 27, 2014, at 2:55 PM, during an interview with LVN 1, she stated, "At about 5:30 AM, on March 25, 2014, I was asked by CNA 1 to help transfer Patient 1 to the shower chair." LVN 1 indicated that she was standing at the foot of Patient 1's bed, when she witnessed CNA 1 say, "I don't have time for this shit." She then witnessed CNA 1 rip Patient 1's legs apart, rip off Patient 1's diaper, and push Patient 1 against the wall. LVN 1 stated that she then assisted CNA 1 with the transfer of Patient 1 to the shower chair. LVN 1 stated that she noticed that Patient 1's left knee was bleeding and she proceeded to apply gauze to the wound.LVN 1 further stated, "I was in shock. I have never seen anything like that before." LVN 1 stated, "CNA 1 had a nasty attitude and I was afraid of her, which is why I did not ask her to clock out immediately. I thought she would hurt me." LVN 1 acknowledged that she allowed CNA 1 to continue her shift and take care of other patients for an hour and a half after the witnessed abuse. LVN 1 stated, "I should have clocked her out immediately." During a review of Patient 1's clinical record on March 27, 2014, a "Licensed Personnel Progress Note" indicated the following entry for Patient 1, dated March 25, 2014, at 7:40 AM, "SBAR (situation, background, assessment and request form)/ incident report initiated for CNA to patient altercation with skin tear to left knee...will continue to monitor for emotional distress.''A form titled "History and Physical Examination," dated September 27, 2013, indicated that, "This patient does not have the capacity to understand and make decisions." Also, a Physician's order dated March 25, 2014, and timed 7:40 AM, indicated an order as follows, "Cleanse left knee s/t (skin tear) with NS (normal saline), pat dry, apply TAO (triple antibiotic ointment) x (times) seven days." During a review of the clinical record for Patient 1 on April 8, 2014, at 10:00 AM, the Quarterly minimum data set (MDS, a tool used by long-term care facilities for assessing and planning care for residents), dated March 12, 2014, was reviewed.Noted under "Section B, Hearing, Speech, Vision," that Patient 1 was coded as "Rarely or never is understood" and "Rarely or never understands others." This same MDS indicated under "Section C, Cognitive Patterns," that Patient 1 was coded as having a long term and short term memory problem. On March 27, 2014, at 4:00 PM, during an interview with the SSD (Social Services Director) she stated, "I want my staff to stand up when something like this happens, the CNA (CNA 1) should have been sent home immediately and the nurse (LVN 1) should have started the abuse protocol immediately." The SSD went on to say that LVN 1, "Should have stopped the abuse when it was happening." A review of facility policy and procedures was conducted on March 27, 2014. A policy titled, "Abuse Prevention and Elder Justice Program," and dated 2013, defines abuse as, "The willful infliction of injury...or punishment with resulting physical harm, pain, or mental anguish." It noted under "Policy," This facility recognizes that each resident has the right to be free from all forms of abuse (verbal, physical...). The policy further notes, "All forms of abuse are strictly prohibited by this facility." A follow up interview with the Administrator was conducted on March 27, 2014, at 4:20 PM, and she stated that, "This (abuse) never should have happened." The failure of the facility to protect Patient 1 from physical and verbal abuse was the direct cause of Patient 1's injuries. The violation of the above regulation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other physical or emotional trauma to patients. |
| 240000080 |
MEDICAL CENTER CONVALESCENT HOSPITAL |
240012199 |
B |
20-Apr-16 |
7TTH11 |
11495 |
REGULATION VIOLATION: Patients' Rights Title 22 72521 (a) & 72527(a)(10) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. (a)Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. 1. The facility failed to ensure that one (1) of three (3) sampled patients (Patient A) was free of mental and verbal abuse when the Maintenance Supervisor (MS) responded to Patient A's request to have his bed repaired, by telling Patient A,"I will blow your head off."2. The facility failed to follow its policies and procedures for abuse reporting, documentation of grievances and monitoring patients after an incident, when the facility failed to immediately investigate and report an allegation of abuse by staff; and by not assessing and monitoring Patient A's mental status within (72 hours) after the incident. Findings: An unannounced visit was made to the facility on January 20, 2015, to investigate an entity reported incident related to resident abuse. A review of the facility's typed summary of the facility investigation, undated, was completed on August 27, 2014. The summary was provided with the facility's SOC 341 (report of suspected adult/elder abuse form) report of the incident to the California Department of Public Health (CDPH) on August 25, 2014. The summary indicated that on August 12, 2014, Patient A asked a Maintenance Supervisor (MS) to fix his bed, and MS replied, "I will blow your head off." Patient A verbalized the comment made him feel threatened. A review of the clinical record revealed Patient A was admitted to the facility on April 14, 2014, and had diagnoses that included: hypertension (high blood pressure) and depressive disorder (a mood disorder of persistent feeling of sadness). The physician's history and physical examination dated April 16, 2014, revealed Patient A "has the capacity to understand and make decisions." During an interview with Patient A on January 20, 2015 at 1:55 PM, when asked to describe what happened, Patient A advised that he asked MS to fix his bed. Patient A stated that MS, who was holding "some kind of a tool," replied, "I will blow your head off." MS then gestured, "Bang, bang," using the tool he was holding. Patient A stated, "I felt threatened. You don't joke like that; I don't really know the guy." Patient A stated this was witnessed by another staff (Housekeeper 1). Patient A stated MS never came back to fix his bed; another maintenance staff came a couple days later to fix his bed.During an interview on January 20, 2015 at 2:15 PM, the Administrator stated the incident was reported to him by the Social Service Director (SSD) on August 12, 2014. He stated he reported the incident to CDPH on August 24, 2014 (14 days after the incident was reported to the Administrator on August 12, 2014. The Administrator stated during the interview, "I admit I reported it late." The Administrator stated he counseled MS on August 13, 2014, and gave a verbal/written warning on August 14, 2014. The Administrator advised that when he interviewed MS on August 13, 2014, MS stated he could have said the words complained of by Patient A, but that he was just joking with Patient A." The Administrator stated, "It was inappropriate."During an interview with MS, in the presence of the Administrator and the Director of Nurses (DON) on January 20, 2015 at 2:55 PM, when asked what happened, MS stated he was fixing Patient A's bathroom and he was holding a caulking gun (a hand tool that dispenses a material used to seal a gap or a seam). MS stated, "We [referring to Patient A and MS] used to joke around like a normal person. I know I said something as a joke, but I don't remember what I said. I didn't know he got upset." MS stated on August 13, 2014, a day after the incident on August 12, 2014, he talked to Patient A by himself and explained to Patient A, "I wasn't trying to hurt your feelings." During an interview on January 20, 2015 at 3:10 PM, the Director of Staff Development/Licensed Vocational Nurse (DSD/LVN) stated on August 12, 2014, a staff member overheard and reported the "threat" to Patient A to her. The DSD/LVN and the Social Service Director (SSD) talked to Patient A, who confirmed the incident. DSD/LVN stated Patient A, "Felt uncomfortable and didn't feel safe."DSD/LVN then reported the incident to the Administrator on the same day. DSD/LVN stated MS was not suspended during that time. The DSD/LVN stated: "The person should be suspended until the outcome and I did not see that; he was still here." During an interview on January 20, 2015 at 3:35 PM, SSD said she and DSD/LVN talked to Patient A on August 12, 2014, who confirmed the incident. SSD stated Patient A, "Felt threatened." A review of the employee file for MS was completed on January 20, 2015. A "Disciplinary Action," form dated August 14, 2014, was reviewed with the Administrator. The "Disciplinary Action" form indicated the MS received notification that he would be, "immediately suspended if he does it to any resident [patient] and agreed." A second "Disciplinary Action" form, dated August 28, 2014, revealed MS was suspended from work from August 25, 2014 (13 days after the incident was reported to the Administrator on August 12, 2014) through August 28, 2014. The document indicated: "Suspension for (3) days for re-investigating the incident." The form reflected MS had an "allegation of verbal abuse against resident [patient] August 12, 2014." Under "Corrective action," the following was listed: "verbal warning/write-up August 14, 2014, Suspension for 3 days for re-investigating the incident." During an interview with the Administrator on January 20, 2015 at 4:00 PM, he stated he had an interdisciplinary team (IDT) meeting with Patient A, and the DON discussed the allegation he made against the MS. Patient A, "accepted his [MS] apology and [MS] was reinstated on August 28, 2014." The Administrator stated he concluded, based on his interview with Patient A and MS during the investigation that MS, "was just joking." The Administrator did not provide an explanation for suspending the MS 13 days after being made aware of the allegation by Patient A. The Administrator stated there was no documented evidence a result of the investigation was reported to CDPH. During a concurrent review of Patient A's clinical record, completed on January 20, 2015, SSD confirmed there was no documented evidence Patient A was assessed and monitored immediately, and following the incident until August 27, 2014 (15 days after the incident on August 12, 2014). SSD also stated there was no documented evidence a "Grievance/Complaint Report" was filled out for the incident. When asked to see the grievance/complaint log, the SSD stated there was no grievance/complaint log in place because the facility never received any grievance or complaints from anyone at all. A concurrent review with the SSD of the facility's policy and procedure entitled, "GRIEVANCES SOCIAL SERVICES ROLE AND RESPONSIBILITIES," Revised February 2005, was completed on January 20, 2015. The policy indicated the following: "The Social Service designee is a key person receiving grievance and/or complaints from residents, family members and/or responsible parties. A grievance/complaint may be oral or written. If the Social Services designee receives an oral grievance/complaint, the information is to be documented on the report form. This is to ensure the grievance/complaint has been acknowledged and actions have been taken in resolution of the problem. Reports are to be forwarded and preferably discussed promptly with the Administrator who may direct additional actions by the Social services designee in resolution of the problem. The Social Services designee may also be requested to assist in upgrading the Grievance/Complaint log. The policy further indicated: "The Social Services designee will also be a primary person responding to the individual making the grievance/complaint. This is to inform the individual the actions taken in resolution of the problem and determine their satisfaction with the facility's efforts."A review of the facility's policy and procedure entitled, "ELDER ABUSE AND DEPENDENT ADULT ABUSE REPORTING," Revised July 2012, set forth the following, under Procedure: "(6)... The Charge Nurse/Supervisor is to interview and obtain written statements." Further, under Procedure, the following was set forth: "(9) The Administrator and DON are responsible to insure that timely inclusive investigate actions have been completed. Administrative action may include suspension of an employee involved in an incident pending completion of investigation results. 11. The Administrator or DON will be responsible to report immediately or as soon as possible or within 24 hours by telephone and to be followed by a written report. SOC 341 should be send (sent) to ombudsman coordinator or to a local law enforcement agency, then to Department of Public Health Services."During an interview with Housekeeper 1, in the presence of the director of nursing (DON) on January 22, 2015 at 8:50 AM, and a concurrent review of Housekeeper 1's undated statement of the incident, Housekeeper 1 stated on August 12, 2014, MS went into Patient A's room looking for another staff. MS, who had a caulking gun in hand, told Patient A, "I can blow your head off with this."An undated incident investigation, signed by the Administrator, was received by the California Department of Public Health on August 26, 2014. The report indicated that on August 13, 2014, the day after the reported incident, the Administrator met with MS. The incident investigation set forth: "The maintenance supervisor [MS] was asked about the incident and admitted that he could have said those words, but he meant no harm and was only joking and assumes that the resident did not take those words seriously."During an interview with the DON on January 22, 2015 at 9:15 AM, and a concurrent review of the clinical record, the DON confirmed there was no documented evidence of the incident, or that Patient A was assessed and monitored immediately following the incident. The DON stated Patient A should have been assessed and monitored for 72 hours for any change in condition. A review of the facility's policy and procedure entitled, "Plan of Care for Resident Concern and/or Change of Condition," Revised July 2012, set forth: "It is the policy of the facility to document in the medical records any concern and/or change of condition/accident/incident regarding a resident which may or may not involve an injury;" and "(4)An assessment of the resident's condition by a licensed nurse including vital signs is to be done at the time of the concern/change of condition or injury and each shift for minimum of seventy-two (72) hour period/or per physician's order, or until stabilized."The facility's failure had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents |
| 240000080 |
MEDICAL CENTER CONVALESCENT HOSPITAL |
240012516 |
A |
18-Aug-16 |
Y46V11 |
7563 |
REGULATION VIOLATION Title 22, California Code of Regulations, Division 5, Article 3, Section 72527 (a)(10) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. FINDINGS: The facility violated the above regulation by failing to: Protect one out of three sampled patients (Patient A) from sexual abuse by Patient B when he entered Patient A's room uninvited and fondled her genitalia area. An unannounced visit was made to the facility on November 4, 2015, at 4:00 PM, to investigate an entity reported incident of sexual abuse of Patient A by Patient B. During a review of the clinical record for Patient A, the admission record indicated Patient A was admitted to the facility on November 19, 2014, with diagnoses which included: Type 2 diabetes mellitus (a condition where the body does not produce insulin, which is needed to produce energy), gastrostomy (a tube placed through the abdomen wall through which liquid nutrition and medication are administered), adult failure to thrive (progressive functional deterioration, physical and cognitive nature, cognitive decline), Huntington's disease (a progressive loss of brain and muscle function), chronic obstructive pulmonary disease (chronically poor airflow), constipation (bowel movements that are hard to pass), and hypertension (high blood pressure). Patient A was a small statured woman, who was totally dependent on staff for all activities of daily living (ADLs), requiring the assistance of two people. She was non-verbal, non-ambulatory, and immobile. During a review of the clinical record for Patient B, the admission record indicated that Patient B was admitted to the facility on November 3, 2015, with diagnoses which included: multiple physical conditions, as well as, Schizophrenia (a breakdown in the relation between thought, emotions, and behavior leading to a faulty perception inappropriate actions and feelings), and major depressive disorder (persistent feelings of sadness). Patient B was alert with confusion, did not have the capacity to make decisions, ambulatory, and 179 pounds. During a phone interview on November 5, 2015, at 10:34 AM, with the Certified Nurse Assistant (CNA 1), who witnessed Patient B fondling Patient A's genitalia on November 4, 2015, at 6:45 AM, CNA 1 described the incident as follows: CNA 1 was doing rounds and walking in the hallway when CNA 1 noticed Patient B was in Patient A's room and CNA 1 observed Patient B fondling Patient A on the genitalia area. CNA 1 told Patient B to get out of the room and escorted Patient B back to his room. Patient B was placed on a 1:1 observation. CNA 1 confirmed that Patient A was quiet; she did not speak, and was confined to bed. During a review of the declaration statement explaining the incident on November 4, 2015, where CNA 1 noticed Patient B's hand on her (Patient A's) private area. CNA 1 immediately redirected Patient B out of Patient A's room. The charge nurse was notified and Patient B was placed on 1:1 watch for close behavioral observation with staff monitoring. A full body assessment was done to Patient A by the charge nurse. The Director of Staff Development, the Administrator, and the Director of Nursing were notified. During a phone interview on November 5, 2015, at 10:38 AM, with CNA 2 who was assigned to Patient A, she described the incident as follows: "I did not see the incident but I did see [Patient B] entering and exiting several times from the outside patio sliding door leading to [Patient A's room]"..."I reported to the charge nurse and to the CNA [CNA 1] who was assigned to the patient [Patient B] about his behavior." During a review of the declaration statement of CNA 2, who witnessed Patient B entering and exiting Patient A's room from the outside patio sliding door on November 4, 2015 (no time was indicated on the statement form), it read, "Witnessed [Patient B] entering and exiting [Patient A's room] outside patio and I told him several times that he couldn't use the sliding door of that room as an entrance or exit. This was reported to his assigned CNA [CNA 1] of Patient's [B's] behavior at that time. [CNA 1] witnessed [Patient B] coming out from [Patients A's room] and CNA 1 addressed Patient B and I continued to finish my rounds." During an interview with the Director of Nursing (DON) on November 6, 2015, at 10:55 AM, when asked if CNA 2 closed the sliding door when Patient B was entering from the patio to Room 32, she said, "Yes, Patient B kept on opening the sliding door. The door was not locked." During a phone interview on November 6, 2015, at 11:34 AM, with the Licensed Vocational Nurse (LVN 1) who was not an eyewitness to the incident, when asked if Patient A's diaper was open when CNA 1 witnessed Patient B fondle Patient A's genitalia, she said, CNA 1 told her that Patient A's diaper was open and Patient B had his hand on Patient A's genitalia, and Patient B was fully dressed. When asked whether CNA 2 notified her regarding Patient B entering through the sliding door coming from the patio to Room 32 before the incident occurred, LVN 1 said, "No." She stated she was told by CNA 2 about CNA 1 witnessing Patient B fondling Patient A's genitalia. The facility policy and procedure titled, "Criteria to Screen Residents for Potential Abuse," dated July 2012, indicated, "Possible signs of Sexual Abuse: cuts, lacerations, bruises, around genital areas, injuries not compatible with history, flirtations, coyness, etc., as possible indicators of inappropriate sexual relationship, helplessness, hesitation to talk openly, fear, withdrawal, depression, denial, agitation, and fear." During a phone interview on November 5, 2015 at 10:34 AM, with CNA 1, stated he witnessed Patient B fondling Patient A's genitalia on November 4, 2015, at 6:45 AM. The facility policy and procedure titled, "Abuse and Neglect Prevention Management," July 2012, indicated, "Screening potential residents will be reviewed for potentially abusive behaviors: the pre-admission screen reviews the residents diagnoses that may cause behavioral symptoms such as dementia, traumatic brain injury, multiple sclerosis, Huntington's disease, and Intellectual Disability/Developmental Disability. The facility makes every effort to ensure residents who have challenging behaviors will receive a psychiatric evaluation for appropriate interventions." Patient B has a history of Schizophrenia. In addition, the policy further states under "Identification", "All staff will be observant for any resident or staff conditions that might be indicative or predictive of potential abuse and/or neglect; such as suspicious bruising, withdrawn behaviors, distress, change in behaviors, etc." Patient B entered Patient A's room multiple through an unlocked sliding door. The facility failed to ensure Patient A was free from sexual abuse by Patient B, by not preventing Patient B from re-entering Patient A's room uninvited. These violations of the regulations jointly, separately or in any combination presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 240000080 |
MEDICAL CENTER CONVALESCENT HOSPITAL |
240012552 |
A |
1-Sep-16 |
XBDF11 |
2603 |
REGULATION VIOLATION: Title 22, 72311(a)(3)(G) Nursing Service-General (a)Nursing service shall include, but not be limited to, the following: (3)Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (G)The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. FINDINGS: The facility failed to ensure licensed staff notified the physician when Patient 3 repeatedly refused medication as ordered by the physician. This failure had the potential to cause the resident to experience physical harm. A review of Patient 3's Medication Administration Record (MAR) dated June 2016, indicated Patient 3 was to receive Lantus Insulin (a long-acting insulin to control blood sugar levels) at 9:00 PM, daily. The MAR indicated Patient 3 refused the Lantus insulin, on the following dates: June: 1, 2, 5, 6, 7, 8, 9, 10, 11, and 12, 2016. A review of the MAR and nurse's progress notes indicated there was no documented evidence that Patient 3's physician was notified for any of the days Patient 3 had refused the insulin. During an interview with the Registered Nurse Supervisor (RN 1) on June 15, 2016, at 9:24 AM, she confirmed there was no documentation to show that a physician was notified of Patient 3's refusals as documented on the MAR. A review of Patient 3's care plan titled, "Noncompliance as evidenced by refusal of Lantus. At risk for medical illness deterioration," dated September 17, 2014, indicated under "approach" column: "Report noncompliant behavior to MD and responsible party." A review of the facility policy and procedure titled, "Medication Documentation," revised June 2012, indicated, "Charting...9. Drugs not given as prescribed. a. When doses are refused or not given for other reasons or given at a time other than that prescribed the nurse shall circle her initials and explain reason on back of medication administration record. b. Physician should be notified of missed doses as appropriate..." Therefore, the facility failed to ensure the patient's physician was notified when Patient 3 refused medication as prescribed by the physician, which had the potential to cause physical harm and prevent the resident from maintaining her highest practicable physical wellbeing. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 240000080 |
MEDICAL CENTER CONVALESCENT HOSPITAL |
240012554 |
A |
1-Sep-16 |
XBDF11 |
4530 |
Regulation Violation Code of Federal Regulation, CFR 483.25 (i) Nutrition: Based on a resident?s comprehensive assessment, the facility must ensure that a resident- 483.25(i)(1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels; unless the resident?s clinical condition demonstrates that this is not possible. The facility failed to ensure that Resident 10 did not experience an undesirable 9 lb. (pound) weight loss in 2 months. The facility also failed to assess Resident 10 after the weight loss. During a review of the clinical record for Resident 10, the "Resident Face Sheet," indicated that Resident 10 was admitted to the facility with a diagnosis of Diabetes Mellitus (uncontrolled blood sugar). A review of the "Care Plan," for Resident 10, dated February 15, 2016, indicated, "Significant change in status assessment: 14 lbs. weight gained in 6 months, Resident desirable weight gained." A review of Resident 10?s "Monthly weight record" dated March 1, 2016, indicated that Resident 10 was 135 lbs. On April 1, 2016, Resident 10 weighed 130 lbs. and on May 1, 2016, Resident 10 weighed 126 lbs. Resident 10 lost a total of 9 lbs. in 2 months. During an interview with the Restorative Nurse Assistant (RNA-Staff responsible for weighing patients) on June 15, 2016 at 2:27 PM, in Nurses' Station A, he stated that when a patient loses weight, "I notify the charge nurse who then notifies the Director of Nursing (DON). The DON will then contact the RNA to provide nourishment to the patient." During an interview with the DON, on June 15, 2016 at 2:35 PM, she stated, "When a patient loses weight, we notify the Registered Dietician (RD), and then follow the RD's recommendation. She said if there is no RD recommendation, then we contact the Doctor. We also have an Interdisciplinary Team (IDT) weight variance meeting (a meeting where residents that are risk for weight loss are discussed and care planned) once a month." She stated, "There are no IDT notes in Resident 10's clinical record. We did not notify the doctor or the dietician." During a review of the clinical record for Resident 10, there were no notes found in the "Care Plan," or documentation of the RD regarding the resident?s weight loss from March 2016 through May 2016. The DON confirmed that there were no nursing notes, no assessment notes, no updated plan of care, or physician's documentation noted in Resident 10's clinical record regarding the resident?s unintended weight loss. There were also no interventions put in place to ensure that Resident 10 regained the lost weight or to prevent future weight loss during this time. During a review of the "Care plan" for Resident 10, dated May 2015, indicated, "At risk for significant weight loss of 5% in a month or 10% in 6 months, secondary to dx (diagnosis) of Dementia (condition of significant memory loss). Approach: Monitor weight as ordered, will notify MD (medical doctor) and Resident's responsible party for any significant COC (Change of condition)." Review of the facility policy and procedure titled, "Weight Assessment and Intervention", dated March 2012, indicated, "Any weight change of 5 pounds or 5% or greater within 30 days will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician and an IDT, then meeting with weight variance will be started...If an unplanned weight loss is identified, and is significant, the IDT will proceed to care plan the weight loss, and analyze the different contributing factors which could result to unplanned weight loss...The attending physician of the subject resident will be notified for the significant weight loss or gain." Review of the facility policy and procedure titled, "Resident's Weight", dated July, 2012, indicated, "The nursing staff is accountable for identifying the residents with considerable unplanned weight gain/loss and meeting with IDT MEMBERS to discuss significant weight gain/loss interventions. The Physician is also notified of significant gain/loss undesirable weight change." Therefore, the facility failed to provide nutritional care and services to Resident 10 consistent with the resident?s comprehensive assessment. These failures resulted in Resident 10 experiencing a decline in nutritional status, and an undesirable, unplanned weight loss. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 240000080 |
MEDICAL CENTER CONVALESCENT HOSPITAL |
240012559 |
B |
6-Sep-16 |
None |
3451 |
REGULATION VIOLATION: 483.70(h) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The facility failed to provide a safe environment when a gasoline container, propane tank, cleaning solutions, other cleaning materials and landscape equipment that may contain gasoline were stored inside two separate outdoor, unventilated large metal storage bins. During an observation on June, 15, 2016 at 9:50 AM, in the outdoor facility parking lot, escorted by the Maintenance Supervisor (MS), there were two large (train car size) metal unventilated storage bins approximately 100 yards from the back of the facility. In a concurrent interview with the MS, when asked what was inside the storage bins, he stated that one bin (Bin 1) had "diapers and supplies" inside, and the other bin (Bin 2) had "activity supplies" (supplies such as craft items, decorations etc., used to provide activities for the residents). On June 15, 2016 at 9:55 AM, inside Bin 1 in the presence of the MS and the Administrator, the bin was observed to be without ventilation and the air was hot. There was no thermometer inside the bin. In addition to the diapers and supplies stored in Bin 1, there were various chemicals and combustibles including but not limited to: a. Two cardboard cases, containing four (one gallon each), plastic containers of Genlabs Orange Deodorant, that indicated, "Store in cool dry place at room temperature." b. Three cardboard cases, containing six (one gallon each), Pure Bright Germicidal Ultra Bleach, that indicated, "Store in a cool dry area away from heat." c. One cardboard case of Glass Cleaner. The cardboard case had stains from spillage. d. Four oxygen concentrators (equipment designed to hold oxygen). On June 15, 2016 at 10:05 AM, inside Bin 2 in the presence of the MS and the Administrator, the bin was observed to be without ventilation and the air was hot. There was no thermometer inside the bin. A strong odor of gasoline was noted upon opening the bin, and throughout the interior of the bin. In addition to the activity supplies stored in Bin 2, there were various chemicals and combustibles including but not limited to: a. One five gallon red plastic container with gasoline inside. b. A lawn mower and other lawn equipment requiring gasoline. c. A propane gas tank (the size and type used for gas barbeques). d. A fire extinguisher in working condition. e. A small plastic container of oil containing petroleum. f. Six plastic containers (one gallon each) of bleach. In a concurrent interview with the MS, when asked who placed the chemicals inside the bins, he stated, "I did." He further stated that the Ecolab (a company that checks chemical supplies for the facility) representative comes weekly to check the supplies and was aware of their storage. When asked if he received training on the safe use and storage of chemicals, he stated, "No." Therefore, the facility failed to provide a safe environment for a universe of 85 patients, facility staff and surrounding community members, when they placed different types of chemicals and combustibles into two separate outdoor, unventilated large metal storage bins. This failure had the potential to result in an explosion, fire and a hazardous materials situation. These violations had a direct or immediate relationship to the health, safety, or security of the patients. |
| 240000029 |
Mill Creek Manor |
240013056 |
B |
16-Mar-17 |
BNTN11 |
3944 |
REGULATION VIOLATION:
TITLE 22 72311 Nursing Service - General
(a) Nursing service shall include, but not be limited to, the following:
(1) Planning of patient care, which shall include at least the following:
(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.
FINDINGS:
The facility failed to develop a Communication Care Plan for Patient 1 who spoke Spanish only. As a result, Patient 1 was unable to communicate her safety needs after a fall incident occurred that resulted in a left eye injury.
On July 28, 2016 at 3:30 PM, Patient 1 was observed ambulating in the front lobby of the facility with a noticeable large area of bruising around her left eye. Patient 1 was alert and able to communicate only in Spanish.
An interview was conducted with Patient 1 on July 28, 2016 at 3:30 PM, with the help of a Spanish interpreter (Staff Member 1). Patient 1 stated that the fall incident happened at about 9 PM on July 23, 2016, when a gentleman (Patient 2) came to her room trying to pull her out of bed. Patient 1 stated that she got up out of bed and tried to get him (Patient 2) out of her room, but in the process of getting him out of her room they both fell to the floor. Patient 1 stated that she immediately went to the Nurses? Station to report the incident to the nurse on duty, but nothing was done until the next morning of July 24, 2016.
During a review of Patient 1?s clinical record, the face sheet and History and Physical revealed that Patient 1 was admitted to the facility on XXXXXXX 2015, with diagnoses that included dementia (brain disorder that causes forgetfulness).
A review of Patient 1?s Resident Assessment Instrument (RAI- a comprehensive assessment), dated December 25, 2015, included the following:
1. Preferred language was Spanish.
2. Interpreter needed to communicate with a doctor or health care staff.
A review of Patient 1?s Nurses Notes, dated July 24, 2016, revealed that a fall incident occurred on July 23, 2016, the time of the fall incident was not documented. The Nurses? Notes showed Patient 1 was sent to the Emergency Room on July 24, 2016 at 7 AM, after a staff member noticed a large bruise on Patient 1's left eye.
A review of Patient 1?s clinical record failed to show documented evidence that a Communication Care Plan was developed to address Patient 1?s language barrier and need for a Spanish Interpreter.
On July 28, 2016 at 3:55 PM, an interview was conducted with Licensed Vocational Nurse 2 (LVN 2), who was in charge on July 23, 2016 at 9 PM, when Patient 1 attempted to communicate the fall incident. LVN 2 stated they did not know what Patient 1 was talking about. LVN 2 stated the staff member that spoke Spanish left at 3 PM that day, and no one on the 3 PM to 11 PM shift could translate to English what Patient 1 was trying to communicate in Spanish.
During an interview with the Registered Nurse Clinical Consultant (RNCC) on August 2, 2016 at 3:30 PM, she verified that a Communication Care Plan was not developed to address Patient 1's need for a Spanish interpreter to communicate with the facility's non-Spanish speaking staff.
A review of the facility?s policy and procedure titled, ?Care Planning- Interdisciplinary Team,? indicated, ?Our facility?s Care Planning Interdisciplinary Team is responsible for the development of an individual comprehensive care plan for each resident. 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS-Minimum Data Set).?
Based on the information obtained, the facility failed to develop a Communication Care Plan to meet Patient 1?s needs.
This violation had a direct or immediate relationship to the health, safety or security of the patient. |
| 250000723 |
MONTEREY PALMS HEALTH CARE CENTER |
250008864 |
B |
04-Jan-12 |
9DEY11 |
4912 |
The facility failed to ensure that Patient A was free from financial abuse. The facility failed to ensure that a credit card belonging to Patient A was not taken from the patient's wallet, without the patient's knowledge, by a certified nursing assistant (CNA 1). On July 21, 2010, an unannounced visit was made to the facility to investigate an entity-reported and complaint-reported event. On July 21, 2010, the record of Patient A, age 87 was reviewed. She was admitted to the facility on June 30, 2010, with diagnoses that included: rehabilitation, high blood pressure, hearing loss, osteoporosis (loss of bone density mass), anemia (low blood count), cellulitis of the leg (inflammation), legal blindness, and dementia (loss of the thinking ability). The Minimum Data Set (assessment tool), dated July 20, 2010, assessed Patient A to be anxious, depressed, and resistive to care. It indicated Patient A was able to make her needs known, and was alert and cooperative. It also indicated she was oriented, but slow to comprehend. The Admission Assessment described Patient A as able to make her needs known, alert, cooperative and slow to comprehend. She was discharged from the facility to an assisted living facility on July 20, 2010. On July 21, 2010, at 11:30 a.m., the administrator and Administrative Staff 1 were interviewed. The administrative staff stated that Patient A's daughter called her on July 19, 2010, to report one of Patient A's credit cards was missing from her wallet. The daughter stated the wallet was lying in the patient's room at the facility, on the counter by the sink next to the bathroom, on the day of the incident, July 17, 2010. Patient A's daughter stated she reported the missing card to the credit card company, who told her the card was used within the last few days. Names of businesses were shared with Administrative Staff 1. Administrative Staff 1 further stated that on July 19, 2010, she contacted the businesses by telephone to ask if any of them had video recordings of credit card transactions, and one told her they did. She stated that she, along with the Business Office Manager, went to the business that had the recording, and viewed the video. The video was date and time-stamped, and it corresponded to the date and time the card was used, according to the credit card company. Administrative Staff 1 stated she was able to identify the person on the video as one of the currently-employed Certified Nursing Assistants (CNA), specifically CNA 1. She stated she returned to the facility and contacted the local police department, who came to the facility and took a report. Administrative Staff 1 further stated that on July 19, 2010, the police officer went to the business and viewed the video. He returned to the facility with a copy of the signed receipt from the transaction. It was signed by printing Patient A's name on the receipt. The receipt was for a purchase totaling $5.85. Administrative Staff 1 stated the police immediately went to see Patient A. Her written consent was obtained to search credit card records. The police officer also stated he would visit the home of CNA 1 after patient consent was obtained. Administrative Staff 1 further stated that on July 19, 2010, immediately after CNA 1 was identified on the video, she and the administrator placed a call to CNA 1, and suspended her based on her possibly having information regarding theft of Patient A's credit card. She stated the employee's response was: "I didn't use anything; I didn't do anything." Administrative Staff 1 further stated Patient A reported to her that, on July 17, 2010, she noticed a staff member go in and out of her room, while Patient A stood at the sink in her room, and while the patient later laid on her bed. Because Patient A was partially blind, she was only able to provide a vague description of the person who kept going in and out. Administrative Staff 1 stated the description matched the picture of the person seen on the video tape. She also stated that Patient A usually kept the wallet in her pant's pocket. On July 21, 2010, at 11:30 a.m., the administrator was interviewed. He stated the facility had not received a police report, and CNA 1 was still on suspension, pending the police investigation. On March 24, 2011, the employee file was reviewed. CNA 1 was terminated by telephone August 4, 2010, by the Human Resources Designee (HRD) and Administrative Staff 1. On March 24, 2011, at 11:10 a.m., Administrative Staff 1 and the HRD were interviewed. They stated that CNA 1 refused to come to the facility, so she was terminated by telephone. Administrative Staff 1stated that CNA 1's response to the termination was, "OK, Thank you." The facility failed to ensure Patient A was free from abuse in the form of misappropriation of personal funds.This violation had a direct relationship to the health, safety, and security of patients. |
| 250000567 |
MANORCARE HEALTH SERVICES-Hemet |
250009184 |
B |
29-Mar-12 |
W3ZX11 |
7248 |
Citation Text for Tag 0863, Regulation 9K1C Rivas, Sonia Manorcare Health Services in Hemet Class B Citation Title 22 - 72527(a)(9)(a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies and procedures available to the patient and to any representative of the patient. These policies shall be accessible to the public upon request. Patients shall have the right:(9) To be free from mental and physical abuse. The facility failed to ensure that a patient was free from mental and physical abuse. The facility failed to ensure that Patient A was free from mental and physical abuse by a Licensed Vocational Nurses (LVN 1).An unannounced visit was made to the facility on May 3, 2006, due to a facility reported incident. A review of the medical record was conducted on May 6, 2006. Patient A was a 95 year-old female re-admitted to the facility on March 2, 2004, with diagnoses that included closed fracture unspecified, joint replacement and senile dementia.A review of the Interdisciplinary Progress Notes from April 26, 2006 through May 16, 2006, indicated Patient A was alert with confusion and able to verbalize needs.Interdisciplinary Progress Notes, dated May 1, 2006, at 4:00 p.m., indicated the Licensed Nurse " tried to force medications by mouth after resident refused. "Interdisciplinary Progress Notes, dated May 3, 2006, May 10, 2006, and May 16, 2007, further documented the patient had no further episodes of refusing medications.An interview was conducted with the Director of Nursing (DON) on May 3, 2006, at 4 p.m. The DON stated the incident was witnessed by one Certified Nurse Assistant (CNA 1) and two Certified Nurse Students (CNAS 1 and CNAS 2). The DON stated LVN 1 was terminated.An interview with Patient A was attempted on May 3, 2006, at 4:30 p.m. Patient A did not recall or want to talk about the incident.The facility investigation report included the following witnesses' statements: CNA 1 documented in her Statement by Witness Form, "The patient was refusing the meds and she (LVN 1) just forced the spoon in the pt mouth, and the meds went all over the pt and the LVN stated that she was not going to deal with this for 16 hours and walked away. And I mentioned to her it would be easier to give it with ice cream and she stated that she doesn't care."CNA 2 documented in her Statement by Witness Form, " She saw (LVN 1's name) giving medications to (Patient A's name) and the resident spit out the meds. She then saw (LVN 1's name) scrape up the meds from the front of the resident and put them in her (Patient A's) mouth." CNA 2 further stated LVN 1 looked mad.An interview was conducted with CNA 2 on August 24, 2006, at 11:15 a.m. CNA 2 stated Patient A would only take her medications with ice cream. CNA 2 stated one of the CNAs told LVN 1 to give Patient A her medications with ice cream. The LVN responded by stating, " You are not going to tell me how to do my job. " CNA 2 stated LVN 1 then shoved the spoon in the patient ' s mouth and the patient spit the medications out. LVN 1 then shoved the spoon in the resident ' s mouth again. CNA 2 stated LVN 1 had a history of being mean and talking forcefully to the patients. CNA 2 stated she heard the sound of the spoon when it hit against Patient A ' s teeth and/or mouth.CNAS 1 documented in her Statement by Witness Form that she saw LVN 1, " Jam the spoon in the resident ' s mouth very hard. " CNAS 1 stated she heard LVN 1 tell a CNA if Patient A needed another medication to calm down that she would give her another one. CNAS 1 stated the, " LVN said that she was not going to put up with this today. " An interview was conducted with CNAS 1 on August 16, 2006, at 1:10 p.m. CNAS 1 stated the patient refused her medications and the nurse (LVN 1) shoved the spoon in her mouth. CNAS 1 stated, " The med nurse told one of the other nurses that if the resident didn ' t calm down and knock it off that she would give her another ' Calmy Downy. ' " CNAS 1 stated that Patient A was very clear when she was telling LVN 1 that she did not want the medication. CNAS 1 stated that she remembered that Patient A was a really nice lady. " Sometimes she (Patient A) was a little louder than the others, but the med nurse (LVN 1) was mean to her. "CNAS 1 stated she reported the incident to her teacher.CNAS 2 documented in her Statement by Witness Form that she heard LVN 1 say, "If she doesn't shut up and stop acting like that, I'll put another one in her mouth. I have a 16 hour shift and I'm not putting up with her today."CNAS 2 stated LVN 1 referred to the medications as "Calm down medicine." An interview was conducted with CNAS 2 on August 16, 2006, at 12:58 p.m. CNAS 2 stated she remembered witnessing the incident with a couple of other students. CNAS 2 stated Patient A didn't want to take her medications and the nurse (LVN1) was forceful in giving them to her. CNAS 2 stated she heard the nurse say "If you don't take these, I'm going to give you more. The nurse then opened the resident's mouth and forced it on her." CNAS 2 stated LVN was too physical and forceful with Patient A. CNAS 2 stated she reported the incident to her teacher. CNAS 3 documented in her Statement by Witness Form, "After the resident finished eating, LVN came to try to give the resident her meds. The resident did not want the meds. She (Patient A) said things about the meds being poison. (Name of LVN 1) put the meds close to the resident's mouth, saying please take it. Patient A blew the meds off the spoon and pulled LVN 1's arm away from her. "That's when (LVN 1's name) jammed the spoon into her mouth. She walked away to the sink and cleaned her arm off saying 'Let me know if she keeps up like this, I'll give her another. I'm not putting up with this for 16 hours.'" CNAS 3 further documented in her statement that she overheard the CNAs who witnessed the incident talking and stating that they weren't going to say anything about the incident because LVN 1 was their boss. A review of LVN 1's personnel file was conducted on May 6, 2006. LVN 1 was hired on May 4, 2004. LVN 1 was suspended while the facility investigated the incident with Patient A on May 1, 2006, and subsequently her employment was terminated on May 1, 2006.The facility failed to ensure Patient A was not physically and mentally abused by LVN 1.The facility failed to ensure that LVN 1 did not physical abuse Patient A by forcing Patient A to take her medications after Patient A made it clear that she did not want the medication and by proceeding to forcefully shove a spoon into Patient A's mouth.The facility failed to ensure that LVN 1 did not verbally and mentally abuse Patient A by forcing Patient A to take her medications after Patient A made it clear that she did not want the medication and by threatening to give Patient A more medications after LVN 1 became angry with Patient A for spitting out her medications.The above violations, either jointly, separately, or in any combination, had a direct or immediate relation to patient health, safety, or security. |
| 250000148 |
MIRAVILLA CARE CENTER |
250009351 |
B |
14-Jun-12 |
TVPO11 |
14308 |
72313 (a) (2) and (3) Nursing Services - Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. (3) Tests and taking of vital signs, upon which administration ofmedications or treatments are conditioned, shall be performed asrequired and the results recorded. On April 19, 2010, an unannounced visit was made to the facility to investigate a facilityreported event. Subsequent visits were made to the facility on May 4, and 25, 2010.The facility failed to ensure: 1. Medications were administered to Patients 1, 2, 3, and 5, as prescribed by thephysicians; and 2. Systolic blood pressure and/or heart rate for Patients 3, 4, 5, 6, 7, 8, and 9, wereobtained as a condition of medication administration as ordered by the physicians.1a. Review of Patient 1's record indicated a 67 year old male, was readmitted to thefacility on October 27, 2009, with diagnoses including hypertension and dementia withpsychosis.The recapitulated "Physician's Order" dated March 2010, indicated Patient 1 was to begiven the following medications at 9 a.m., on March 23 and 24, 2010: A. Depakote ER (Divalproex sodium) 1,000 mg for psychosis, hitting and verbalaggression; B. Aspirin 81 mg for cardio vascular accident prevention; C. Folic acid 1 mg for anemia; D. Vitamin B12 500 mcg for nutritional supplement; E. Vitamin B6 100 mg for nutritional supplement; F. Artificial tears drops 1 gtt both eyes for dry eyes; G. Risperdal 0.5 mg for psychosis, verbal aggression and hitting; andH. Ditropan 5 mg for bladder spasms.The Medication Administration Record (MAR), dated March 23, 2010, at 9 a.m.,indicated Patient 1 was given the above medications as ordered by the physician.The MAR, dated March 24, 2010, at 9 a.m., indicated Patient 1 was not given the abovemedications as ordered by the physician and the medications were "withheld" due to"Resident Refused 9AM meds (medications) verbal aggression."b. Review of Patient 2's record indicated an 84 year old female, was readmitted to thefacility on February 5, 2009, with diagnoses including atrial fibrillation (irregular andoften rapid heart rate).Patient 2 had a physician's order, dated June 9, 2009, to receive digoxin 125micrograms (mcg) daily.The MAR, dated March 21 and 25, 2010, indicated the digoxin 125 mcg was "withheld"and not given to Patient 2.The Nurse's PRN/Medication Notes, dated March 21, 2010, at 9 a.m., indicated "heldDig. (digoxin) HR 65 parameter hold if 60." There was no indication why the digoxin 125 mcg was "withheld" and not given to Patient 2 on March 25, 2010.On May 4, 2010, at 10:05 a.m., an interview was conducted with the Director of Nursing(DON). The DON stated, she did not know why LVN 1 "withheld" the digoxin for Patient2 on March 21 and 25, 2010.c. Review of Patient 3's record indicated an 82 year old male, was readmitted to thefacility on January 8, 2008, with diagnoses including hypertension.Patient 3 had a physician's order, dated April 26, 2009, to receive metoprolol(medication used in the treatment of high blood pressure) 25 milligrams (mg) twice aday.Patient 3 had a physician's order, dated May 23, 2009, to receive Norvasc (medicationused in the treatment of high blood pressure) 5 milligrams (mg) once a day.The MAR, dated March 21 and 25, 2010, at 9 a.m., indicated the metroprolol 25 mg andNorvasc 5 mg were "withheld" and not given to Patient 3.There was no documentation why the medications were "withheld" and not given toPatient 3.d. Review of Patient 5's record indicated a 60 year old male, was admitted to the facilityon January 14, 2010, with diagnoses including hypertension.Patient 5 had a physician's order, dated March 17, 2010, to receive metolazone(medication used in the treatment of high blood pressure) 2.5 mg three times a week, every Monday, Wednesday, and Friday.The MAR, dated March 24, 2010, indicated the metolazone 2.5 mg was not given toPatient 5. Additionally, there was no documentation why the medication was not givento Patient 5.On April 21, 2010, at 12:25 p.m., an interview was conducted with Licensed VocationalNurse (LVN) 1. LVN 1 stated during the month of March 2010, there were four timesshe had not given or offered Patient 1 his medications. She further stated, this occurredon two different days and at two different times during the days. LVN 1 stated, "I neveroffered the pills to the resident. I made the mistake of popping his pills and throwingthem in the trash can. I wasn't thinking of long term affects and ramifications, and wenton to the next room." LVN 1 also stated, she had student LVNs following her on these days and she told them, "You did not see this. Don't do this."On April 21, 2010, at 3:10 p.m., an interview was conducted with the LVN Instructor.The LVN Instructor stated, on April 7, 2010, at 7:20 a.m., Student Vocational Nurse (SVN) 1 reported to her that, students did not want to follow LVN 1 because she was throwing medications away and not giving them to the residents. The LVN Instructor further stated, SVN 1 reported to her that LVN 1 documented she had given the medications to the residents but she threw the medications away in the trash can.On April 21, 2010, at 3:35 p.m., an interview was conducted with SVN 1. She statedshe had been assigned to follow LVN 1 on March 23, 2010, for medication pass.SVN 1 further stated, LVN 1 dispensed the medications for Patient 1 and then threwthem in the trash can attached to the medication cart. In addition, SVN 1 stated,LVN 1 "charted on the MAR that she gave the 9 a.m. medications to the resident (Patient 1)." SVN 1 stated, she asked LVN 1, "Are you going to say that you gave it?" and LVN 1 replied, "Yes, it doesn't matter he will get more later." SVN 1 also stated, LVN 1 stated, "You did not see this. Don't do this."On April 21, 2010, at 3:24 p.m., an interview was conducted with SVN 2. She statedshe had been assigned to follow LVN 1 on March 24, 2010, for medication pass. Shefurther stated, LVN 1 was dispensing medications for more than one resident at a timeand she was not sure which residents the medications were for. In addition, SVN 2stated, LVN 1 threw "3 or 4, maybe 6, cups of medications in the trash can attached tothe medication cart and there was more than one pill in each cup." Also, SVN 2 statedLVN 1 made the comment, "Oh he (Patient 1) is being an a..h... and he doesn't needhis medications."2. On April 21, 2010, at 3:35 p.m., an interview was conducted with Student Vocational Nurse (SVN) 1. She stated she had been assigned to follow LVN 1 on March 23, 2010,for medication pass. SVN 1 further stated LVN 1 had not obtained a "blood pressureon any resident" during the 9 a.m. medication pass. In addition, SVN1 stated she was asked by LVN 1 to do an apical pulse for Patient 8 before digoxin was administered.SVN 1 stated she was unable to hear the apical pulse and told LVN 1. SVN 1 thenstated, LVN 1 made the following comment, "Don't worry about it, I usually cannot get iteither." SVN 1 stated, LVN 1 gave Patient 8 the digoxin medication.On April 21, 2010, at 3:24 p.m., an interview was conducted with SVN 2. She stated she had been assigned to follow LVN 1 on March 24, 2010, for medication pass.SVN 2 further stated LVN 1 had not taken the systolic "blood pressure on several residents, at least two, as ordered but she (LVN 1) gave the medications forblood pressure." In addition, SVN 2 stated LVN 1 said, "Oh it isn't important, itis always the same."a. Review of Patient 9's record indicated a 91 year old female, was admitted to thefacility on January 10, 2007, with diagnoses including hypertension and hypertensive heart disease.Patient 9 had a physician's order dated August 4, 2009, to receive Vasotec (medication used in the treatment of high blood pressure) 20 milligrams (mg) twice a day, and to hold the medication if Patient 9's systolic blood pressure (SBP) was less than 110.Patient 9 had a physician's order, dated December 29, 2009, to receive metoprolol12.5 mg twice a day, and to hold the medication if Patient 9's SBP was less than 100 or heart rate (HR) was less than 60.The MAR, dated March 23, 2010, at 9 a.m., indicated a systolic blood pressure (SBP) of 130 and a heart rate (HR) of 75; and March 24, 2010, at 9 a.m., a SBP of 105 and aHR of 70.The MAR, dated March 23 and 24, 2010, at 9 a.m., indicated the Vasotec andmetoprolol were given to Patient 9.b. Review of Patient 3's record indicated an 82 year old male, was readmitted to thefacility on January 8, 2008, with diagnoses including hypertension.Patient 3 had a physician's order, dated April 26, 2009, to receive metoprolol(medication used in the treatment of high blood pressure) 25 milligrams (mg) twice aday, and hold the medication if Patient 3's SBP was less than 100 or HR was less than 60.Patient 3 had a physician's order, dated May 23, 2009, to receive Norvasc (medicationused in the treatment of high blood pressure) 5 milligrams (mg) once a day, and holdthe medication if Patient 3's SBP was less than 100 or HR was less than 60.The MAR, dated March 23, 2010, at 9 a.m., indicated a SBP of 130 and a HR of 75; and March 24, 2010, at 9 a.m., a SBP of 130 and a HR of 80.The MAR, dated March 23 and 24, 2010, at 9 a.m., indicated the metoprolol andNorvasc were given to Patient 3.c. Review of Patient 4's record indicated a 91 year old male, was admitted to the facilityon March 27, 2009, with diagnoses including hypertension.Patient 4 had a physician's order dated March 27, 2009, to receive lisinopril (medication used in the treatment of high blood pressure) 10 mg once a day and Cardizem CD (medication used in the treatment of high blood pressure) 120 mg once a day, and hold both medications if Patient 4's SBP was below 110.The MAR, dated March 23 and 24, 2010, at 9 a.m., indicated a SBP of 130.The MAR, dated March 23 and 24, 2010, at 9 a.m., indicated the lisinopril and Cardizem CD were given to Patient 4.d. Review of Patient 5's record indicated a 60 year old male, was admitted to the facilityon January 14, 2010, with diagnoses including hypertension.Patient 5 had a physician's order dated January 19, 2010, to receive Coreg (medicationused in the treatment of high blood pressure) 20 mg once a day, and hold themedication if Patient 5's systolic blood pressure was less than 100.The MAR, dated March 23, 2010, at 9 a.m., indicated a SBP of 135; and March 24, 2010, at 9 a.m., a SBP of 130.The MAR, dated March 23 and 24, 2010, at 9 a.m., indicated the Coreg was given toPatient 5.On April 21, 2010, at 12:25 p.m., an interview was conducted with LVN 1. LVN 1 statedthe systolic blood pressure for Patient 5 "when ordered was sometimes not taken but Irecorded a systolic blood pressure on the MAR," and gave the 9 a.m. dose of bloodpressure medication.e. Review of Patient 6's record indicated a 72 year old male, was readmitted to thefacility on March 9, 2010, with diagnoses including hypertension and atrial fibrillation(irregular and often rapid heart rate).Patient 6 had physician's orders dated March 9, 2010, to receive digoxin (used in thetreatment of irregular heart beats) 250 micrograms daily and hold if heart rate was lessthan 60, and diltiazem (medication used in the treatment of high blood pressure) 30 mgevery six hours and hold if the systolic blood pressure was less than 100 or the heartrate was less than 55.The MAR, dated March 23, 2010, at 9 a.m., indicated a HR of 78 and at 12 p.m., a blood pressure of 130/80.The MAR, dated March 24, 2010, at 9 a.m., indicated a HR of 80 and at 12 p.m., a blood pressure of 135/80.The MAR, dated March 23 and 24, 2010, at 9 a.m., indicated the digoxin and diltiazemwere given to Patient 6.f. Review of Patient 7's record indicated a 62 year old male, was admitted to the facilityon March 3, 2009, with diagnoses including hypertension.Patient 7 had a physician's order dated March 3, 2009, to receive atenolol (medicationused in the treatment of high blood pressure) 50 mg daily, and hold medication if Patient7's systolic blood pressure (SBP) was less than 110.The MAR, dated March 23 and 24, 2010, at 9 a.m., indicated a SBP of 130.The MAR, dated March 23 and 24, 2010, at 9 a.m., indicated the atenololwas given to Patient 7.On April 21, 2010, at 12:25 p.m., an interview was conducted with LVN 1. She stated, for Patient 7 the systolic blood pressure was not taken but she recorded asystolic blood pressure on the MAR and gave Patient 7 his 9 a.m. dose of bloodpressure medication. LVN 1 further stated, Patient 7 was "scary to be around when heis in one of his moods" and that was the reason she did not take Patient 7's systolicblood pressure.g. Review of Patient 8's record indicated a 91 year old male, was readmitted onDecember 19, 2007, with diagnoses of hypertension and congestive heart failure.Patient 8 had a physician's order dated March 9, 2010, to receive digoxin 125micrograms every morning, and hold the medication if Patient 8's apical pulse was lessthan 60.The MAR, dated March 23, 2010, at 9 a.m., indicated an apical pulse of 84; and March24, 2010, at 9 a.m., an apical pulse of 75.The MAR, dated March 23 and 24, 2010, at 9 a.m., indicated digoxin was given toPatient 8.On April 4, 2010, at 9:45 a.m., an interview was conducted with the Administrator andthe DON. They stated LVN 1 should have given the patients their medications asordered by the physicians or if she could not the charge nurse or the DON should havebeen notified. In addition, they stated the patients' blood pressure and heart rate shouldhave been taken as ordered before the medications were given.The facility failed to ensure medications were administered to patients as ordered bythe physician, and failed to ensure the systolic blood pressure and heart rate ofpatients were obtained, not just recorded, as a condition of medication administrationas ordered by the physician. This had the potential to result in patients' medicalcondition deteriorating because they were not receiving medications as ordered by thephysician or receiving medications they should not have received because their systolicblood pressure or heart rate was too low.The violations had a direct or immediate relationship to the health, safety, or security ofpatients in the facility. |
| 250000270 |
MISSION CARE CENTER |
250009539 |
B |
04-Oct-12 |
39U311 |
3017 |
Health and Safety Code 1418.91. Reports of incidents of alleged abuse or suspected abuse of patients. Based on interview and record review, the facility failed to ensure an incident of alleged abuse or suspected abuse of a resident of the facility was reported to the department immediately, or within 24 hours. Findings: Patient 20 was a 48 year old female admitted to the facility on July 22, 2009, and readmitted after an acute care hospitalization on October 28, 2009, with diagnoses including respiratory failure. A MDS assessment (minimum data set, an assessment tool) dated August 5, 2009, indicated Patient 20 had no short or long term memory deficits and was able to make her own decisions. In addition, the MDS assessment indicated Patient 20 was incontinent of bowel and bladder. During the recertification survey confidential group meeting conducted on November 3, 2009, at 10:50 a.m., Patient 20 reported the following incident. "It was about two or three weeks ago on night shift. A CNA (certified nursing assistant) with short dark hair, who was not wearing a name tag, answered my call light. I had to go to the bathroom. I can use the bathroom, but I cannot get there on my own. I asked her to help me. She was in a really bad mood. She turned off my light and told me it was not her job to take me to the bathroom all the time. She spoke harsh like. She said I should go in there (points to diaper). I was upset, embarrassed." The patient started to cry as she spoke about the incident. When she was able to continue she stated, "I did not want to dirty myself. I can use the bathroom. But she would not help me and left the room. I was really upset and hurt. I was embarrassed. It made me cry and feel bad about myself." Patient 1 continued to sob as she spoke about the incident.On November 3, 2009, an interview was conducted with the Activities Aid identified by Patient 1. The Activities Aid stated Patient 20 told her about the incident a few weeks before but she "forgot" to tell anyone. The Activities Aid stated she had training and knew she should have told the Administrator or Director of Nursing but she forgot. The facility policy and procedure titled, "(85) Reporting Abuse to Facility Management," was reviewed. It indicated, "3. Employees, facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Administrator of the facility or his/her designee. In the absence of the Administrator such reports may be made to the Director of Nursing Services or the Nurse Supervisor on duty." On November 24, 2009, at 11:30 a.m., an interview was conducted with the Facility Administrator. He stated incident was not reported by the Activities Aid because she felt it was not important and she forgot about the incident. The Administrator stated the abuse was not reported to the department within 24 hours. The facility failed to ensure an allegation of abuse was reported to the department within immediately, or within 24 hours. |
| 250001724 |
MURRIETA HEALTH AND REHABILITATION CENTER |
250009585 |
B |
14-Nov-12 |
8XZI11 |
7049 |
72319 (b) (c) (d); 72527 (a) (23)72319 (b) Restraints shall only be used with a written order of a licensed healthcare practitioner acting within the scope of his or her professional licensure. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. [as needed] orders for physical restraints.(c) The only acceptable forms of physical restraints shall be cloth vests, soft ties, soft cloth mittens, seat belts and trays with spring release devices. Soft ties means soft cloth which does not cause abrasion and which does not restrict blood circulation. (d) Restraints of any type shall not be used as punishment, as a substitute for more effective medical and nursing care, or for the convenience of staff.72527 (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, 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.An unannounced visit was made to the facility on September 24, 2009, at 8:45 a.m., to investigate an entity reported incident. It was determined that the facility failed to ensure Patient A was free from physical restraint for the purpose of controlling the patient's behavior or staff convenience. RN 1, LVN 1 and CNA 1 inappropriately tied Patient A to a handrail using a bed sheet while on her wheelchair. Patient A, a 95 year old patient, was admitted to the facility on November 23, 2007, with diagnoses that included dementia (a degenerative disease causing loss of ability to think and reason correctly) and high blood pressure. A Minimum Data Set (an assessment tool) dated July 20, 2009, indicated the patient had short-term memory problem, anxiety and was able to propel self in wheelchair with supervision. Patient A required extensive assistance with transfer and bathing and limited assistance with dressing and personal hygiene. An interview was conducted with the DON on September 24, 2009, at 8:45 a.m. The DON stated she overheard CNA 2 say that when coming onto her shift on September 22, 2009, at 6:20 a.m., CNA 2 observed CNA 1 untying Patient A from the handrail with a bed sheet. The DON stated after further investigation, the DON learned that on September 22, 2009, at 4:30 a.m., RN 1, LVN 1 and CNA 1 placed a bed sheet around Patient A's wheelchair and tied the bed sheet on the handrail to stop the patient from wandering around the facility. She stated the patient was tied to the handrail from 4:30 a.m., until about 6:20 a.m. The DON stated according to the staff, the patient was having a lot of behaviors, (ex: trying to get up unassisted, locking herself in the therapy room and wandering into other residents' room). She stated the staff failed to follow the facility's restraint policy, did not obtain physician's order and did not notify another physician for guidance when there was no return call from the on-call physician. She stated she did not become aware of the incident until 2 p.m., on September 22, 2009, after overhearing CNA 2 talking about the incident.A telephone interview was conducted with CNA 2 on September 28, 2009, at 10:30 a.m. CNA 2 stated she came into the facility at 6:15 a.m., on September 22, 2009, and saw Patient A in front of Nursing Station 2 in her wheelchair, with a bed sheet wrapped around her waist and tied to the handrail. She stated she observed CNA 1 laughing and stating, "Look what we did." She stated she did not mention what she observed to the DON until that afternoon. An interview was conducted with CNA 3 on September 24, 2009, at 10:20 a.m. CNA 3 stated at 6:20 a.m., on September 22, 2009, while coming onto her shift, she noticed CNA 1 untying a bed sheet from the handrail and Patient A's wheelchair. She stated she asked CNA 1 what happened, and CNA 1 responded, "This is what I have to do to continue working."The record for Patient A was reviewed on September 24, 2009. A nurse's note, dated September 22, 2009, indicated the following; 2 a.m. - "CNA got resident up due to restlessness and attempting to get up unassisted from bed. Resident was restless, agitated, disoriented and confused. Resident insisted on getting up. Stated her sister was waiting for her outside." 3 a.m. - "Resident roaming around facility propelling herself around going in and out of other residents rooms. Placed resident near nurses station for close supervision." 3:15 a.m. - "Resident unable to stay in one place. Several times resident was placed near nurses station, but was able to unlock brakes from W/C (wheelchair) and propelled her self around Station 2." 3:30 a.m. - "Resident pulled fire alarm near exit door in Station 2." 4 a.m. - "Paged Dr. (name of doctor) on call for Dr. (name of doctor) to inform him of resident aggressive behavior. Awaiting call back." 6 a.m. - "1:1 supervision provided resident still went around propelling herself via w/c and continue to go into other res (resident) rooms... Resident at nurses station at this time with 1 nurse closely monitoring." Further review of the record revealed there was no physician notification until 4 a.m., two hours after the patient started wandering around the facility. The documentation was not consistent with what CNA 2 and CNA 3 had witnessed. The documentation was also not consistent with the DON's statements from the interview conducted on September 24, 2009, at 8:45 a.m. According to the DON, after an interview with the three staff in question, Patient A was tied to the handrail with a bed sheet from about 4:30 a.m. through about 6:20 a.m. There was no physician's order for the restraint used.The facility failed to ensure Patient A's right to be free from restraint when RN 1, LVN 1 and CNA 1, tied Patient A with a bed sheet to the handrail to prevent the resident from wandering the facility, resulting in Patient A's rights being violated and restricting the patient's freedom of movement voluntarily. These violations had a direct relationship to the health, safety, or security of Patient A. |
| 250000985 |
MOUNTAIN SHADOWS SPECIAL KIDS HOMES-HALBROOK HOUSE |
250009660 |
A |
06-Dec-12 |
LRVM11 |
6971 |
Citation Class "A" Citation CFR # 483.460 K (2) / W 369 (2) All drugs, including those that are self administered, are administered without error.The facility failed to administer a medication (Baclofen, an anti spasmodic) as prescribed by the physician, failed to follow procedures to alert their staff about medication concentration change, and failed to ensure that their staff followed Medication Administration Procedures resulting in Client A receiving ten times the amount prescribed by the physician. On June 20, 2007, at 10 a.m., an unannounced visit was made to the facility to investigate the incident in which Patient A sustained a medication overdose. It was determined that the facility failed to administer a medication (Baclofen, an anti spasmodic) to one patient (Patient A), as prescribed by the physician. The supplying pharmacy provided a higher concentration of the liquid medication from a one to one solution, to a ten to one solution. The facility failed to follow procedures to alert their staff about the concentration change, and failed to ensure that their staff followed Medication Administration Procedures. As a result, Patient A received ten times the amount prescribed by the physician. Patient A was a twelve year old male admitted to the facility on March 26, 2003 with diagnosis that included profound mental retardation, and seizure disorder.According to the Special Incident Report, on June 19, 2007, a medication error was identified. On June 19, 2007, at 6 a.m., Patient A was given his morning medication. "A new bottle of Baclofen was opened and the staff gave him the dose she was accustomed to giving him. His dose had been 20 ml of Baclofen 1mg/l ml and the new strength was Baclofen 10mg/ml. She should have given only 2ml, but gave 20ml...When he boarded the bus, he appeared to be sleepy...The school staff noted he was very lethargic when he arrived...The school staff unable to arouse called 911." Patient A was transported to the acute hospital. The Special Incident Report further indicated, "The new pharmacy dispensed Baclofen 10mg/1ml and previously had been using Baclofen 1mg/ml. The new bottle was opened and the staff did not observe the 5 rights of giving medications."The acute hospital Emergency Room Treatment Summary, dated June 19, 2007, indicated, "The patient got off the school bus and was unresponsive which is not normal for him. He is usually alert and awake. There was an episode of vomiting. The patient was transported to the hospital for evaluation. After the initial evaluation was initiated, a nurse from the group home came... The patient had a new Baclofen formulation change, and they believe that he advertently got a dose of Baclofen 10 times more than the normal. They believe he got 200 mg instead of 20 mg." Hospital Transfer Request & Physician Certification Statement, dated June 19, 2007, indicated Patient A required pediatric specialties for a diagnosis of Baclofen overdose. Drugs.com on Baclofen overdose indicated, "Overdosage signs and symptoms: vomiting, muscular hypotonia (Decreased tone of skeletal muscles), drowsiness, accommodation disorders (inability of the eye to automatically change focus from distance to near objects, which can cause blurred vision, double vision, tired eyes, headaches and concentration problems), coma, respiratory depression, and seizures." An interview was conducted with (Registered Nurse) RN 1 on June 20, 2008, at 10:30 a.m. The RN stated that the facility changed Pharmacy on June 15, 2007. The RN stated that the new pharmacy's formula concentration for Baclofen was different from the previously used pharmacy. The previous pharmacy used a one mg to one ml solution, and the new pharmacy used a concentration of ten mg to one ml solution. RN 1 stated that the med nurse did not notice the concentration change and gave Patient A ten times more than prescribed by the physician. RN 1 further stated that a sticker should have been placed on the MAR(Medication Administration Record) to alert staff of the concentration change. The RN stated that all the Patients on Baclofen had the stickers put on their MAR except for Patient A.Further Record review was conducted for the patients who were prescribed Baclofen. Three of the four patients on Baclofen had the stickers on the Mar to alert staff of the concentration change. The stickers indicated, "Direction Change-Different Strength." Patient A's MAR did not have the sticker to alert staff of the change.An interview was conducted with RN 2 on June 20, 2007, at 10:45 p.m. RN 2 stated that she felt that the error could have occurred because on Friday, June 15, 2007, Patient A's Baclofen medication had not arrived, and the medication nurse borrowed medication from another client to give Patient A his Baclofen medication. RN 2 stated that the med nurse should have never borrowed medication from another patient. RN 2 stated that it was against facility policy to borrow medications from another patient.The facility's policy and procedures were reviewed on June 20, 2007. The Medication Administration Procedures indicated that the seven rights of medication administration that had to be observed and verified prior to giving medication to a patient were: 1. Right Patient 2. Right Medication3. Right Dose 4. Right Time 5. Right Route (po, rectal, topical, etc.) 6. Right Expiration Date 7. Right Strength/Concentration An interview was conducted with the (Qualified Mental Retardation Professional) QMRP on January 14, 2009, at 12:09 p.m. The QMRP stated that the medication overdose was the fault of the med nurse and had been terminated because she did not follow policy and procedure of administering medications.An interview was conducted with RN 1 on January 14, 2009, at 12:51 p.m. RN 1 stated that the medication error was the med nurse's fault because she did not follow the facility's policy and procedure of medication administration. RN 1 stated that the med nurse did not follow the seven rights of medication administration, and if she would have, the medication overdose could have been avoided.The facility failed to administer medications as prescribed by the physician. Patient A received ten times the prescribed dose of the medication Baclofen. The facility failed to follow procedures to alert their staff about the concentration change, and failed to ensure that their staff followed Medication Administration Procedures. As a result, Patient A suffered a Baclofen overdose putting him at risk for accommodation disorders, muscular hypotonia, coma, respiratory depression, seizures, and death. As a result of the medication overdose, Patient A had to be rushed to the emergency room and hospitalized for treatment and medical stabilization. The above violation, either jointly, separately, or in any combination, presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 250000634 |
MANORCARE HEALTH SERVICES-PALM DESERT |
250009834 |
B |
07-May-13 |
JVNY11 |
1668 |
Title 22 - 72523(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to investigate an allegation of physical abuse per facility policy for a resident. The allegation was that staff had thrown Resident 140 on the bed. On January 6, 2012, an unannounced visit was made to the facility to investigate an anonymous complaint regarding resident rights and quality of care/treatment. On January 6, 2012, at 10 a.m., the Administrator was interviewed. The Administrator indicated he had received an allegation, on January 5, 2012, of potential staff-to-resident abuse. The allegation was that staff had thrown Resident 140 on the bed. On April 26, 2012, at 9:35 a.m., the Administrative Director of Nursing Services (ADNS) was interviewed. The facility information provided to the survey team indicated the designated abuse prevention coordinator for the facility was the ADNS. The ADNS was unable to provide evidence the allegation had been investigated according to the Abuse Policy and Procedure. During the investigation, it was determined that the facility failed to implement the facility Abuse Policy and Procedure to conduct a "timely, thorough and objective investigation of all allegations of abuse, neglect, mistreatment..." The failure placed all patients at risk for abuse, neglect, or mistreatment. The facility failed to immediately investigate the allegation that staff threw Resident 140 on the bed while Resident 140 was at the facility. These violations had a direct relationship to the health, safety, or security of patients. |
| 250001723 |
MOUNTAIN SHADOWS SPECIAL KIDS HOMES - MAGGIE MARSH HOUSE |
250009902 |
A |
16-May-13 |
1X3O11 |
7728 |
CLASS A CITATIONW&I 4502(h) Welfare and Institutions Code Section 4502 Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.The facility failed to ensure Client 1's right to be free from harm when warming measures were implemented and an electric heating blanket was used. Client 1 sustained second degree burns (burns involving the outer and second layers of skin with the development of blisters) to the anterior (top) area of both thighs on December 4, 2008. An unannounced visit was conducted on December 9, 2008, at 3:30 p.m., to initiate an investigation of the facility-reported event involving burns to Client 1's upper legs. Staff A reported that a heating blanket was used to raise the client's body temperature. This warming measure resulted in burns to Client 1's upper legs. Client 1 was observed, Client 1's record was reviewed, facility staff were interviewed, the client's physician was interviewed, and the electric heating blanket was observed. Client 1, a 13 year-old male, was admitted to the facility on June 30, 2003. Diagnoses included profound mental retardation, shaken baby syndrome, cerebral palsy/spastic quadriplegia (paralysis of all four limbs with spasticity) and temperature instability (the inability to regulate body temperature). Observation of Client 1, on December 9, 2008, at 3:50 p.m., revealed multiple blisters in an area approximately three by two and one-half inches on the right anterior thigh and a raised blister, three-quarter inches in diameter, on the left anterior thigh. Staff B documented on the Communication Log, December 4, 2008, for the morning shift, "[Client 1] has burns on both upper legs." RN 1 was interviewed on December 9, 2008. at 4:00 p.m. RN 1 indicated that warming measures did not include an electric heating blanket and there was no facility policy for the application of an electric heating blanket as a heating measure. RN 1 further indicated a lack of awareness regarding the use of an electric heating blanket in the facility. RN 1 stated, "Staff have not been trained." RN 1 indicated the previous owner of the facility had provided the electric blanket. Staff B was interviewed on December 10, 2008, at 8:45 a.m. Staff B stated, "I pulled [the] covers off - sheet than the electric blanket. [Client 1] had two red marks on his thighs. I looked closer and saw blisters. The blanket was plugged in but turned off."RN 1 documented on the RN (Registered Nurse) Notes, December 4, 2008, at 8:30 a.m., "[Client 1] has been needing warming measures due to low temps. This morning staff were going to get him up and noticed blisters on each thigh. On my exam he has [two] areas of redness on each thigh with some blisters - largest is on right thigh about [one and one-half by one inch], [two medium] about [one-half inch and two small about one-quarter inch]." Further documentation by RN 1 indicated the physician was notified and treatment to the burns was prescribed. Staff C was interviewed on December 11, 2008, at 3:30 p.m. Staff D stated, "The electric blanket is used almost every night and is usually plugged in. I have turned it on in the past." Staff D was interviewed on December 11, 2008, at 3:45 p.m. Staff D worked the night shift from December 3 to the morning of December 4, 2008. Staff D stated, "The blanket was plugged in. The thermostat was turned around and the control couldn't be seen." Staff D further indicated she did not know if the blanket had been turned on. Documentation on the monthly treatment record for December, 2008, indicated, "check rectal temperature every shift: if below 95 degrees rectally start warming measures with dryer heated blankets, caps and disaster blanket: if not above 95 degrees rectally in [one hour] notify RN. Documentation indicated Client 1's temperature on the PM shift, December 3, 2008, was 95.0 degrees. Documentation indicated Client 1's temperature on the AM shift, December 4, 2008, was 96.8 degrees. Further documentation on the back side of the form under Reason PRN (as needed) Administered indicated warming measures were applied on December 4, 2008, at 11:30 p.m. There was no documentation to indicate warming measures were applied on December 3, 2008. There was no physician's order for the application of an electric heating blanket.The health care plan, developed by nursing, identified Problem #2: Alteration in temperature regulation related to recurring hypothermia (subnormal temperature of the body). The goal was to maintain a body temperature at or above 95.0 degrees rectally. The method included: Will be dressed warmly according to the weather/room temperature; Take and record rectal temperature each shift and PRN (as needed) if he feels cold; If rectal temperature is below 95.0 degrees DCS (Direct Care Staff) will start warming measures with dryer-warmed towels, warm blankets, cap, warmed rice bags or disaster blanket as needed; DCS will notify MD (physician) of all concerns related to temperature control. Staff did not follow the health care plan for the application of warming measures to maintain Client 1's body temperature at or above 95.0 degrees rectally. The health care plan did not include the application of an electric heating blanket. Directions on the label sewn into the heating blanket indicated, "Do not use on infants, invalids, paraplegics, quadriplegics, a helpless person, diabetics, a person insensitive to heat such as a person with poor circulation." Photos, taken on December 10, 2008 at 8:30 a.m., revealed a blister on the left anterior thigh and multiple blisters on the right anterior thigh. Client 1's burns were not assessed by the physician until seven days later. Documentation on the physician's Progress Notes, dated December 11, 2008, indicated an open, four by five inch area of second degree burn on the right anterior thigh and "others closed, minimal redness at periphery." Under New Diagnoses: "[second degree] burns over both thighs - healing." The facility failed to ensure the right of Client 1 to be free from harm when an electric heating blanket was applied as a warming measure for hypothermia. The label on the blanket clearly identified/indicated situations/conditions in which the blanket was not to be used. An electric heating blanket had not been prescribed by the physician. Client 1's health care plan did not include an electric heating blanket in the methods to maintain a body temperature at or above 95.0 degrees rectally. Staff did not follow the health care plan for the application of warming measures that was developed by nursing. This failure resulted in Client 1 sustaining bilateral, second degree burns to the thighs.This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. The above violation either jointly, separately, or in any combination presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 630012886 |
Mesa House |
250010035 |
B |
19-Aug-13 |
XX7Q11 |
2865 |
HSC 1418.91(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. On May 23, 2012, at 9 a.m., a visit was made to the facility for the purpose of investigating a complaint allegation.Based on record review, document review and interview, the facility failed to report to the California Department of Public Health immediately, or within 24 hours, to confirmed verbal abuse Client 4, which occurred on May 11, 2012, at approximately 12 noon at the Day Program. The Day Program reported the verbal abuse to the facility on May 15, 2012, four days after the occurrence and the facility failed to report the verbal abuse to California Department of Public Health. On May 15, 2012, a report was made to the Department from another state agency regarding a confirmed verbal abuse on Client 4 that occurred on May 11, 2012, while the client was at the Day Program.On May 22, 2012, at 9:30 a.m., during an interview with the Quality Mental Retardation Professional (QMRP), 11 days after the confirmed verbal abuse, she stated, "There has not been any incidence of abuse reporting in the home or from the Day Program." A review of the facility's "Abuse Policy" stated any accidents or injuries of unknown origin will be documented on the incident report form and will be reported immediately to Facility Manager, Registered Nurse, and QMRP and will be reported to the California Department of Public Health within 24 hours.Record review for Client 4 revealed the client had severe mental retardation, was non-verbal, and was dependent on a wheel chair for mobility.On May 23, 2012, at 12:10 p.m., during an interview with the Day Program Administrator regarding a report of verbal abuse to Client 4, she stated, "We reported the verbal abuse to other agencies and the client's family. I reported to the QMRP. An incident report was done and the staff was placed on administrative leave. The Quality Assurance department handled the investigation. The Direct Support Professional [DSP 1] resigned by phone yesterday." At 12:40 p.m., in an interview with DSP 2, she stated, "I heard [DSP 1], under his breath say to the client, 'fucking retard.' Hopefully the client didn't hear it." A review of the Day Program's Incident Report at 12:45 p.m., it stated, "While having lunch [DSP 1] allegedly became agitated and called [Client 4] a f---ing(curse word) retard. [DSP 1] placed on administrative leave pending outcome of investigation." On May 24, 2012, at 2:15 p.m., a review of Client 4's record in the QMRP's narrative notes, dated May 15, 2012, showed, "Notified by Day Program that staff had called consumer [client] a bad name on Friday 5/11/12. Day program stated they are investigating and the staff is on administrative leave pending investigation." |
| 250000850 |
MOUNTAIN SHADOWS SPECIAL KIDS HOMES-GLEN HOUSE |
250010053 |
B |
15-Aug-13 |
OZNI11 |
9574 |
MSSKH - Glen House - Complaint #: CA00250477 "B" citation W&I (4502) (d) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (d) A right to prompt medical care and treatment. The facility failed to provide Client A with the right to prompt medical care and treatment when the RN failed to assess the client's distress accurately and inform the physician of the distress as reported by direct care staff and LVN (Licensed Vocational Nurse). This failure resulted in the client's death on 11/26/10. On 12/3/10, California Department of Public Health conducted an unannounced visit at the facility to investigate a facility-reported incident regarding Client A's death. Client A, a 16-year-old female, was admitted to the facility on 4/11/10 with the current diagnoses that included: 1. Profound intellectual disability with microcephaly (abnormal smallness of the head) 2. Cerebral palsy (disorder that affects muscle tone, movement, and motor skills) with spastic quadriparesis (weakness of both arms and both legs) 3. GT (tube inserted through a small incision in the abdomen into the stomach) dependent, status post Nissen fundoplication (surgical procedure which upper part of the stomach is wrapped 360 degrees around the esophagus (muscular canal through which food/liquids pass from mouth to the stomach), and 4. Constipation (difficulty having a bowel movement) The physician's orders in 10/10 for Client A's feeding included the following: NPO (nothing by mouth), Replete Fiber (a GT formula) 210 ml (milliliters) 5X (five times) per day via GT (gastrostomy tube), 240 ml water GT three times a day over 30-40 minutes, flush with 75 ml of water following each feeding or medication administration, and check residuals (liquid left in stomach from a previous feeding that have not been digested) prior to feedings. If residuals are over 80 ml, hold feeding and notify the RN (registered nurse)...May substitute formula with Pedialyte (oral hydration solution) same amount as feeding 210 ml via GT prn (as needed) for diarrhea or vomiting X2 (two times). PRN medications included Tylenol elixir (160mg -milligrams/5ml) give 768 mg/24 ml via GT every 4 hours for pain...and Midol 2 capsules via GT every 6 hours for premenstrual/menstrual symptoms. During an interview with the Qualified Intellectual Disabilities Professional (QIDP) on 12/3/10, he stated that Client A had a fever, a GT with residuals above the usual, and later was found unresponsive and not breathing. He stated the LVN started cardio-pulmonary resuscitation (CPR), and the paramedics continued CPR until Client A was admitted to the ER (emergency room), where she was pronounced dead. During an interview with the facility's Registered Nurse (RN) on 12/3/10, she stated that on 11/26/10 around 8 a.m., she received a call from Direct Care Staff (DCS) 1 that Client A was crying and her abdomen was distended. The RN had documented the call in her notes.Review of the RN notes dated 11/26/10, indicated the following: 7:15 a.m., DCS notified the RN that Client A appeared a little uncomfortable. Midol was given to Client A since it was close to her menses (menstrual period). 10:20 a.m., the RN arrived at the house. DCS 1 had reported that it was difficult to get feeding down for the client. Client A's abdomen was distended and firm and bowel sounds were diminished in all quadrants. DCS 1 had gotten residuals of 200 cc. 10:30 a.m., the physician was notified with the telephone order, "Hold regular formula feeding. Allow bowels to rest for 2 hours. Give Pedialyte next 2 feedings. Then resume regular formula." DCS 1 had gotten additional residuals that totaled 1200 cc. The physician was again notified, "Continue to rest stomach, and if client looked worse would need to go to ER for eval (evaluation)." 10:45 a.m., Client A's abdomen was soft and round. RN instructed DCS staff to wait to a couple of hours and attempt to feed Pedialyte as ordered. The physician was notified. Vital signs were within normal limits. 2:45 p.m., staff notified the RN that Client A appeared to have a little discomfort when trying to give Pedialyte. Tylenol for pain was given and tried to give Pedialyte later. The physician was notified of the client's distress and the RN continued to monitor the client. 5:03 p.m., the RN called the staff to check on Client A. The client tolerated Pedialyte feeding, and vital signs were stable. The physician was notified. 5:15 p.m., the RN received a call from the LVN that Client A was not breathing and unresponsive. The RN instructed the LVN to call 911 and start CPR. The physician was notified. The paramedics arrived and took the client to the ER. Client A expired at 6:09 p.m. DCS 1's written statement on 11/26/10, no time, indicated she had received report from DCS 3, at 5 a.m., that Client A had been crying throughout the night, and thought the client was about to start her menstrual period. DCS 3 gave Client A Midol for menstrual cramps. Around 8 a.m., Client A's abdomen was distended. DCS 1 notified the RN and was asked to check for residuals. The residual exceeded 60 cc and was brown in color. When the RN arrived at the facility, Client A's total residuals had been measured at 1200 cc, temperature was 97.9, and feeding at 10 a.m., was held. "She (Client A) was still whinnying (sic)/crying until 1 p.m." At 1:30 p.m., Client A had no residual, so DC S 1 gave the client Pedialyte. Client A would cry every now and then. The RN was notified. DCS 2's written statement on 11/26/10, no time, indicated Client A was crying, when she came in at 1:30 p.m. Client A's temperature was 99.0 at 2:20 p.m. Per the RN instruction, the LVN gave Client A Tylenol 5 ml at 2:30 p.m. (the order was written for 24 ml), and her temperature was 98.3 at 4:15 p.m. Client A was still clammy (moist, sticky, and cold to touch) and sleepy, and was not crying as much as she was before. DCS 2 checked on the client at around 5 p.m., and found that she was unresponsive. The LVN's written statement dated 11/26/10 at 8:15 p.m., indicated Client A was cold and clammy to touch, temperature was 99.0 at 2:20 p.m., and the client received Tylenol 5 ml. Client A was crying out for 20 minutes then stopped, quiet but still clammy. At 5:05 p.m., Client A was not breathing. DCS 2 called 911, the LVN started CPR until the paramedics arrived and took over. During an interview with DCS 1 on 1/13/11, she stated Client A was non-verbal and usually a happy kid, but when in pain, like having menstrual cramps, she would be crying. During an interview with DCS 2 on 1/13/11, she stated that when she came in on her shift, Client A was clammy to touch, crying, and moaning continuously. At 2:30 p.m., Client A received Tylenol. Client A's crying was less, but she was still clammy to touch and sleepy. During an interview with the LVN on 1/13/11, she stated that Client A was not her normal self, as the client was moaning and crying. The LVN reported the findings to the RN, and the RN instructed her to give Tylenol 5 ml to Client A for pain related to menstrual cramps. Client A kept moaning but was less than before. On 2/4/11, the coroner's autopsy report was received. The autopsy report indicated Client A's cause of death was "septic complications of ruptured stomach." The autopsy report also indicated Client A's final diagnoses, "Ruptured stomach localized to the gastric cardiac (upper part of the stomach connecting to the tube that carries food to the stomach) and fundic (deepest part of the stomach curvature) portions; etiology not grossly apparent: Decedent status post remote gastric surgeries with associated adhesion noted and gastrostomy tube normally positioned and without gross abnormality." The autopsy report also read, "The internal examination of the gastrointestinal system indicated Client A's stomach was normally formed but there was extensive rupture and gastromalacia (abnormal softening of the stomach wall) of the fundus (base or deeper part of the stomach)) and gastric cardiac portions with the defect measuring up to 10 cm (centimeter), or approximately four inches, which the gastric contents had escaped into the peritoneal cavity." A phone interview was conducted with Client A's physician on 5/5/11. He stated the RN notified him twice in the morning of the incident as follows: Client A's abdomen was distended, vital signs were stable, and the client was not in distress. Client A's high residuals were removed, and her abdomen was not distended at this time. The physician stated the protocol was to call the physician when the client's vital signs are not normal and the client is in distress. The facility failed to provide Client A's right to prompt medical care and treatment when the RN failed to assess the client's distress accurately and inform the physician of the distress as reported by DCS and the LVN. This failure resulted in the client's death on 11/26/10. The above violation had a direct or immediate relationship to the health, safety or security of the patient. |
| 250001332 |
MOUNTAIN SHADOWS SPECIAL KIDS HOMES-JUNIPER HOUSE |
250010418 |
B |
04-Feb-14 |
XZPU11 |
6831 |
Class "B" citation Welfare & Institutions Code 4502(d) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (d) A right to prompt medical care and treatment. The facility failed to provide cardiopulmonary resuscitation (CPR) to Client A to prevent anoxic brain (total lack of oxygen to the brain) injury when Direct Care Staff (DCS) 1 found the client face down in pillows and pulseless on 10/23/11. On 10/24/11, the facility self-reported that Client A was found lying face down on stomach and wedged between his pillows. The facility staff turned Client A over, and found him to be without pulse, and he was not breathing. The facility staff called 911. The ambulance arrived in four and one-half minutes later. After Client A's pulse was restored, the ambulance transported the client to the nearest hospital. Client A, a 14-year-old male, was admitted to the facility on 10/23/08, with diagnoses that included: 1. Severe intellectual disability 2 Cerebral palsy (disorder that affects muscle tone, movement, and motor skills) with spastic quadriparesis (weakness of both arms and legs) 3. Seizure disorder, well controlled 4. GJ ( gastrojejunostomy), combination device that accesses both stomach and part of middle small intestine) dependent, Nissen fundoplication (surgery for gastric reflux disease to reinforce the lower part of the tube that carries food from mouth to the stomach) 5. VP (ventriculoperitoneal) shunt (surgery to relieve increase pressure inside the skull due to excess fluid) for hydrocephalus (fluid buildup inside the skull that leads to brain swelling) 6. Status post choroid plexus (area of the brain that makes the spinal fluid) carcinoma (tumor) resection On 10/24/11, at 1:45 pm, the Qualified Intellectual Disability Personnel (QIDP) was interviewed. She stated DCS 1 walked out of the bathroom, passed through Client A and Client B's room, and DCS 1 saw Client A's face down in bed between his wedge and body pillows and not breathing. She stated DCS 1 left the room, went into the kitchen, got the phone, and called 911. She also stated DCS 1 did not provide CPR to Client A. On 10/24/11, at 2:10 pm, DCS 1 was interviewed. She stated she did not do CPR when she found Client A in bed and not breathing. Instead, she ran to the kitchen, got the phone and called 911. During the interview, the surveyor asked DCS 1 to write a statement of declaration of the incident.DCS 1's statement of declaration on 10/24/11 at 3 pm, read as follows:"On 10/23/11, at 6:55 am, Sunday, I arrived at 6:36 am for my shift...(DCS 2's name) left about five minutes to 7 am. I had to use the bathroom, so I walked through Client A and Client B's room when (Client B's name) called me to let me know his feeding had stopped. I primed his (Client B's name) bag, un-hooked him and took it into the kitchen...Walked back to (Client B's name) and flushed him (the client's feeding tube) and took off his extensions...Went to the bathroom, came out and I pushed (Client A's name) wheel chair out to the living room Went back to the room...I find (Client A's name) face down on his stomach in the pillows His back not rising. I quickly flipped him over to see him blue eyes shut, tongue slighly (sic) hanging out. Checked for pulse on his wrist, and then his neck no pulse. I ran to call 911. I called the Noc Shift to ask her how was (Client A's name) when she last changed him. I called (LVN-On-Call's name) to notify her of the emergency. The paramedics arrived in 4.5 min and started on (Client A's name) ASAP. The Sheriff talked to me (DCS 1) asked what time did find him (Client A), right at 7am. They worked on him for at least 10 minutes, and then came to ask me if there was a DNR (do not resuscitate order). I said no, they ran back about five mins later DCS 2 arrived back to the house & they bringing (Client A's name) out the room to the stretcher (sic). They had gotten a pulse back & they rushed him to "name of the hospital". We followed right to the hospital where they took him. (Client A's name) eyes were shut (L) eye & right eye cracked a little. Both arms were underneath his body. (Client A's name) was blue & hand & arm Right arm was cold." DCS 2's statement of declaration on 10/24/11 at 2:30 p.m., indicated as follows:"...it was more like 5:30 a.m. or so. Changed his diaper then put him on his (L) side w/ a toy started the other feedings and came out of the room. (AM) Staff came in around 6:35 a.m. or so we talked for a minute and I left. I made it hon (sic) and (DCS 1's name) called and said (Client A's name) was blue...then came back here to see if he was ok. I talk to a Dep. And he said they was able to get a plus (sic) after working with him...me and (DCS 1's name) went to the hospital we sat there and talk to the doc and was also giving info about him and that night. After I/we came from the hospital they transp. him to (Name of another hospital) hosp...(Client A's name) was also on a ventilator when we went up there..." On 10/25/11, DCS 1's training files were reviewed. The form, "RESPONSIBILITY IN THE EVENT OF AN EMERGENCY", indicated "...To help me be prepared for any emergency that may occur, I agree to...Maintain current CPR and First Aid certification..." signed by DCS 1 on 1/17/11. On 10/25/11, at 2:30 pm, Client A's record was reviewed. The Ambulance Pre-Hospital Care Report indicated as follows: Time call received: 07:10:42, time at patient side: 07:19:00 (nine minutes after call was placed), nature of call: cardiac/respiratory arrest, regained carotid pulse: 07:35:00, time transporting: 07:39:00 and time transport arrived at hospital: 07:46:00.The Emergency Room Treatment Summary indicated Client A arrived by ambulance with chief complaint of cardiac arrest and found unresponsive (had rolled over in bed, face down between pillows). On 3/23/12, the discharge summary for Client A was reviewed and indicated Client A expired on 10/28/11 with diagnoses of anoxic (total lack of oxygen) brain injury and cardiopulmonary arrest status post CPR. Therefore, the facility failed to provide CPR to Client A to prevent anoxic brain injury when DCS 1 found the client face down in pillows and pulseless on 10/23/11. The above violation had a direct relationship to the health, safety, or security of Client A. |
| 250000567 |
MANORCARE HEALTH SERVICES-Hemet |
250010574 |
B |
27-Mar-14 |
T0JZ11 |
10921 |
72311. Nursing Service ? General (a) Nursing service shall include, but limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.During the investigation of a complaint initiated on March 8, 2012, at 10:25 a.m., it was determined that the facility failed to confirm Patient A?s resuscitation status, failed to timely initiate cardio-pulmonary resuscitation (CPR), and failed to identify the need to call 9-1-1 after Patient A was found without respirations and pulses. The facility?s failure to act on Patient A?s wishes resulted in her death on February 29, 2012. Patient A, an 85 year old female, was re-admitted to the facility on January 1, 2012, with diagnoses that included chronic lung disease, dementia (memory problems) and heart disease. On March 8, 2012, Patient A?s record was reviewed. The Minimum Data Set ( MDS, an assessment tool), dated January 24, 2012, indicated Patient A was alert, responsive, able to make her needs known to the staff, had the ability to understand others, and could make herself understood.Patient A had a POLST (Physician Orders For Life- Sustaining Treatment) form in her record that directed full resuscitation measures to be taken in the event Patient A had a cardio-pulmonary arrest (the heart and lungs cease to function). Patient A?s responsible party had signed the POLST on January 24, 2012. The patient?s physician signed the POLST on January 27, 2012.On March 8, 2012, an interview was conducted with the Director of Nursing (DON). She stated that Certified Nursing Assistant (CNA) 1 found Patient A without respiration and pulses at 5:45 a.m. on February 29, 2012. She stated that CNA 1 reported Patient A?s condition to the Charge Nurse (RN 1), and RN 1 confirmed that Patient A had no respiration, pulse or blood pressure. The DON further stated that RN 1 checked Patient A?s record and located a physician?s order that indicated the patient was to go home on February 29, 2012, with hospice services. The DON said that RN 1 assumed that Patient A was a DNR (Do Not Resuscitate) and told CNA 1 to prepare Patient A?s body for the mortuary (funeral home).The DON said that RN 1 contacted Physician 1?s answering service and left a message that Patient A had died. RN 1 also attempted to call Patient A?s daughter but was unable to reach her.The DON further stated that on February 29, 2012, she had been in the building at 2 a.m. to make early rounds but was not made aware of Patient A?s death at 5:45 a.m.At 6:30 a.m., the day shift staff members learned that Patient A had died. The DON was called to Station 2?s Nursing Station at that time and was told that Patient A had died at 5:45 a.m. The DON checked Patient A?s record and could not locate a DNR order. The DON stated that she spoke with Patient A?s daughter at 8 a.m. on February 29, 2012, to inform her of Patient A?s death. The DON said the patient?s daughter was upset. She had planned to take Patient A home with hospice care service.On March 8, 2012, at 1:25 p.m., an interview was conducted with LVN 1. He stated that on February 29, 2012, between 7 a.m. and 7:30 a.m., RN 1 told him to call a Code Blue (a term used in health care facilities to indicate CPR is needed). He said that he had initiated pulmonary resuscitation (breathing) for Patient A. He described Patient A as pale, with fixed and dilated pupils (the center of the eye). He further stated that the patient did not have pulses or a blood pressure. He said he left the patient?s room when the fire department crew members arrived and further stated that RN 1 remained in Patient A?s room, giving report to the fire department crew members.At 2:05 p.m., the Social Services Designee (SSD) was interviewed. The SSD stated that on February 22, 2012, RN 2 had received a doctor?s order for Patient A to be evaluated for hospice services, per the daughter?s request. The SSD stated Patient A?s daughter met with the hospice representative and decided to wait for the service until the patient was discharged home. At 2:20 p.m., the Assistant Director of Nursing (ADON) for Station 2 was interviewed. The ADON stated Patient A was a full Code, and the patient?s daughter had signed the POLST, to perform CPR and deliver full resuscitation treatments. She further stated that facility staff members were trained to always check all patients? record in the Advance Directive Section for the Code status. At 2:45p.m., LVN 2 was interviewed. LVN 2 stated that on February 29, 2012, between 7:15 a.m. and 7:30 a.m., he responded to the Code Blue for Patient A. He found Patient A in her bed without respiration, pulses, and blood pressure. He performed chest compression and he stated that Patient A was connected to the facility?s AED (Automatic External Defibrillator, a machine that detected if the patient had a heartbeat). He stated there was no heartbeat detected. He described Patient A as pale, with her mouth wide open and in rigor (rigor mortis, a stiffening of the body after death). He further stated he did not know that Patient A had died at 5:45 a.m. when he responded to the Code Blue. At 3 p.m., LVN 3 was interviewed. LVN 3 stated that on February 29, 2012, at about 7:15 a.m., she was at Station 2 when she heard LVN 4 ask if someone had called a Code Blue for Patient A. She further stated LVN 4 checked Patient A?s record. The POLST form indicated that the patient was a full Code. She observed LVN 4 approach the Charge Nurse from the night shift (RN 1) and the incoming day shift Charge Nurse (RN 2), who were conducting their nursing rounds. She stated LVN 4 told her (LVN 3) that the two charge nurses continued their rounds even after they were told by LVN 4 that Patient A was a full Code. LVN 3 went to DON?s office and told the DON that Patient A had died at 5: 45 a.m. The patient had been a full Code, but the night shift staff had not called a Code or 9-1-1. LVN 3 said she heard RN 1 tell the DON, ?She was going home on hospice anyway. What?s the point? I made a mistake. I am sorry.? LVN 3 went to Patient A?s room and saw the patient was clean and ready for the mortuary. Then she heard a staff member call a Code Blue, and everyone rushed into Patient A?s room. LVN 3 said that facility staff started CPR. When the fire department?s emergency responders came into the room, RN 1 told them that Patient A had died at 5:45 a.m. On March 9, 2012, at 2:10 p.m., an interview was conducted with LVN 4. The LVN stated that on February 29, 2012, she came into work at 6:30 a.m. She was approached by a staff member who asked her if Patient A had died.When LVN 4 went to the patient?s room, she observed Patient A in her bed. She stated Patient A was wearing a hospital gown, had a rolled towel placed under her chin, and was covered with a blanket up to her shoulder area. LVN 4 described Patient A as pale, and she had no respirations or pulse. She checked Patient A?s record and located a POLST form that indicated to perform CPR and provide full resuscitation measures if Patient A lost her pulse and was not breathing. She asked RN 1 if Patient A was a DNR. RN 1 stated, ?Yes, she was supposed to go home with hospice today.? She told RN 1 that Patient A?s record indicated to provide CPR and provide full treatment measures associated with a Code Blue. On March 12, 2012, at 9:40 a.m., the first emergency responder from the Fire Department was interviewed. He stated that on February 29, 2012, at 7:38 a.m., he observed the facility staff performing CPR on Patient A. He was told by RN 1 that Patient A was found without respiration, pulse or blood pressure at 5:45 a.m. He was further informed by RN 1 that Patient A was scheduled to go home with hospice care, and she had assumed the patient was a DNR. The fire department crew members determined at 7:40 a.m. that Patient A was in rigor. He stated RN 1 had contacted Patient A?s physician to obtain a DNR order. Patient A?s physician refused. The facility staff called 9-1-1 and initiated CPR one hour and forty-eight minutes after the patient was found without respiration and pulse. On March 14, 2012, a telephonic interview was conducted with LVN 5. She stated that on February 29, 2012, around 4:30 a.m., CNA 1 informed her that Patient A was having some breathing problems. Patient A?s respiration rate was 29 breaths per minute (normal adult rate is 8-20 per minute). LVN 5 stated she gave the patient a breathing treatment with Albuterol Sulfate (a medication that is dispensed as a mist and inhaled to cause the bronchial tubes to dilate, making breathing easier). The patient had a physician?s order to use the Albuterol treatment every four hours as needed for shortness of breath. LVN 5 said she was approached later by CNA 1 to inform her that Patient A had no respiration and pulses. RN 1 was notified of Patient A?s condition, and both the RN 1 and LVN 5 confirmed that Patient A had no vital signs. LVN 5 stated, ?RN 1 took care of the situation and I continued my med (medication) pass, since I was so behind.? She further stated, ?They did not call a Code on Patient A.?The Nurses Progress Note dated February 29, 2012, at 5:45 a.m., indicated that, Patient A ?Expired, DNR. Unable to hear respirations or appreciate heart sounds.? This note was documented by RN 1. On March 14, 2012, at 3:05 p.m., an interview was conducted with Patient A?s physician. The physician stated that she had ordered a hospice evaluation for Patient A, but Patient A?s daughter decided to wait to start hospice service until the patient was discharged to home. She further stated Patient A was still a full Code while a patient in the facility. The physician stated that on February 29, 2012, in the early morning, she was informed by the night Charge Nurse (RN 1) that Patient A had been found at 5:45 a.m. without respirations and pulses. She further stated that the RN asked if she would order a DNR for Patient A. The physician said that she told the RN, ?Why should I give a DNR order for a patient who was a full Code and had expired??Therefore, the facility failed to confirm Patient A?s resuscitation status, failed to immediately initiate CPR, and failed to identify the need to call 9-1-1 after Patient A was found without respirations and pulses. The facility proceeded to perform CPR on Patient A at least one hour and forty-eight minutes after the patient was found without vital signs and after they discovered that the Physician?s Orders for Life Sustaining Treatment form directed full resuscitation measures. Moreover, the facility staff contacted the physician to change her order from ?full resuscitation? to ?no resuscitation? after Patient A died.This violation had a direct relationship to the health, safety, or security of Patient A. |
| 250000567 |
MANORCARE HEALTH SERVICES-Hemet |
250010576 |
B |
27-Mar-14 |
OP8111 |
7121 |
T22 DIV5 CH3 ART#-72313(a)(2)(7) Nursing Service?Administration of Medication (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. (7) Patients shall be identified prior to administration of a drug or treatment. On September 1, 2010, an unannounced visit was made to the facility to investigate a complaint allegation.Based on interview and record review, the facility failed to ensure that medications were administered as prescribed, when a registered nurse (RN 1), administered the wrong medications to Patient A. This medication error caused Patient A to receive insulin (medication used to decrease blood sugar) and additional blood pressure medications (medications used to decrease blood pressure), causing her to have low blood sugar and low blood pressure. Patient A had to be transported to an acute care hospital and admitted to the Intensive Care Unit. Review of Patient A?s medical record indicated the 94 year old female was admitted to the facility on August 9, 2010, from the acute care hospital, with diagnoses including cerebral vascular accident (stroke) with right side hemiplegia (weakness), coronary heart disease, and hypertension (high blood pressure).A Nursing note, dated August 23, 2010, indicated Patient A was alert, oriented, and able to make her needs known but forgetful of time, had a poor memory, and had poor vision. On September 10, 2010, at 2:30 p.m., during an interview with the Director of Nursing (DON), she stated on August 23, 2010 at 3:00 p.m., a Registered Nurse (RN) administered the morning medications ordered for Patient B to Patient A instead. The DON stated the RN reported she had not been able to find Patient B in her room during the morning medication administration time. The RN continued to look for Patient B during the morning. At 3 p.m., the RN was told Patient B was in the activity room. The RN went to the activity room and asked Patient A if she was (Patient B?s name). The RN reported she looked for an arm band but was unable to find one. She reported that Patient A responded to Patient B's name. The RN administered Patient B?s morning medications including insulin, to Patient A at 3 p.m. Patient A became alarmed when she received an injection and was told she had diabetes. Patient A went to the nurses? station afterwards and the error was discovered.At 5:30 p.m., Patient A's blood sugar was 55 (normal 60-120) and blood pressure was 70/40 (normal 120/70). Patient A was sent to the acute hospital and admitted to the Intensive Care Unit (ICU).The recapitulated (monthly summary of current orders) physician's orders, dated August, 2010, for Patient A indicated: -Aspirin 81 mg (milligrams) by mouth daily; (blood thinner) -Plavix 75 mg by mouth daily; (blood thinner) -Norvasc 8 mg by mouth daily; (control blood pressure) and -Baclofen 5 mg by mouth twice daily (muscle spasms). The daily doses were recorded as being given at 8 a.m. Patient B was admitted on February 2, 2008 with diagnoses including congestive heart failure, atrial fibulation (irregular heart rhythm) high blood pressure, heart disease, and insulin dependent diabetes. The recapitulated physician's orders, dated August, 2010, for Patient B indicated: -Novolin R (insulin) 100 units/milliliter subcutaneous injection per sliding scale before meals and at bedtime; (four times a day) (control blood sugar) -Glyburide 5 mg by mouth twice daily; (control blood sugar) -Lasix 20 mg by mouth daily (increase urination to eliminate excess fluid from the body); -Synthroid 0.05 mg per mouth daily; (thyroid replacement); -Magnesium Oxide 400 mg per mouth twice daily; (supplement); -Klor-con M20 Extended Release tablet 20 milliequivelent by mouth, daily; (potassium supplement) -Aricept 5 mg per mouth daily; (improve memory); -Aspirin 325 mg per mouth daily; (blood thinner); -Nitroglycerin 2.5 mg per mouth twice daily; (increase the blood flow to the heart) -Digoxin 0.125 mg per mouth daily; (strengthen heart beat) -Vasotec 10 mg per mouth twice daily; (lower blood pressure) -Lopressor 50 mg per mouth twice daily; (lower blood pressure) -Procardia XL 60 mg per mouth twice daily; (control blood pressure) Clonidine 0.1 mg per mouth twice daily; (control blood pressure). In addition to receiving her own medications on August 23, 2010, Patient A also received all the above morning medications, prescribed for Patient B, including insulin. The nursing note of August 23, 2010, indicated the following: At 4 p.m., ?Resident (Patient A) c/o (complained) someone had given her an insulin shot, and checked her blood sugar and informed her she?s diabetic. Resident requested to call (representative)... 5 p.m., (Representative) came?awaiting call from MD.? At 5:30 p.m., ?Resident given orange juice, protein crackers with peanut butter for blood sugar of 55?MD ordered orange juice and recheck blood sugar every 1 hour?She claims that she also took multiple medication, doesn?t know what are those medications, BP checked 70/40, HR 55.? At 5:45 p.m., ?Re-checked BP 80/45, HR 59, BG (Blood sugar) 77.? At 6 p.m., ?MD called back and made her aware, Resident claiming she took multiple PO meds aside from her regular medication in the morning. OK to send Resident to ER for further evaluation?? At 6:20 p.m., ?Transferred via paramedics to acute hospital.BS 77, BP 90/50, HR 70, R 20.? Patient A was admitted to the ICU for three days, transferred to a medical floor for two days, and then discharged home with her granddaughter.During an interview on September 10, 2010, at 4:15 p.m. with the granddaughter, she stated that Patient A had been ?getting very comfortable? in the nursing facility prior to this incident and planned on staying. After this incident, Patient A refused to go to any skilled nursing facility because she was frightened of the nurses. A review of the personnel file for the Registered Nurse indicated she was a per diem (as needed) employee and had worked four shifts in August of 2010. The facility initiated an investigation of this incident and terminated her employment on August 24, 2013.The policy, "Medication Administration: Medication Pass," dated March, 2010, indicated, "9. Administer medication: administer medication in accordance with frequency prescribed by physician-within 60 minutes before or after prescribed dosing time-if patient is not in room to received medication, flag MAR (Medication Administration Record) and at conclusion of medication pass, roll cart to patient's location and administer medications...Identify patient by calling name, checking identification band, referring to photo..." The facility?s failure to ensure the correct medications, as ordered by the physician, were administered to the correct patient resulted in Patient A receiving medications that were not prescribed by her physician, including insulin and antihypertensive medication resulting in a five day hospitalization, three days of which were in the Intensive Care Unit. These violations had a direct relationship to the health, safety, and security of the patient. |
| 250000077 |
MAGNOLIA REHABILITATION & NURSING CENTER |
250010605 |
A |
10-Apr-14 |
VB4V11 |
10083 |
H& S Code - 1424(d) 1424. Citations issued pursuant to this chapter shall be classified according to the nature of the violation and shall indicate the classification on the face thereof. (d) Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious, harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. A physical condition or one or more practices, means, methods, or operations in use in a long-term health care facility may constitute a class "A" violation. The condition or practice constituting a class "A" violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the state department, is required for correction. Except as provided in Section 1424.5, a class "A" citation is subject to a civil penalty in an amount not less than one thousand dollars ($1,000) and not exceeding ten thousand dollars ($10,000) for each and every citation. If the state department establishes that a violation occurred, the licensee shall have the burden of proving that the licensee did what might reasonably be expected of a long-term health care facility licensee, acting under similar circumstances, to comply with the regulation. If the licensee sustains this burden, then the citation shall be dismissed. Title 22- 72319(g)-Restraints shall be used in such a way as not to cause physical injury to the patient and to insure the least possible discomfort to the patient. The facility failed to use soft roll waist restraint in such a way not to cause physical injury to Patient A. This failure led to his death on 5/28/10. On 6/1/2010, the facility self-reported that Patient A, a hospice patient, had died due to a non-hospice related incident. On 6/2/10, Assistant Administrator (AA) 1 reported that Patient A had on a soft roll waist restraint and may have strangled himself because of restlessness. Patient A, an 82-year old male, was admitted to the facility on 11/12/09, with diagnoses including osteomyelitis (inflammation of bone and marrow, usually caused by infection), non-healing wound of the right foot, diabetes mellitus type 2 (insulin resistance, with inadequate insulin secretion to sustain normal metabolism), and peripheral vascular disease (any condition that causes partial or complete obstruction of the flow of blood to or from the arteries or veins outside the chest). On 4/23/10, Patient A was put on hospice care for end stage of coronary artery disease (narrowing of the coronary - pertaining to the heart - arteries). (In reference to all definitions, Taber's CYCLOPEDIC MEDICAL DICTIONARY. Edition 19, 2001. F.A. Davis Company). Patient A was alert and oriented with periods of confusion. On 6/9/10 at 3:45 p.m., AA 1 was interviewed. She stated that on 5/28/10, around 4:40 p.m., a Certified Nursing Assistant (CNA) entered Patient A's room. The CNA saw Patient A's lower body on the floor with the upper body suspended from the bed by the soft waist restraint. The patient was unresponsive. The CNA called for help, and the Licensed Vocational Nurse (LVN) came into Patient A's room to help the CNA. The CNA found Patient A with the soft waist restraint under the patient's right arm, across the chest, and under the left side of the neck. She further stated that Patient A had multiple falls, and he was put in a soft waist restraint while in bed for safety. The physician's order dated 5/25/10 included "siderails up X2 (times two) with soft waist restraint while in bed", and consent by telephone was received from the patient's daughter on the same date. On 7/8/10, Patient A's record was reviewed. The "NURSES' PROGRESS NOTES" indicated Patient A had experienced multiple falls in May 2010, with the following entries in the record: -5/1/10 at 6:30 p.m., "...found patient on the floor kneeling position in front of the sofa in lobby..." -5/15/10 at 11:30 p.m., "CNA called charge nurse into room. Pt (patient) is found on the floor." -5/24/10 at3:45 p.m., "...pt found on the floor laying next to bed. Pt on low bed with matress on floor, however, pt is not on top of matress when found." Per the physician's telephone order, provide mattress on the floor on the other side of the bed. 5/25/10 at 2:30 p.m., "...while trying to transfer to w/c (wheelchair) pt was loosing balance RNA (Restorative Nursing Assistant) was assisting him to the floor & w/c was in back of him & his back was rubbing with seat of w/c, small scrape noticed to back." Per the physician's telephone order, discontinue low bed with one side rail up and mattress on the floor; provide side rails up times two with soft waist restraint while in bed. 5/26/10 at 6:55 p.m., "...found pt sliding down his w/c in his room with his back against the front of wheelchair & buttocks touching the ground with hands supporting on the ground." On 7/8/10, at 11 a.m., AA 2 and the Director of Nursing (DON) were interviewed together. AA 2 stated that on 5/28/10, on the p.m., shift, the CNA found Patient A half in bed and half on the floor. The soft waist restraint was across the chest, the left arm was out, and the right arm was up.The DON stated, "Yes, that was how the CNA found the patient (Patient A), and he was unresponsive." The DON stated, "The patient knew what was going on. He was alert and oriented with periods of confusion." On 7/26/10, at 3:42 p.m., the LVN's statement of declaration was obtained. The statement was reviewed and indicated that she heard the CNA yelling for help. The LVN wrote that she had been in another room when she heard the CNA calling for help. She left and reported to Patient A's room. The LVN wrote, "There I found (Patient A's name) half on bed & (CNA's name) trying to get him free. He (Patient A) was very pale & unresponsive at that point." The LVN further wrote that other licensed nurses (LNs) were in the room at that time and took over. She indicated that the LNs assessed Patient A and said he was dead. On 7/27/10, at 11:36 a.m., the DON showed the surveyor a bed that was similar to the bed that Patient A had been in on 5/28/10. Using a 12-inch ruler, the surveyor measured the height of the bed from the floor to the top of the bed frame at approximately 24 inches. This measurement did not include a mattress. The DON also showed the surveyor the same type of soft waist restraint that had been used on Patient A on 5/28/10. The soft waist restraint was made of cloth and measured 22-1/2 inches long. The middle part of the soft waist restraint was lightly padded and measured 5-1/2 inches wide. On 7/25/10, the "Autopsy Protocol" report was received. The report indicated Patient A's cause of death was, "Undetermined, cannot exclude asphyxia." Webster's New World College Dictionary, Fourth Edition, defines asphyxia as, "Too little oxygen and too much carbon dioxide in the blood; suffocation causes asphyxia." The report also indicated Patient A's conjunctiva (clear mucous membrane that covers the white part of the eyes) had rare bulbar "petechial hemorrhages." A reference in the World of Forensic Science. Ed. K. Lee Lerner and Brenda Wilmoth Lerner. Gale Cengage, 2006. 5 Sep, 2011, entitled "Asphyxation (Signs Of)." indicated, "Evidence of suffocation may include small red or purple splotches (petechiae) in the eyes." On 9/14/11, at 3:30 p.m., the DON and AA 2 were interviewed together again. The DON stated that there was no monitoring or documentation every two hours when Patient A was in the waist restraint because there was a video camera that monitored the staff members who went in and out of the patient's room. AA 2 stated that at least the staff could see what was going on with the patient (Patient A) if the staff checked the patient's roommate. The surveyor asked the DON and AA 2 how they would know the staff who checked on Patient A's roommate could see what was going on with Patient A since there was a privacy curtain provided. The DON and AA 2 did not respond. On 9/28/10, at 11:47 a.m., the CNA's statement of declaration, written on 5/28/10, was reviewed. The statement of declaration read, "...as I walked into the room. I saw (Patient's Name) with his body hanging by the side of the bed with the waist restraint around his neck and right arm pit. His head was @ (at) mattress level, the back of the bed was elevated. His eyes and mouth were open, feet and legs were in the direction toward the head of the bed and he was unresponsive...The restraint was too tight. I tried untying the restraint from the bed frame as I called out for (Name of the LVN) ... (LVN's Name) got it (the restraint) untied quickly, I removed the restraint from around (Patient's Name) neck and gently laid (Patient's Name) on the floor. At this point (Patient's Name) head was at the foot of the bed and his feet were at the head of the bed." On12/5/10, the facility's policy and procedure entitled "Restraints-Physical" was reviewed. Under Procedure #4d, it reads, "A resident placed in restraint will be checked at least every two (2) hours by nursing personnel and an account of any changes in resident's condition shall be recorded in the resident's medical record." There was no indication or evidence in Patient A's record that the facility followed Procedure #4d. On 1/12/12, at 2 p.m., the DON was interviewed. She stated that a CNA applied the restraint to Patient A. The DON also stated that she did not know if the CNA from morning or afternoon shift had applied the restraint on Patient A prior to his death. She stated, "I don't even know the CNA's name." Therefore, the facility failed to use a soft roll waist restrain in such a way as not to cause physical injury to Patient A. This failure led to the patient's death on 5/28/10. The above violation presented either an imminent danger of death or serious harm or substantial probability of death or serious physical harm to the patient. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010667 |
B |
13-May-14 |
U4F111 |
7029 |
483.13(c) F224 42 CFR 488.301?Misappropriation of resident property ?means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident?s belongings or money without the resident?s consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident O: 1. The safe keeping and security of the resident?s trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident?s family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had ?suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, ?I immediately contacted a third party auditor to research the matter.? Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. ? During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature...? In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1?s] personal bank account. ?The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired (died) she (BOM) took money from."Resident O expired at the facility on July 26, 2012. Resident O?s family as responsible party did not receive a refund of $3,189.36 from the resident?s trust fund. Resident O had a combined interest of $126.77 Resident O?s combined trust fund account and interest totaled $3,316.13 During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1.? BOW 1 stated, ?The facility did not follow through with a (formal) month to month review of the resident trust account.? Individual ledgers to reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one- to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, ?Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported?.Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented...? The facility?s failure to safeguard the resident trust funds for Resident O caused misappropriation of Resident O?s trust fund monies totaling $3,316.13. The facility?s failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010668 |
B |
13-May-14 |
U4F111 |
7136 |
483.13(c) F224 42 CFR 488.301?Misappropriation of resident property ?means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident?s belongings or money without the resident?s consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident GG: 1. The safe keeping and security of the resident?s trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident?s family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had ?suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, ?I immediately contacted a third party auditor to research the matter.?An interview was conducted with the ADM on October 3, 2013, at 2:50 p.m. A phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. ? During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature...? In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1?s] personal bank account. ?The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired she (BOM) took money from."Resident GG Passed away at the facility on March 30, 2013. Resident GG?s family as responsible party did not receive a refund of $1,780.02 from the resident?s trust fund. Resident GG had a combined interest of $46.94 which was not received as a refund with the above amount. The combined total of interest and trust account totaled $1,826.96. During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1.? BOW 1 stated, ?The facility did not follow through with a (formal) month to month review of the resident trust account.? Individual ledgers reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one -to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, ?Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported?.Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented...? The facility?s failure to safeguard the resident trust funds for Resident GG caused misappropriation of Resident GG?s trust fund monies totaling $1,826.96. The facility?s failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010669 |
B |
13-May-14 |
U4F111 |
6914 |
483.13(c) F224 42 CFR 488.301?Misappropriation of resident property ?means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident?s belongings or money without the resident?s consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident CC: 1. The safe keeping and security of the resident?s trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident?s family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had ?suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, ?I immediately contacted a third party auditor to research the matter."Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end.? During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature...? In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1?s] personal bank account. ?The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired (died) she (BOM) took money from."During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1.? BOW 1 stated, ?The facility did not follow through with a (formal) month to month review of the resident trust account.? Individual ledgers reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one-to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, ?Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported?.Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented...? Resident CC had a trust fund account totaling $2,002 Resident CC had a combined interest of $92.32 Resident CC combined trust fund account and interest totaled $2,094.32 The facility?s failure to safeguard the resident trust funds for Resident CC caused misappropriation of Resident CC?s trust fund monies totaling $2,094.32. The facility?s failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010670 |
B |
13-May-14 |
U4F111 |
6917 |
483.13(c) F224 42 CFR 488.301 ?Misappropriation of resident property ?means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident?s belongings or money without the resident?s consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident AA: 1. The safe keeping and security of the resident?s trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident?s family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had ?suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, "I immediately contacted a third party auditor to research the matter."Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. ? During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature...? In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1?s] personal bank account. ?The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired (died) she (BOM) took money from."During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1.? BOW 1 stated, ?The facility did not follow through with a (formal) month to month review of the resident trust account.? Individual ledgers reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one-to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, ?Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported?.Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented...? Resident AA had a trust fund account totaling $5,430 Resident AA had a combined interest of $233.49 Resident AA combined trust fund account and interest totaled $5,663.49 The facility?s failure to safeguard the resident trust funds for Resident AA caused misappropriation of Resident AA?s trust fund monies totaling $5,663.49. The facility?s failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010671 |
B |
13-May-14 |
U4F111 |
7080 |
483.13(c) F224 42 CFR 488.301?Misappropriation of resident property ?means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident?s belongings or money without the resident?s consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident I: 1. The safe keeping and security of the resident?s trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident?s family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had ?suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, ?I immediately contacted a third party auditor to research the matter.?Then at at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. ? During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature...? In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1?s] personal bank account. ?The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired (died) she (BOM) took money from."Resident I expired at the facility on July 21, 2012. Resident I?s family as responsible party did not receive a refund of $2861.68 from the resident?s trust fund. Resident I had a combined interest of $92.25 which was not received as a refund with the above amount. The combined total of interest and trust account totaled $2,953.93. During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1.? BOW 1 stated, ?The facility did not follow through with a (formal) month to month review of the resident trust account.? Individual ledgers reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one -to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, ?Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported?.Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented...? The facility?s failure to safeguard the resident trust funds for Resident I caused misappropriation of Resident I?s trust fund monies totaling $2,953.93. The facility?s failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010672 |
B |
13-May-14 |
U4F111 |
6893 |
483.13(c) F224 42 CFR 488.301?Misappropriation of resident property ?means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident?s belongings or money without the resident?s consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident D: 1. The safe keeping and security of the resident?s trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident?s family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had ?suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013, On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, ?I immediately contacted a third party auditor to research the matter.? Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. ? During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature...? In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1?s] personal bank account. ?The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired (died) she (BOM) took money from."During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1.? BOW 1 stated, ?The facility did not follow through with a (formal) month to month review of the resident trust account.? Individual ledgers to reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one -to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, ?Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported?.Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented...? Resident D had a trust fund account totaling $1,575 Resident D had a combined interest of $68.64 Resident D?s total combined amount was $1,643.64 The facility?s failure to safeguard the resident trust funds for Resident D caused misappropriation of Resident D?s trust fund monies totaling $1,643.64. The facility?s failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010673 |
B |
13-May-14 |
U4F111 |
7159 |
F224 42 CFR 483.13(c) 42 CFR 488.301"Misappropriation of resident property" means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facilities failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident BB: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident's trust funds, affecting Resident BB. 4. Reconcile (verify) trust fund balances for the resident's family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. The ADM stated that she had employed BOM 1 (Business Office Manager 1) and stated she had "suspicion of an employee who may have done fraud..." The BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. The BOM did not show up for work.On October 3, 2013, at 2:45 p.m., the ADM stated, "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (resident trust) funds." The ADM further stated, "I immediately contacted a third party auditor to research the matter."An interview was conducted with the ADM on October 3, 2013, at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated that BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end.During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM provided the job description of BOM 1. A record review was conducted of BOM 1's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature..." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., the auditor stated, "I was recently hired on October 7, 2013, to complete the audit of the facility's resident trust funds and so far most of the resident's trust fund accounts were transferred to [BOM 1's] personal bank account." The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired she (BOM) took money from."Resident BB passed away at the facility on July 21, 2012. Resident BB's family as responsible party did not receive a refund of $962.20 from the resident's trust fund. Resident BB had a combined interest of $37.70 which was not received as a refund with the above amount. The combined total of interest and trust account totaled $999.90 During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1. The worker stated the facility did not follow through with a (formal) month to month review of the resident trust account. Individual ledgers to reconcile (verify) the Patient Trust control Account was not taking place. Families of deceased residents did not receive their trust fund money. There were no formal one to one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, "Policies and Procedures in Handling Patient Trust Fund," indicated the following: "... A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on-going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported....Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated: "... When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Moneys or Valuables: "...Should be adequately safeguarded and accurately accounted for and documented... The facility's failure to safeguard the resident trust funds for Resident BB caused the misappropriation of Resident BB's trust fund monies totaling $999.90. The facility's failures to manage, protect, and verify resident funds had a direct relationship to the health, safety, and security of patients." |
| 250000148 |
MIRAVILLA CARE CENTER |
250010674 |
B |
13-May-14 |
U4F111 |
7092 |
F224 42 CFR 483.13(c) 42 CFR 488.301"Misappropriation of resident property "means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident FF: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident's family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had "suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, "I immediately contacted a third party auditor to research the matter."Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. " During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature..." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1's] personal bank account. "The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired (died) she (BOM) took money from."Resident FF Passed away at the facility on May 30, 2013. Resident FF's family as responsible party did not receive a refund of $1,325.00 from the resident's trust fund. Resident FF had a combined interest of $19.66 which was not received as a refund with the above amount. The combined total of interest and trust account totaled $1,344.66. During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1." BOW 1 stated," The facility did not follow through with a (formal) month to month review of the resident trust account." Individual ledgers to reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money. There were no formal one- to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, "Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported....Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented..." The facility's failure to safeguard the resident trust funds for Resident FF caused misappropriation of Resident FF's trust fund monies totaling $1,344.66. The facility's failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010675 |
B |
13-May-14 |
U4F111 |
6915 |
F224 42 CFR 483.13(c) 42 CFR 488.301"Misappropriation of resident property "means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident Q: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident's family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had "suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, " I immediately contacted a third party auditor to research the matter." Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. " During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature..." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1's] personal bank account. "The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired she (BOM) took money from."During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1." BOW 1 stated, "The facility did not follow through with a (formal) month to month review of the resident trust account." Individual ledgers to reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one-to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, "Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported....Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented..." Resident Q had a trust fund account totaling $1,883 Resident Q had a combined interest of $80.34 Resident Q combined trust fund account and interest totaled $1963.34 The facility's failure to safeguard the resident trust funds for Resident Q caused misappropriation of Resident Q's trust fund monies totaling $1,963.34. The facility's failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010676 |
B |
13-May-14 |
U4F111 |
6921 |
F224 42 CFR 483.13(c) 42 CFR 488.301"Misappropriation of resident property "means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident EE: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident's family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had "suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, "I immediately contacted a third party auditor to research the matter." Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. " During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature..." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1's] personal bank account. "The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired she (BOM) took money from."During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1." BOW 1 stated, "The facility did not follow through with a (formal) month to month review of the resident trust account." Individual ledgers reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one-to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, "Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported....Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented..." Resident EE had a trust fund account totaling $3,062.54 Resident EE had a combined interest of $38.38 Resident EE combined trust fund account and interest totaled $3,100.92 The facility's failure to safeguard the resident trust funds for Resident EE caused misappropriation of Resident EE's trust fund monies totaling $3,100.92. The facility's failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010678 |
B |
13-May-14 |
U4F111 |
7257 |
483.13(c) F224 42 CFR 488.301"Misappropriation of resident property "means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident H: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident's family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had "suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, "I immediately contacted a third party auditor to research the matter." Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. " During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature..." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1's] personal bank account. "The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired (died) she (BOM) took money from."Resident H Passed away at the facility on August 19, 2012. Resident H's family as responsible party did not receive a refund of $1, 632.53 from the resident's trust fund. During an interview conducted with Resident H's daughter on October 14, 2013, at 3:30 p.m., the daughter stated, "I did not receive any trust statements from the facility and was not reimbursed within thirty days after my mother's death." During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1." BOW 1 stated, "The facility did not follow through with a (formal) month to month review of the resident trust account." Individual ledgers reconciling (verifying) the Patient Trust Control Account were not taking place." Families of deceased residents did not receive their trust fund money refund. There were no formal one- to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, "Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported....Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented..." Resident H had a trust fund account totaling $1,573.89 Resident H had a combined interest of $58.64 The facility's failure to safeguard the resident trust funds for Resident H caused misappropriation of Resident H's trust fund monies totaling $1,632.53. The facility's failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010683 |
B |
13-May-14 |
U4F111 |
7608 |
483.13(c) F224 42 CFR 488.301"Misappropriation of resident property "means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Residents: X, Y, DD, KK, LL, MM, OO, PP, QQ, and RR 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident's family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had "suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013, On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, " I immediately contacted a third party auditor to research the matter." Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. " During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature..." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1's] personal bank account. "The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired she (BOM) took money from."Resident Y expired (died) at the facility on November 23, 2011. Resident RR expired at the facility on November 8, 2013.The residents families as responsible parties did not receive a refund of $35.40 for Resident Y and $17.67 for Resident RR from their respective trust funds. Other Residents:Resident X- trust fund totaled $5.00 Resident Y- trust fund totaled $35.40 Resident DD- trust fund totaled $63.10 Resident KK- trust fund totaled $52.69 Resident LL- trust fund totaled $20.51 Resident MM- trust fund totaled $433.27 Resident OO- trust fund totaled $8.62 Resident PP- trust fund totaled $30.00 Resident QQ- trust fund totaled $60.00 Resident RR- trust fund totaled- $17.67 Trust Fund Combined Interest Totaled $45.49 Trust Fund Combined Total: $771.75 During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1." BOW 1 stated, "The facility did not follow through with a (formal) month to month review of the resident trust account." Individual ledgers reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one-to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, "Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported....Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented..." The facility's failure to safeguard the resident trust funds for Residents X, Y, DD, KK, LL, MM, OO, PP, QQ, RR caused misappropriation of Residents X, Y, DD, KK, LL, MM, OO, PP, QQ, RR trust fund monies totaling $771.75. The facility's failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010684 |
B |
13-May-14 |
U4F111 |
6895 |
483.13(c) F224 42 CFR 488.301"Misappropriation of resident property "means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Residents B and F: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident's family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had "suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013, On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, "I immediately contacted a third party auditor to research the matter." Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end." During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature..." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1's] personal bank account. "The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired she (BOM) took money from."Resident B-trust fund totaled $609.00 Resident F-trust fund totaled $440.00 Trust Fund Interest Totaled $20.12 Trust Fund Combined Total equaled $1,069.12 During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1. BOW 1 stated, "The facility did not follow through with a (formal) month to month review of the resident trust account." Individual ledgers reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money. There were no formal one- to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, "Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported....Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented..." The facility's failure to safeguard the resident trust funds for Residents B and F caused misappropriation of Resident trust fund monies totaling $1,069.12. The facility's failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010685 |
B |
13-May-14 |
U4F111 |
6913 |
F224 42 CFR 483.13(c) 42 CFR 488.301"Misappropriation of resident property "means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident S: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident's family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had "suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, "I immediately contacted a third party auditor to research the matter."Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. " During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature..." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1's] personal bank account. "The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired she (BOM) took money from."During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1." BOW 1 stated, "The facility did not follow through with a (formal) month to month review of the resident trust account." Individual ledgers to reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one-to-one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, "Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported....Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented..." Resident S had a trust fund account totaling $1,781 Resident S had a combined interest of $78.33 Resident S combined trust fund account and interest totaled $1.859.33 The facility's failure to safeguard the resident trust funds for Resident S caused misappropriation of Resident S's trust fund monies totaling $1,859.33. The facility's failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010686 |
B |
13-May-14 |
U4F111 |
6951 |
F224 42 CFR 483.13(c) 42 CFR 488.301"Misappropriation of resident property "means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident SS: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident's family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had "suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, "I immediately contacted a third party auditor to research the matter."Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. " During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature..." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1's] personal bank account. "The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired (died) she (BOM) took money from."During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1." BOW 1 stated, "The facility did not follow through with a (formal) month to month review of the resident trust account." Individual ledgers to reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one-to-one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, "Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported....Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented..." Resident SS had Trust fund account of $1,363.10 which was not received as a refund. Resident SS's interest totaled $80.18 Resident SS's combined total of interest and trust account was $1,443.28 The facility's failure to safeguard the resident trust funds for Resident SS caused misappropriation of Resident SS's trust fund monies totaling $1,443.28. The facility's failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010687 |
B |
13-May-14 |
U4F111 |
7708 |
F224 42 CFR 483.13(c) 42 CFR 488.301"Misappropriation of resident property "means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Residents: A, E, G, L, M, P, R, and V and Residents C, N, T, II, JJ, and NN. 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident's family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager 1 (BOM 1) and that she had "suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, "I immediately contacted a third party auditor to research the matter."Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. " During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature..." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1's] personal bank account. "The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired (died) she (BOM) took money from."Residents at the facility who expired included: Resident A- trust fund totaled $17.00 Resident G- trust fund totaled $115.01 Resident R- trust fund totaled $35.07 Residents A, G, and R the families or responsible parties did not receive the above amounts listed as a refund from the Resident's trust funds equaling $167.08. Other Residents:Resident E- trust fund totaled $3.00 Resident L- trust fund totaled $40.00 Resident M- trust fund totaled $40.00 Resident P- trust fund totaled $42.98 Resident V- trust fund totaled $176.80 Other Resident's (C, N, T, II, JJ, and NN) Total equals: $302.78 (not added to total) Trust Fund Combined Interest Totaled $19.03 Trust Fund Combined Total: $515.89 Residents C, N, T, II, JJ, and NN all had Resident Trust Fund amounts each under 3 dollars and were not added to the above combined amount. During an interview with Business Office Worker 1 (BOW 1) on October 10, 2013, at 12:40 p.m., BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in (name of BOM 1)." BOW 1 stated, "The facility did not follow through with a (formal) month to month review of the resident trust account." Individual ledgers reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one-to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, "Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported....Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented..." The facility's failure to safeguard the resident trust funds for Residents A, E, G, L, M, P, R, and V caused misappropriation of Residents A, E, G, L, M, P, R, and V trust fund monies totaling $515.89. The facility's failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010688 |
B |
13-May-14 |
U4F111 |
6912 |
483.13(c) F224 42 CFR 488.301"Misappropriation of resident property "means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Residents U and HH: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident's family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had "suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, I immediately contacted a third party auditor to research the matter.Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. " During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature..." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1's] personal bank account. "The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired (died) she (BOM) took money from."Resident U-trust fund totaled: $400.00 Resident HH-trust fund totaled: $630.26 Trust Fund Interest Totaled $46.34 Trust Fund Combined Total equals: $1,076.60 During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1. BOW 1 stated, "The facility did not follow through with a (formal) month to month review of the resident trust account." Individual ledgers reconciling (verifying) the Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one-to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, "Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported....Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented..." The facility's failure to safeguard the resident trust funds for Residents U and HH caused misappropriation of Residents trust fund monies totaling $1,076.60. The facility's failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250010690 |
B |
13-May-14 |
U4F111 |
11324 |
483.13(c) F224 42 CFR 488.301"Misappropriation of resident property" means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility failed to ensure for Residents J and K: 1. The safe keeping and security of each resident's trust fund account(s). 2. Implement a policy of prevention and prohibition of financial abuse with resident ('s) monies.3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident's trust funds, affecting Residents J and K. 4. Reconcile (verify) trust fund balances for resident(s') family members/responsible parties who had a relative had pass away at the facility. The facility failed to ensure residents were free from financial abuse. The facility failed to ensure residents' trust fund monies were free from financial abuse affecting Residents J and K. The facility's failure to safeguard the resident trust funds for Residents J and K, had the potential to cause misappropriation of resident property- which means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. These failed practices placed the safety and security of resident trust funds in jeopardy; resulting in the theft of the resident trust account of $1,167 with interest of $43.71 combined total $1,210.71 by the former Business Office Manager (BOM) from November 2011 to August 2013.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. The ADM stated that she had employed a BOM (Business Office Manager) whom she had "suspicion of an employee who may have done fraud..." The BOM was hired September 1, 2011, and her last day of employment was August 17, 2013, in which the BOM did not show up for work. The ADM continued to state that it was reported to her by a nearby facility manager (owned by the same company as this facility), where the BOM had also worked, that there was speculation that something had happened in the payroll department regarding financial inconsistencies at that facility. On October 3, 2013, at 2:45 p.m., the ADM stated, "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (resident trust) funds." The ADM further stated, "I immediately contacted a third party auditor to research the matter." The Governing Body (people who represent the facility) was then alerted to this information. The ADM further stated, "On October 3, 2013, at 2:45 p.m., a report was made to the Riverside District Office and a police report was made. "The same day the ADM continued to state, "The main bank [Name Withheld] that handles the Resident Trust fund ...the account was put on hold." An interview was conducted with the ADM on October 3, 2013, at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated that the BOM was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (the BOM) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. "The lawyer stated he was working with the former BOM to come to an agreement to return the resident trust funds. During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM's duties in the facility business office. The ADM provided the job description of the former BOM. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (former BOM) got the money from...a signature stamp was used to make the check(s)." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (the BOM)." The ADM stated that the signature on the check was "Not my signature..." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the former BOM and not kept secured at the facility. The ADM further stated, "The Governing Body directed me to turn over the signature stamp to the Governing Body." The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., the auditor stated the company auditors that the facility utilized were not responsible for validating the individual resident trust accounts. She stated, "We (auditors) mostly recommend related to trust and accounts and balances...we are not responsible for overseeing accounts on a month to month basis." The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [Name Withheld] personal bank account belonging to the former BOM." The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired she (BOM) took money from." The auditor further stated the former BOM also took the residents' interest from the trust fund accounts.A record review of the auditor's final report was conducted on October 17, 2013. The auditor listed 45 residents in spread sheet format in which the former BOM had conducted financial abuse. There were originally 17 checks made out to the personal bank account of the former BOM while she was employed at the facility from September 1, 2011 and to August 17, 2013. Additional checks were found by the auditor and were listed on the final spread sheet dated October 14, 2013. Of the 45 residents in which the former BOM took funds from, 12 passed away at the facility. The families and or responsible person of the deceased did not receive those refunds within 30 days of the former residents' death. During an interview conducted with Resident H's daughter on October 14, 2013, at 3:30 p.m., the daughter stated, "I did not receive any trust statements from the facility and was not reimbursed within thirty days after my mother's death." A record review was conducted on October 14, 2013, of the residents affected by the alleged financial abuse conducted at the facility. Of the 45 residents affected with the alleged financial abuse, 12 had a psychiatric diagnosis, 11 residents had dementia (brain decay), or Alzheimer's disease (progressive loss of mental capacity), and three residents had mental disorders consisting of mental retardation, traumatic brain injury, and brain cancer.During an interview with Business Office Worker 1 on October 10, 2013, at 12:40 p.m., the worker stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in [Name Withheld] (former BOM). The worker stated the facility did not follow through with a (formal) month to month follow through of the resident trust account. Individual ledgers to reconcile (verify) with Patient Trust control Account were not taking place. Families of deceased residents did not receive their trust fund money. There were no formal one to one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts. Office Worker 1 acknowledged that the facility's business office was now printing out on a monthly basis, all monthly checks made. She continued to stated, the checks now have to match the monthly reconciliation statement. Office Worker 1 further stated (there) is no authorization (now) by any workers except the administrator to sign any checks or to use a check stamp. The facility policy and procedure titled, "Policies and Procedures in Handling Patient Trust Fund," indicated the following: 3. "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on-going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported. 4. Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated, "6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Moneys or Valuables: "...2. Should be adequately safeguarded and accurately accounted for and documented... ...6. Of dead residents without a representative or known heirs (relatives), are given to the County Public Administrator and a copy of notice is given to the department of Health."The facility's failure to safeguard the resident trust funds for Residents J and K had the potential to cause misappropriation of resident property- which means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. These failed practices placed the safety and security of resident trust funds in jeopardy; resulting in the combined theft of $1,210.71 by the former Business Office Manager (BOM) from November 2011 to August 2013. The facility's failures to manage, protect, and verify resident funds had a direct relationship to the health, safety, and security of patients." |
| 250000148 |
MIRAVILLA CARE CENTER |
250010692 |
B |
13-May-14 |
U4F111 |
6905 |
483.13(c) F224 42 CFR 488.301 "Misappropriation of resident property "means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident W: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies.3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident's trust funds.4. Reconcile (verify) trust funds for the resident's family members as responsible party.An interview was conducted with the facility Administrator (ADM) on October 3, 2013, at 2 p.m. and stated she had employed Business Office Manager (BOM 1) and that she had "suspicion of an employee (BOM 1) who may have done fraud." BOM 1 was hired September 1, 2011, and her last day of employment was August 17, 2013. On August 17, 2013, BOM 1 did not show up for work.The ADM stated on October 3, 2013, at 2:45 p.m., "We were doing bank reconciliation (verification) on September 30, 2013...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, "I immediately contacted a third party auditor to research the matter."Then at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated BOM 1 was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (BOM 1) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. " During an interview with the ADM, conducted on October 7, 2013, at 10 a.m., the ADM was questioned about the BOM 1's duties in the facility business office. The ADM handed over the job description of BOM 1. A record review was conducted of the former BOM's duties at the facility on November 3, 2013. The listed duties included: "1.Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on October 7, 2013, at 11 a.m., the ADM stated, "I did not know where she (BOM 1) got the money from...a signature stamp was used to make the checks." "There was a questionable check... number 2374 dated March 9, 2013, for the amount of $1,790.67 written out to her (BOM 1)." The ADM stated that the signature on the check was "Not my signature..." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the BOM 1 and not kept secured at the facility. The ADM stated, "I did not see any of those checks." During an interview with the facility's auditor on October 10, 2013, at 1:20 p.m., "The auditor stated she was recently hired on October 7, 2013 to complete the audit of the facility's resident trust funds and stated so far "Most of the resident's trust fund accounts were transferred to a [BOM 1's] personal bank account. "The auditor continued to state, "Look at the discharge dates... (There) were multiple residents who expired she (BOM) took money from."During an interview with Business Office Worker 1(BOW 1) on October 10, 2013, at 12:40 p.m., the BOW 1 stated the monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office. She stated all the numbers added up (with the resident trust fund). She stated, "We put too much trust in BOM 1." BOW 1 stated, "The facility did not follow through with a (formal) month to month review of the resident trust account." Individual ledgers reconciling (verifying) Patient Trust Control Account were not taking place. Families of deceased residents did not receive their trust fund money refund. There were no formal one-to- one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts.The facility policy and procedure titled, "Policies and Procedures in Handling Patient Trust Fund," indicated the following: ... "A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator.... c. Recordings and postings to the trust fund ledgers should be done daily.d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported....Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust Control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated:"6. When a resident is discharged, refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Monies or Valuables: "... Should be adequately safeguarded and accurately accounted for and documented..." Resident W had a trust fund account totaling $3,471.95 Resident W had a combined interest of $157.04 Resident W combined trust fund account and interest totaled $3,628.99 The facility's failure to safeguard the resident trust funds for Resident W caused misappropriation of Resident W's trust fund monies totaling $3,628.99. The facility's failures to manage, protect, and verify resident trust funds had a direct relationship to health, safety, and security of patients. |
| 250001615 |
Mountain Shadows Special Kids Homes - Cami House |
250011210 |
B |
22-Jan-15 |
021I11 |
6091 |
W 150 483.420(d)(1)(i) STAFF TREATMENT OF CLIENTS Staff of the facility must not use physical, verbal, sexual or psychological abuse or punishment. W 153 483.420(d)(2) STAFF TREATMENT OF CLIENTS The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures. On January 10, 2014, at 12:43 p.m., an unannounced visit was made to the facility to investigate one entity reported incident. It was determined that the facility failed to ensure Client 1 was treated with dignity and free from verbal abuse when LVN 1 told Client 1 "Sit the fuck down and stop being a bitch" while trying to give the client's medications. It was further determined that Direct Care Staff (DCS 1) and DCS 2 who witnessed the verbal abuse failed to report the incident to the Qualified Intellectual Disabilities Professional (QIDP) immediately. The staff witnessed the abuse incident on December 27, 2013, at 10 p.m. and did not report until December 30, 2013, at 8 a.m. On January 10, 2014, Client 1's record was reviewed. Client 1 was admitted to the facility on May 2, 2013, with diagnoses that included severe intellectual disability, Smith- Lemli - Opitz (SLO) syndrome (a developmental disorder that is characterized by distinctive facial features, small head size, intellectual disability or learning problems, and behavioral problems), and a gastrostomy tube (GT- tube inserted through the skin and the stomach wall, directly into the stomach for nutrition, hydration, and medication administration purposes). On January 10, 2014, the facility's form titled "Special Incident Report" (SIR) dated December 30, 2013, at 8 a.m., was reviewed. The report indicated, "...Section C: Description of incident: On 12/30/13 at 8 a.m., Direct Care Staff (DCS 1) reported to the Qualified Intellectual Disabilities Professional (QIDP) and Residential Care Coordinator, that she witnessed LVN 1 on 12/27/13 at 10 p.m., yelling at Client 1 "Sit the fuck down and stop being a bitch." DCS 1 said she was in the kitchen with the on- coming Noc (night) shift as she was clocked out and on her way out, when they saw the licensed Vocational Nurse (LVN 1) go to give Client 1 her medications and heard her say the above mentioned. DCS 1 reported that the Noc shift immediately went in and got Client 1 and began to hold and play with her (Client 1)." During further review of the facility's investigation report for the incident of verbal abuse by LVN 1 toward Client 1, written statements by the facility staff members included: 1. DCS 2 - "... LVN 1 as a little behind on medications and was very stressed out and appeared anxious...heard her using curse words, but could not recall exactly what she said..." 2. DCS 3 - "... feels that LVN 1 is not fit for working for this company...gets very stressed over passing medications and her mood quickly changes when she is stressed..."3. DCS 4 - "...LVN 1 does talk to Client 1 and (name of another client), in a mean/frustrated voice..." 4. DCS 5 - "...LVN 1 does use curse words in the house when talking with staff or when she is frustrated... often gets frustrated when giving Client 1 her medications because Client 1 likes to grab her extension or the staff." On January 10, 2014, the facility's work schedule dated 12/25 - 12/31/2013, was reviewed. The schedule indicated LVN 1 worked on December 27, 2013, from 1:45 p.m., to 10:15 p.m., and on December 28, 2013, from 2:45 p.m., to 10:45 p.m. On January 10, 2014, at 1:15 p.m., the QIDP was interviewed. She stated the facility initiated the verbal abuse investigation on December 30, 2014, and substantiated the incident of verbal abuse by LVN 1 toward Client 1. She stated LVN 1 was suspended from work on December 30, 2013, and was terminated on January 7, 2014. She stated DCS 1 and DCS 2 should have reported the incident immediately to the "on call" QIDP on December 27, 2013. DCS 1 reported the incident to the QIDP on December 30, 2014. She further stated when she asked DCS1 and DCS 2 why they did not report the incident immediately, both DCSs told her they "were afraid and did not want to make it worst." On January 10, 2014, the facility's undated policy titled "Acknowledgement Of Obligation To Report Abuse" was reviewed. The policy indicated, "It is the policy of (name of the company) to proactively protect the rights of consumers and assure that individuals are free from serious and immediate threat to their physical and psychological health and safety. (Name of the company) forbids any form of abuse, neglect or mistreatment, including the use of corporal punishment. It is the responsibility of every employee to intervene to prevent abuse of a consumer by another individual. Failure to do so will subject the employee to disciplinary action up to and including termination...Every employee of (Name of Company) is legally obligated to report any form of abuse that is witnessed by the employee or reported to the employee by a resident or other individual. Types of behavior that may be considered to be abusive included, but are not limited to:..Profanity directed at a resident...Any act that appears to be contrary to the philosophy and policies of (Name of Company) should be reported immediately!" The facility failed to ensure Client 1 was treated with dignity and free from verbal abuse, as evidenced by LVN 1, yelling profanity directed at Client 1. The failure of DCS 1 and DCS 2, who did not report immediately the incident of verbal abuse that occurred on December 27, 2013, at 10 p.m., had potential to result in further abusive behavior by LVN 1 towards Client 1, and / or the other five clients living in the facility, when LVN 1 continued to work for eight hours and 15 minutes. The incident of witnessed verbal abuse was not reported until December 30, 2014, at 8 a.m. These violations had a direct or immediate relationship to the health, safety, and security of Client 1 and all other clients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250011479 |
B |
08-Jun-15 |
PHV211 |
9788 |
F 225 483.13(c)(1)(ii)-(iii), (c)(2) - (4) INVESTIGATION/REPORT ALLEGATIONS/INDIVIDUALS The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries 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). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On June 17, 2014, at 9:30 a.m., an unannounced visit was made to the facility to investigate an entity reported incident. It was determined that the facility staff failed to report sexual and physical abuse incidents of two staff members, a male Certified Nursing Assistant 1 (CNA 1), and a female Certified Nursing Assistant 2 (CNA 2), to three residents (Resident 1, Resident 2, and Resident 3), to the Administrator immediately. Additionally, the facility Administrator failed to follow his policy and procedure to report the sexual and physical abuse to the police. On June 17, 2014, at 9:35 a.m., during the interview with the Administrator, he stated on June 13, 2014, at 10 a.m., he met with the Activity Director (AD), regarding incidents of inappropriate sexual behaviors by two Certified Nursing Assistants (CNA 1 and CNA 2). The Administrator stated, the AD, Rehabilitative Nursing Assistant (RNA), Activity Aide 1 (AA 1), Activity Aide 2 (AA 2), and Activity Aide 3 (AA 3), reported they saw the two CNAs tweaking, pinching and rubbing residents' nipples or chests. The Administrator stated the CNAs have been put on administrative leave since June 13, 2014. The Administrator stated these staff had submitted written statements of their observations.On June 17, 2014, a review of these written statements of sexual and physical abuse incidents was conducted. The AD documented in her written statement dated June 11, 2014, that she had observed CNA 2 circling the nipples of Resident 2 with her fingers in the dining room on May 5, 2014. The AD documented AA 2 was standing next to her, and had also witnessed the incident. The staff members had failed to report the incident until June 13, 2014, which was 39 days later. On June 24, 2014, at 10:30 a.m., the AD was interviewed. The AD confirmed her written statement, dated June 11, 2014. She stated she attended a mandatory sexual harassment meeting on June 3, 2014, and thought she should report her observations of CNA 2 inappropriately touching Resident 2's chest area, which occurred on May 5, 2014, but failed to report the incident to the Administrator until June 12, 2014. On June 30, 2014, the AD notes were reviewed. The AD documented, in her written statement, she reported the sexual and physical abuse to the facilities corporate nurse consultant, on June 11, 2014, and not the Administrator, due to feeling more supported and less intimidated by her corporate representative. The facility corporate nurse consultant advised the AD that she should compose her written statement, and to collect written statements from her staff. The AD then collected the written statements from the RNA, AA 1, AA 2, and AA 3. On June 12, 2014, the AD spoke to the facilities corporate nurse consultant, who said he had notified the Administrator of the incidents, at approximately 12 noon. The AD documented she contacted the Administrator on June 12, 2014, by phone, since the Administrator was at his other facility, to confirm he received the information reported to him by the facilities corporate nurse consultant on June 12, 2014. The AD spoke to the Administrator who said to leave the paperwork on his desk, and he would discuss the information on June 13, 2014. On June 24, 2014, at 12:30 p.m., AA 2 was interviewed. She submitted a written statement to the AD, on June 11, 2014, regarding witnessing intermittent observations of sexual and physical abuse, by CNA 1 and CNA 2, tweaking the nipples of Resident 1, Resident 2, and Resident 3. AA 2 stated she cannot recall the actual date of the incidents, but stated it occurred intermittently prior to lunch and dinner. She stated she did not report her observations to the Administrator, but submitted a written statement to the AD because she is afraid of retaliation. AA 2 stated she found it difficult to report her observations due to the Administrator's door being shut, so she reported the incidents to the AD who was her immediate supervisor. AA 2 stated on June 13, 2014, when she met with the Administrator, the Administrator asked her, "Have they slashed your tires, or scratched the paint on your car?" AA 2 stated she did not feel supported by the Administrator or safe at the facility. On June 24, 2014, at 11 a.m., AA 1 was interviewed. AA 1 confirmed her written statement, dated June 12, 2014. She witnessed CNA 2 inappropriately rubbing Resident 2's chest, and twisting the nipples of Resident 2 a few times, in the dining room, on June 10, 2014, at approximately 4:45 p.m. AA 1 submitted a written report to the AD, her supervisor, on June 12, 2014, and did not say anything to the Administrator because she felt she would be retaliated against, and management would ignore and belittle her. On June 24, 2014, at 11:30 a.m., the RNA was interviewed. She stated she and AA 3 witnessed CNA 1 touching Resident 2's nipples on June 9, 2014, but the incident was not reported to the AD until June 11, 2014, which was two days later. Additionally, the RNA stated when she met with the Administrator, on June 13, 2014, she felt "lamb blasted" by him and retaliated against. The RNA stated the work environment is uncomfortable, and she is not receiving the support from the Administrator. On June 24, 2014, a review of the written statement documented by AA 3, dated June 13, 2014, indicated that she had witnessed the CNAs rubbing the chest of Resident 1 and Resident 2, and also pinching their nipples. AA 3 did not have definitive dates and times, and did not report the incidents to the AD until June 13, 2014. AA 3 was afraid and felt she would be retaliated against to speak out by having her name known, and being identified as someone who reported her co-workers. During the interview with the facility Administrator, on June 24, 2014, at 3:15 p.m., the Administrator stated he completed a Resident Abuse Investigation Report on June 13, 2014. The Administrator stated, "I do not feel the CNAs touched the residents' nipples or chest inappropriately because I felt it calms the residents down. I did not report the two CNAs to the CNA board, the Department of Justice, nor the police, because the incident had not gone beyond playfulness by the two CNAs." On July 31, 2014, the facility policy and procedure titled, "Resident Abuse, Neglect, or Mistreatment," dated July 24, 2013, was reviewed. The policy indicated, "Each resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse, or involuntary seclusion from any source...1. Any alleged violation involving mistreatment, misappropriation of property, abuse, exploitation, or neglect of a resident shall be immediately reported to the Administrator, Director of Nursing, or designee(s)...3. The Administrator or designee will notify the resident's representative, and any State or Federal agencies of allegations within 24 hours...9. The Administrator shall take the following actions to assure that the investigation is conducted timely and effectively:...b. The Administrator or designee shall immediately call local police when assault, sexual abuse, homicide, forgery, or wanton neglect are suspected or have occurred...The investigative report will include:...k. Names of people outside the facility who were notified of the incident, including the police..." On July 31, 2014, the facility policy and procedure titled, "Resident/Staff/Family Abuse Reporting," dated July 24, 2013, was reviewed. The policy indicated, "It is the policy of the facility to encourage and support all residents, staff, and families in feeling free to report any suspected acts of abuse,...The facility will take all measures possible to assure residents, staff and families are free from fear of retribution if reports or incidents are reported to the facility...1. Any person(s) witnessing or having knowledge of potential or actual abuse must report the incident to the Administrator and/or designee immediately...Everyone is required to make a report of known or suspected abuse to the local ombudsman or the local law enforcement agency..." The violation of this regulation has a direct or immediate relationship to the health, safety, or security of the patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250011495 |
B |
08-Jun-15 |
PHV211 |
7711 |
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. An unannounced visit was made to the facility on June 17, 2014, at 9:30 a.m., to investigate an entity reported incident. It was determined that the facility failed to ensure three residents (Resident 1, Resident 2, and Resident 3) were free from sexual and physical abuse by two staff members, when a male Certified Nursing Assistant 1 (CNA 1) twisted Resident 1 and Resident 2's nipples, and a female Certified Nursing Assistant 2 (CNA 2) inappropriately rubbed Resident 1, Resident 2, and Resident 3's chest and twisted the residents' nipples. On June 17, 2014, at 9:35 a.m., during an interview with the Administrator, he stated on June 13, 2014, at 10 a.m., he met with the Activity Director (AD), regarding incidents of inappropriate sexual behaviors by two Certified Nursing Assistants (CNA 1 and CNA 2). The Administrator stated, the AD, Rehabilitative Nursing Assistant (RNA), Activity Aide 1 (AA 1), Activity Aide 2 (AA 2), and Activity Aide 3 (AA 3), reported they saw the two CNAs tweaking, pinching and rubbing residents' nipples or chests. The Administrator stated the CNAs have been put on administrative leave since June 13, 2014. The Administrator stated these staff had submitted written statements of their observations.On June 17, 2014, a review of these written statements of sexual and physical abuse incidents was conducted. The AD documented in her written statement dated June 11, 2014, that she had observed CNA 2 circling the nipples of Resident 2 with her fingers in the dining room on May 5, 2014. The AD documented AA 2 was standing next to her. CNA 2 stated, "I can get him to behave and do whatever I want, when I do this."On June 24, 2014, at 10:30 a.m., the AD was interviewed. The AD confirmed her written statement, dated June 11, 2014. She stated she attended a mandatory sexual harassment meeting on June 3, 2014, and thought she should report her observations of CNA 2 inappropriately touching Resident 2's chest area, which occurred on May 5, 2014. On June 24, 2014, at 12:10 p.m., AA 2 was interviewed. She stated the abuse incidents occurred intermittently prior to lunch time and dinner time in the dining room. AA 2 witnessed CNA 2 stimulating Resident 1's nipples and stating, "Look he is getting sexually aroused, because his nipples are getting hard." AA 2 told CNA 2 to stop, but CNA 2 laughed and said Resident 1 likes it. AA 2 also stated she witnessed CNA 2 stimulate Resident 3's nipples and stated, "I can get them to do what I want them to do."AA 2, stated she saw CNA 1 tweak the nipples of Resident 1 and Resident 2, after coming up behind the Residents, who were in their wheelchairs. AA 2 states this occurs intermittently prior to lunch and dinner time, in the dining room. On June 24, 2014, at 11 a.m., AA 1 was interviewed. She stated she witnessed CNA 2 inappropriately rubbing Resident 2's chest, and twisting the nipples of Resident 2 a few times, in the dining room, on June 10, 2014, at approximately 4:45 p.m. On June 24, 2014, at 11:30 a.m., the RNA was interviewed. The RNA confirmed her written statement, dated June 11, 2014. She stated, "On Monday, June 9, 2014, AA 3 and myself witnessed CNA 1 touching Resident 2's nipples inappropriately, by rubbing and pinching Resident 2's nipples in an erotic nature, at the same time blowing in his ear and rubbing his arm in a sensual nature, between 10 a.m. and 12 p.m."AA 3 documented, in her written statement, dated June 13, 2014, "I have seen many times the CNAs rubbing the chest of Resident 1 and Resident 2, and also pinching their nipples." On June 17, 2014, a review of Resident 1's record indicated, the resident was a 65-year-old male, admitted to the facility on April 25, 2014, with diagnoses including hemiplegia (weakness to one side of the body) due to a stroke.The Minimum Data Set (MDS - a standardized, primary screening and assessment tool of resident health status) dated May 23, 2014, described Resident 1 as being alert with fluctuations in behavior. Resident 1 requires extensive assistance for bed mobility, transferring, and toilet use. Resident 1 has weakness in his lower extremities, and requires a wheelchair for transportation. On June 17, 2014, at 9:50 a.m., Resident 1 was interviewed. Resident 1 was observed to be restless and uncomfortable while talking about the incidents. Resident 1 stated the two CNAs have rubbed his chest area persistently. He stated it made him upset since this happened all the time. He stated he was going to report them, but the CNAs thought it was a joke, and the staff did not take Resident 1 seriously. On June 17, 2014, at 10:45 a.m., during an interview with the Medical Social Worker (MSW), she stated she had contacted and spoke with the wife of Resident 1, who stated she did not want inappropriate playfulness by the CNA toward her husband.On June 17, 2014, a review of Resident 2's record indicated the resident was a 71-year-old male, admitted to the facility on October 10, 2009, with diagnoses including dementia, and bipolar disorder (mood disorder).The MDS dated April 11, 2014, described Resident 2 as having short term and long term memory problems, being alert with moderate cognitive impairment, and could recall location of his own room and staff names and faces. Resident 2 requires extensive assistance for all Activities of Daily Living (ADL), and requires a wheelchair for transportation.On June 17, 2014, a review of Resident 3's record indicated, the resident was a 66-year-old male, admitted to the facility on June 25, 2009, with diagnoses including bipolar disorder, anxiety, and a stroke. The MDS dated March 25, 2014, described Resident 3 as having short term and long term memory problems, being alert with moderate cognitive impairment. Resident 3 requires extensive assistance with ADL, and has weakness in his lower extremities, so requires a wheelchair for transportation. When attempted to interview Resident 2 and Resident 3, on June 17, 2014, at 10:15 a.m., Resident 2 was not able to respond to questions, and could not recall the events associated with the abuse incident. Resident 3 could only make facial gestures, and was unable to verbalize. During the interview with the facility Administrator, on June 24, 2014, at 3:15 p.m., the Administrator stated he completed a Resident Abuse Investigation Report on June 13, 2014. The Administrator stated, ?I do not feel the CNAs touched the residents' nipples or chest inappropriately because I felt it calms the residents down.I did not report the two CNAs to the CNA board, the Department of Justice, nor the police, because the incident had not gone beyond playfulness by the two CNAs.? On June 24, 2014, the facility policy and procedure titled, "Abuse Program," dated July 24, 2013, was reviewed. The policy indicated, "It is the policy of the facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals." The violation of this regulation has a direct or immediate relationship to the health, safety, or security of the patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250011569 |
B |
24-Jun-15 |
EWEZ11 |
3735 |
Miravilla "B" Citation HSC 1418.91(a)(b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation.On January 30, 2014, an unannounced visit was made to the facility to investigate a complaint regarding an incident of alleged resident abuse. The alleged incident was not reported by staff or the facility Administrator in a timely manner. Based on interview and record review, the facility failed to notify CDPH within the 24 hours required of an allegation of abuse that CNA 1 had slapped Resident A on the left side of his face. This failure put all the residents in the facility at risk for abuse by CNA 1 for at least 44 days after the alleged incident. The written report sent to California Department of Public Health (CDPH) that indicated: "This is a late report for an allegation of abuse that allegedly happened involving a C.N.A. (Certified Nursing Assistant's name written in parenthesis) and resident in RM. [Room number omitted] (Resident A's name written in parenthesis). A C.N.A. (CNA 2's name written in parenthesis) was having a conversation with a Licensed Nurse, (LN 1's name written in parenthesis), and in the course of their conversation and incident regarding a resident (Resident A's name written in parenthesis) and C.N.A. (CNA 1's name written in parenthesis). (CNA 2) Said certified nursing assistant allegedly slapped resident on one side of his face but could not remember the exact date." Resident A's record indicated the resident was a 67 year old male who had been admitted to the facility on September 13, 2013, with diagnoses including Cerebral Vascular Accident (stroke), with right sided deficit, (right sided weakness), aphasia, (unable to express self), dysphagia, (difficulty in swallowing), and a mood disorder. Review of the patient's initial history and physical indicated that the patient did not have the capacity to understand or make decisions. Patient A's assessment and screening indicated the resident had short and long term memory problems. His daily decision making skills were severely impaired.An interview was conducted with the DON (Director of Nurses) on January 30, 2014. She said that the Nursing Supervisor (NS) had notified her of the abuse allegation on December 17, 2013. The DON stated, "I gave all my investigation, written statements to the administrator.I'm not sure why she did not report to CDPH. We got busy because we had a survey, a revisit, another revisit, and roof problems." In addition she stated, "The report is to be reported within 24 hours." An interview was conducted with the Administrator on January 30, 2014. The Administrator stated, "This has been an overwhelming year (2013). I had problem with the roof. This has been a taxing survey. I was with Office of Statewide Health Planning and Development (OSHPD), and auditors. The ombudsman asked me about this case. Then I remembered. I had to review everything all over again." A review of the facility's policy titled, "Resident Abuse, Neglect, or Mistreatment," indicated: It is the policy of the facility to report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department (State) immediately, or within 24 hours...."Therefore, the facility failed to notify CDPH within the 24 hours required of an allegation of abuse that Certified Nursing Assistant 1 (CNA 1) had slapped Resident A on the left side of his face. This failure put all the residents in the facility at risk for abuse by CNA 1 for at least 44 days after the alleged incident. |
| 250000723 |
MONTEREY PALMS HEALTH CARE CENTER |
250011604 |
B |
14-Jul-15 |
UGEG11 |
8813 |
Citation: B 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. During a complaint investigation, initiated on January 2, 2014, it was determined that the facility failed to ensure that a plumbing leak in Resident 1's bathroom had been completely repaired after the resident had reported the leak to maintenance. This failure resulted in Resident 1 slipping and falling in water that was on the bathroom floor. This fall caused the resident to hit her head and re-injure her left humerus (upper arm bone) that had been surgically repaired with a titanium (a metal) plate (a metal bone stabilizer) on September 19, 2013. Resident 1's record indicated that the resident, a 66 year old female, was admitted to the facility on September 22, 2013, for rehabilitation following shoulder surgery where a long humeral (upper arm bone) locking plate had been surgically placed into her left upper arm. Resident 1's other diagnoses included pain and anxiety. On January 2, 2014, an interview was conducted with the Director of Nurses (DON). The DON stated that Resident 1 had an unwitnessed fall on November 12, 2013. She said that the resident was ambulatory with no assistive devices. The DON stated that the resident fell in her bathroom during the night and got a bump on her head. The DON stated the resident had gone to the Nurses' Station after the fall and reported it to the Charge Nurse (CN). The DON said that Resident 1 told the CN she had fallen because there was water on the bathroom floor. The Charge Nurse administered first aid to the head bump. The DON further stated that the resident complained of pain at the bump site on the following day, and she was transported to the local emergency room for further evaluation and an x-ray. On January 2, 2014, Resident 1 was interviewed outdoors on the smoking patio. She was observed smoking and conversing with other residents. Her left arm was in a sling. The resident ambulated independently without assistive devices to an unoccupied table to converse privately with the surveyor. Resident 1 was found to be alert and oriented and able to describe the fall incident. Resident 1 stated that if she had not fallen, she would have been home in six weeks after her admission to the facility.She stated that she was scheduled to see her orthopedic doctor (a physician who specializes in diseases/injuries of bones) in six days and could require more surgery because her plate was now bent. Resident 1 stated that the pain in her arm had become more severe since the fall due to the bent plate.Resident 1 stated, "There was water on the floor." She stated that she hit her head and bruised both elbows when she fell. She further stated, "When I slipped, the commode (toilet riser) landed on top of me." The resident stated that she braced her fall by placing her bent arms and elbows to the wall but still hit her head. She said that she had told the CN, the Administrator, and maintenance about the leaking toilet two months ago. The resident further stated that about a month before, a man from "Corporate" was visiting, and she told him about the plumbing problem. She said, "I took him to my bathroom and flushed the toilet. The toilet erupted, sprayed him in the face, and flooded the room and the room next door. They (facility Maintenance Department employees) had to use a wet/dry vac (vacuum) to clean it up." The resident further stated that they (maintenance) replaced some fittings and told her it was fixed. Resident 1 further stated, "It happened again three days ago. The toilet is leaking. They put a blanket around the bottom. It is not fixed." On January 2, 2014, the bathroom adjoining Resident 1's room was observed. There was a blanket that had been folded up and placed on the floor in front of the toilet. Grout (a plaster substance used to fill between tiles) was missing around the base of the toilet on the left side. There was a black substance surrounded by white residue where the grout should have been. On January 2, 2014, the Maintenance Employee was interviewed. The Maintenance Employee stated, "The lady stopped me in the hall about a week ago and told me the toilet water was still leaking." On January 2, 2014, the Facility Administrator (FA) was interviewed and stated he was aware last month during a corporate employee's visit at the facility that the toilet handle was sticking in the bathroom of Room (room number). The FA stated, "The toilet bowl would fill with water and run over." The nursing notes, "Additional Narrative Notes," dated and timed November 12, 2013, at 11:35 p.m., indicated that Resident 1 had come to the Nurses' Station and reported that she slipped on water from her toilet, and as she was getting up from the toilet she fell and hit her head on the wall. The notes further indicated that Resident 1 had a red mark on top of her right forearm and a small abrasion to her right knee. An ice pack had been provided. The note indicated the resident had complained of pain but did not want pain medication. The note further indicated that the resident's physician and family had been notified of the fall, but Resident 1 refused to go to the hospital for further evaluation. The "Incident/Accident Report" dated, November 13, 2013, indicated that the incident occurred November 12, 2013, at 11:55 p.m. The report indicated that Resident 1 had an unwitnessed fall. The resident stated that she had slipped on water from the toilet as she was getting up and fell, hitting her head on the wall. Physical findings indicated a bruise on the right side of the resident's forehead and a small one inch abrasion on her right knee. The treatment provided was an ice pack and neurological checks (assessment used to determine the extent of actual or potential injury to the brain). The "Incident/Accident Post Review" report, undated, indicated that environmental factors leading to the incident was a leaking toilet per patient. Recommended interventions included "Maintenance to fix toilet." The "Post-Fall Rehab Screen" report, dated November 13, 2013, indicated the circumstances of the fall were that Resident 1 ambulated to the bathroom but in the process of getting up from the toilet, the resident had slipped in water that was on the floor. The Physical Therapist recommended that maintenance address the leaking/faulty toilet to prevent the resident from slipping again since the resident reports having addressed the issue two months ago.The Emergency Department record was reviewed and indicated that Resident 1 was seen in the emergency room on November 13, 2013. The report indicated that the patient (Resident 1) was injured in a fall. The patient slipped and fell on a wet surface. The triage nurse (the nurse who screens, assesses and classifies patients as they arrive in the emergency department) indicated that the patient had a mechanical fall on the previous night after slipping on a wet bathroom floor.The orthopedic consultation performed January 10, 2014, indicated... "In November, the patient had a fall at the skilled nursing facility. Following that event she has had increasing pain (in the left arm). Progressive x-rays after that fall reveal loss of fixation of the proximal (nearest the point of attachment of the plate in the arm) screws and the plate and now there is diathesis (separation) of the plate away from the humerus proximally."A radiology (x-ray) report, dated January 10, 2014, of the AP (Anterior Posterior or front and back) and lateral (side) left humerous revealed, "Further displacement of the proximal portion of the plate with backing out of screws... Further loosening of left humeral plate following secondary fall after treatment of the humeral nonunion." In preparation for upcoming surgery, another orthopedic consultation was performed on January 25, 2014. The consultation revealed that approximately three to four months ago, the patient was operated on and a long humeral locking plate had been placed. The patient then went to the skilled nursing facility and did well until she fell and as indicated by x-rays started to develop pulling out of the superior (towards the head) screws. Therefore, the facility's failure to ensure that a plumbing leak in Resident 1's bathroom had been completely repaired resulted in Resident 1's slipping and falling in water that was on the bathroom floor. The fall caused Resident 1 to re-injure her left upper arm that had been surgically repaired with a titanium (a metal) plate (a metal bone stabilizer). The violation of the above regulation had a direct or immediate relationship to the health, safety, or security of patients. |
| 250000077 |
MAGNOLIA REHABILITATION & NURSING CENTER |
250011699 |
B |
03-Sep-15 |
4GMW11 |
3556 |
CFR 483.13(b) 483.13(c)(1)(i) 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 female patient (Patient 1) was protected from staff-to-patient sexual abuse. The facility failed to ensure Patient 1 was free from sexual abuse by Certified Nursing Assistant (CNA 1) on May 27, 2015.On June 9, 2015, an unannounced visit was made for the purpose of investigating an entity reported incident. The facility?s investigation indicated CNA 1 kissed Patient 1 on her cheek on May 27, 2015. Patient 1 then pushed CNA 1 away; next, CNA 1 sat down on Patient 1?s bed.On June 9, 2015, the record for Patient 1 was reviewed. The Physician History and Physical, dated May 12, 2015, indicated Patient 1 was oriented to person, place, and time. The History and Physical indicated Patient 1 was admitted to the facility for physical and occupational therapies. An entry in the Nurses' Progress Notes, dated May 27, 2015, at 12 noon, indicated, "Patient (1) reported to administrator that a male staff member kissed patient on her cheek. Patient claims she felt uncomfortable afterwards and waited for a female staff member to assist her in the commode...." On June 9, 2015, at 9:45 a.m., an interview was conducted with the Administrator. On May 27, 2015, Patient 1 told the Administrator that CNA 1 had kissed the patient between 2-3 a.m. on May 27, 2015. The Administrator stated Patient 1 was "very alert and oriented and credible." She stated that there were other residents whom had previously complained of inappropriate behavior by CNA 1. On June 9, 2015, at 11:45 a.m., an interview was conducted with Physical Therapy Assistant 1 (PTA 1). PTA 1 stated Patient 1 told PTA 1 that Patient 1 had something to report to the Administrator before Patient 1 was discharged. Patient 1 did not want to talk about it at that time. PTA 1 and Patient 1 worked on Patient 1's physical therapy program. After therapy, PTA 1 checked with Patient 1 again to see if Patient 1 was "all right." PTA 1 stated that Patient 1 "started to cry" and had not been treated with respect. PTA 1 paraphrased what Patient 1 said, as follows: "I can't believe they treat people like this. What if I was like my neighbor and didn't know what was going on and can't protect myself. I can't believe that someone would do that." On June 19, 2015, at 9:41 a.m., a telephone interview was conducted with Patient 1, who had been discharged from the facility. Patient 1 stated that, while she was at the facility, CNA 1 had come into her room to take her blood pressure at approximately 2-3 o'clock, early in the morning. Patient 1 stated CNA 1 "kissed my right cheek." She stated she pushed CNA 1 away. Then, CNA 1 sat on her bed and asked questions, such as, "You have kids...? Are you married...?" After that, she stated she pretended to be asleep. She stated she needed assistance to get off the commode, but waited until there was a female CNA to help her. She stated she was "scared." She stated she really needed help, but was "afraid." She stated she remained ?embarrassed, ashamed, [and] afraid still? (23 days after CNA 1 kissed Patient 1 and sat on her bed at the facility). The facility failed to ensure Patient 1 was free from sexual abuse by CNA 1 on May 27, 2015. These violations had a direct relationship to the health, safety, or security of the patients. |
| 250000148 |
MIRAVILLA CARE CENTER |
250011722 |
B |
24-Sep-15 |
EWEZ11 |
4158 |
"B" citation - Abuse 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. On January 30, 2014, an unannounced visit was made to the facility to investigate a facility reported incident of alleged resident abuse that the facility was made aware of on December 17, 2013. (Exact date of abuse occurrence was unknown). Based on interview and record review the facility failed to protect one resident, (Resident A) from abuse from a certified nursing assistant (CNA 1) when CNA 1 slapped Resident A on the side of his face in the presence of a second CNA (CNA 2). The facility sent a written report to California Department of Public Health (CDPH) that indicated the facility was late in reporting an allegation of abuse that occurred between CNA 1 and Resident A. The report indicated: "CNA (name omitted) was conversing with an LVN (licensed vocational nurse) in the PM (evening shift) about a particular CNA (name omitted) and in the course of the conversation she mentioned an incident involving said CNA and (resident's name and room number omitted) allegedly slapped resident on the cheek." Resident A's record indicated the resident was a 67 year old male admitted to the facility on September 13, 2013, with diagnoses that included cerebral vascular accident (stroke), with right sided deficit, (right sided weakness), aphasia, (unable to express self), dysphagia (difficulty in swallowing), and bipolar disorder, (mood disorders). Review of the Resident A's initial history and physical indicated he did not have the capacity to understand or make decisions. Resident A's assessment and screening indicated the resident had short and long term memory problems. His daily decision making skills were severely impaired. In an interview with the Director of Nursing (DON) on January 30, 2014, at 10:48 a.m., she stated that Resident A was hit by a staff member. In addition, she stated that during a conversation between CNA 2 and Licensed Nurse 3 (LN 3), CNA 2 mentioned that CNA 1 had hit Resident A. In an interview with the Administrator on January 30, 2014, at 11:30 a.m., she stated that there had been a conversation between LN 3 and CNA 2 regarding CNA 1. During their conversation, the issue of CNA 1's abuse of Resident A came up. In an interview with CNA 2 on January 30, 2014, at 12:35 p.m., she stated, "I went to see (CNA 1's name omitted). The Resident (Resident A) was restless, trying to get out of bed. The Resident was sitting on the left side of the bed. I was trying to talk to the resident, sometimes he listens and sometimes not. I guess (CNA 1's name omitted) got tired with the resident, and I saw him (CNA 1) slap Resident A on the left cheek. I heard the slap. I was there, and the resident put his hand on his left cheek."In an interview with the Licensed Social Worker on February 11, 2013, she stated on December 17, 2013, the DON had reported to her about CNA 1 slapping Resident A as reported by CNA 2. She further stated that she had spoken to CNA 2 and that's when she was first aware that CNA 1 had slapped Resident A. Review of an undated policy titled "Resident Abuse, Neglect, or Mistreatment Policy and Procedure," on February 13, 2013, indicated, "Each resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse, or involuntary seclusions from any source. .....It is the responsibility of all staff to provide a safe environment for the residents." Therefore the facility failed to protect Resident A from abuse by a CNA when the CNA slapped Resident A on the side of his face in the presence of a second CNA. The above violation had a direct or immediate relationship to the health, safety, and security of Resident A, and placed all 49 residents residing in the facility at risk for abuse by CNA 1. |
| 250000869 |
MARIAN JAMES TRANSITIONAL HOUSE |
250012647 |
B |
20-Oct-16 |
5RJO11 |
4665 |
W149 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. The facility failed to ensure facility policies and procedures were implemented to prohibit mistreatment or abuse from Client B to Client A. An unannounced visit was made for the purpose of investigating an abuse allegation between two clients, Clients A and B. Client A, a 32 year old female, was admitted to the facility on February 21, 2003, with diagnoses that included moderate intellectual disability. Client B, a 29 year old female, was admitted to the facility on May 12, 2014, with diagnoses that included mild intellectual disability. Clients A and B had been roommates. On December 3, 2014, at 10:35 a.m., an interview was conducted with the Facility Manager (FM), who stated she talked with Client B after finding the bite marks on Client A's cheek. The FM stated Client B told her that she (Client B) "got up and bit her roommate" because she "wanted to." The facility letter, dated December 2, 2014, indicated, "On Monday morning December 1st, 2014, Client B (Client's name) (totally blind) got out of her bed and approached her roommate and decided to bite her on the cheek. Her roommate is (Client A's name)...(Client A) has two bite marks on her left cheek. RN (Registered Nurse) was notified and came to assess the client..." The facility document titled, General Event Reports (GER), dated December 2, 2014, indicated an entry by the RN; "This nurse assessed the facial scarring caused by human bite marks x (times) 2. It was very apparent that the scarring was caused by human bite marks due to the ability to see the teeth indentions..." The facility document titled, "Individual Program Plan (IPP), dated November 16, 2012, indicated, "...(Client B) has had several episodes of being aggressive towards another consumer. These cannot be explained and when asked (Client B) is not able to say why she hit, pinched, and even bit another person. She experienced a week suspension at day program due to biting and is working hard to avoid this in the future..." "... (Client B) appears to target consumers that get to close to her and she strikes back by scratching or biting them..." The facility document titled, "The Person's Individualized Service Environment,"indicated, "... (Client B) is not meeting her aggression program, and has a total of 5 incidents, with the last few incidents being biting another peer...All parties agreed to the discussion and possible termination for biting..." On the same date, at 11:10 a.m., the FM was interviewed. The FM stated Client B did not have any episodes of biting at their facility. Client B had been transferred from another facility. The FM stated she thought she "might have seen something" in the record about Client B's behavior of biting, previous to Client B being admitted to their facility. On the same date, at 12:25 p.m., a visit was made to the day program. Observation of Client A's left side of her face showed a reddened area with teeth indentations on her cheek. The left side of her face near her chin had a circular, reddened area approximately six centimeters long (approximately two inches). The document for the day program titled, "Observation/Information Report," dated December 2, 2014, indicated, "...While consumer (Client A) sat down (name of staff) noticed red marks on Client A's left cheek, behind her left ear, the bottom of the right side of her neck, and the back of her neck...Assessed client's face & neck, multiple bite marks and scratches. Measurements of scratches are approximate...R (right) cheek-2 cm (centimeters) x (by) 0.1 cm. w (width), 0.5 cm l (length) x 0.1 cm w, 5 cm. l x 0/1 cm. w.," (approximately 1 inch x 2 inches). On April 1, 2015, at 9:34 a.m., Licensed Vocational Nurse 1 (LVN), from the day program, was interviewed. LVN 1 stated there was an error in documentation. The bite marks on Client A were on the left cheek. LVN 1's documentation indicated measurements on the right cheek. On December 3, 2014, review of the facility (where the client lived) policy and procedure titled, "Abuse Prevention, Abuse Investigation and Abuse Reporting Policy and Procedure," effective May 1, 2014, indicated, "...It is the policy of (name of corporation) to assure that all clients of (name of facility) are protected from abuse..." The facility failed to ensure that Client A was free from physical abuse from another facility client. The facility failed to protect Client A from facial bites from Client B. The violation presented a direct or immediate relationship to the health, safety or security of Patient A. |
| 250001700 |
MOUNTAIN SHADOWS SPECIAL KIDS HOMES-LAUREL PARK HOUSE |
250012810 |
B |
21-Dec-16 |
HUC111 |
2485 |
HS 1418.91 (a) A long term care facility shall report all incidents or 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 departments of this section shall be a class "B" violation. The facility failed to report an alleged incident of that direct care staff (DCS) 1 allegedly held Client A's testicles after his shower on July 19, 2015. On July 31, 2015, at 12 p.m., an unannounced visit was made to the facility to investigate an entity reported incident of sexual abuse toward Client A. Client A, a 19-year-old male, was admitted to the facility on xxxxxxx with diagnoses which included mild intellectual disability. The Physical Therapy MTU (Medical Therapy Program) Summary dated January 23, 2015, indicated, "...is an articulate well-spoken young man...He is able to communicate his wants and needs as well as participate in daily conversation and banter with peers, adults, and professional". On July 31, 2015, at 12 noon, an interview was conducted with the Qualified Intellectual Disabilities Professional (QIDP). The QIDP stated after she heard about the alleged incident, she interviewed DCS 2 on July 27, 2015 (no time). DCS 2 stated she saw DCS 1 holding Client A's testicles up during transfers after his shower on July 19, 2015. On August 10, 2015, at 2 p.m., a follow up visit to the facility was conducted. During an interview conducted with the QIDP at 2:10 p.m., The QIDP stated she heard about the alleged incident on July 27, 2015, at 2 p.m. The QIDP stated she did not report the incident to the CDPH immediately because it took days for the facility staff to come forward and report the incident to her. The QIDP also stated she wanted to conduct the investigation first to determine if the alleged incident was substantiated. On August 10, 2015, the facility's policy and procedures, titled, "Consumer Abuse and Neglect prevention," was reviewed. It specified, "Report...Any incident of alleged or suspected abuse as defined by the agency policies and procedures will be reported to the local Department of Health Services Licensing and Certification office by telephone or within 24 hours...in accordance with H&S code section 1418.91 (a)." The facility failed to report an alleged incident of sexual abuse toward Client A immediately or within 24 hours, to CDPH. This violation had direct or immediate relationship to the health, safety, or security of the client. |
| 250001700 |
MOUNTAIN SHADOWS SPECIAL KIDS HOMES-LAUREL PARK HOUSE |
250012811 |
B |
21-Dec-16 |
HUC111 |
3245 |
HS 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 departments of this section shall be a class "B" violation. The facility failed to report immediately or within 24 hours to the California Department of Public Health (CDPH) that a direct care staff (DCS) 1 allegedly held Client A's erect penis while the client was masturbating on June 29, 2015. On July 31, 2015, at 12 p.m., an unannounced visit to the facility was made to investigate an entity reported incident of alleged sexual abuse to Client A. Client A, a 19-year-old male, was admitted to the facility on xxxxxxx, with diagnoses which included mild intellectual disability. The Physical Therapy MTU (Medical Therapy Program) Summary, dated January 23, 2015, indicated, "...is an articulate well-spoken young man...He is able to communicate his wants and needs as well as participate in daily conversation and banter with peers, adults, and professional." On July 31, 2015, at 12 p.m., an interview was conducted with the Qualified Intellectual Disabilities Professional (QIDP). The QIDP stated when she heard about the alleged incident, she interviewed the Licensed Vocational Nurse (LVN) on July 27, 2015 (no time). The LVN stated she walked into Client A's room and observed DCS 1 holding the client's erect penis during catheterization (tube inserted into the bladder to drain urine) during the first week of July (June 29, 2015). There was no indication the facility reported this observation immediately to CDPH. On July 31, 2015, at 12 p.m., an initial interview was conducted with Client A. Client A denied DCS 1 held his erect penis while he was masturbating. On August 10, 2015, at 2 p.m., a follow up visit was made to the facility. At 2:10 p.m., the QIDP was interviewed and stated she heard about the alleged incident on July 27, 2015, at 2 p.m. The QIDP stated she did not report the incident to the CDPH immediately because it took days for the facility staff to come forward and report the incident to her. The QIDP also stated she conducted an investigation first and the alleged incident was not substantiated. On August 10, 2015, at 3:10 p.m., a second interview with Client A was conducted. Client A was verbal and alert to name, time, and place. Client A denied that DCS 1 held his erect penis while he was masturbating. On August 10, 2015, at 3:45 p.m., the facility's policy and procedures, titled, "Consumer Abuse and Neglect prevention," was reviewed. Under, "REPORT...Any incident of alleged or suspected abuse as defined by the agency policies and procedures will be reported to the local Department of Health Services Licensing and Certification office by telephone or within twenty four hours...in accordance with H&S code section 1418.91 (a)." The facility failed to report an alleged incident of sexual abuse toward Client A immediately or within 24 hours to the CDPH. The alleged incident occurred on June 29, 2015, and was reported to the QIDP on July 29, 2015, 30 days later. This violation had direct or immediate relationship to the health, safety, or security of the client. |
| 250001724 |
MURRIETA HEALTH AND REHABILITATION CENTER |
250012937 |
B |
15-Feb-17 |
3HRD11 |
6561 |
F226 (?483.12 (b) (1))
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.
On June 2, 2016 at 1:55 p.m., an unannounced visit was made to investigate a complaint regarding an incident of alleged stolen property.
During the investigation, it was discovered the facility failed to protect Resident A from the misappropriation of the resident's property by Licensed Vocational Nurse 1 (LVN 1) when Resident A's wedding ring was stolen and pawned.
On June 1, 2016 at 2: 30 p.m., Family Member 1 (FM 1) was interviewed. FM 1 stated she discovered her mother's wedding ring, appraised at $2840, was missing when her mother was transferred to a board and care facility on January 5, 2016. FM 1 stated she was with her mother and had seen the ring on her mother's finger just prior to her mother leaving the facility. FM 1 stated she was asked to come to the nurse's station to sign discharge papers. FM 1 stated she remembered seeing a female staff member go into her mother's room and cover her mother's hands with a blanket.
FM 1 stated when her mother arrived at the board and care, the ring was missing. Her mother appeared distraught over the ring, as she repeatedly kept shaking her hand in the air and crying out. FM 1 stated her mother could not be consoled and continued to be distraught throughout the following days. FM 1 stated her mother would call out for her deceased husband and refused to eat or even drink water. FM 1 stated her mother died 17 days after the ring was stolen.
FM 1 stated she immediately called the skilled nursing facility on that same day, January 5, 2016, to report the missing ring. FM 1 stated she did not hear back from the facility, but continued to leave messages on subsequent days for Administrator 1 (ADM 1) to call her.
Because the facility was not responding to her, FM 1 elected to do her own investigation by sending pictures of the ring to the local pawn shops. FM 1 stated she received a call from a pawn shop near the facility. They told her the ring had been pawned by a woman on the same date her mother was transferred from the skilled nursing facility.
The police were notified on March 5, 2016, and on March 9, 2016, Licensed Vocational Nurse 1 (LVN 1) was arrested for theft of the ring. The police would only tell FM 1 that the alleged perpetrator was someone who worked at the facility and her first name was (first name omitted). FM 1 stated she immediately called ADM 1 to give him the information and he agreed to meet with her that same day. However, when she arrived for the appointment with ADM 1, she was told he was not at the facility and would not be available for two weeks.
On June 2, 2016, the medical record for Resident A was reviewed. Resident A was an 80 year old female, admitted to the facility on XXXXXXX, 2016, with diagnoses including dementia (decline in mental function) and difficulty in walking. A facility form titled, "Theft/Loss Report" was reviewed. The form indicated a report of a loss of a ring on January 5, 2016. An undated notation indicated Family Member 1 (FM 1), "claims that ring found at pawn shop near facility, and police know of person that pawned the ring...a report filed with law enforcement."
On June 2, 2016, at 1:55 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she was not aware a former resident's ring had been reported missing. The ADON stated both ADM 1 and the Director of Nurses, who were working at the time of the alleged theft, no longer worked at the facility. The ADON confirmed LVN 1 currently worked at the facility. The ADON stated LVN 1 had left employment earlier in the year but had come back. The ADON did not know the reason why LVN 1 had left or why she was rehired.
On June 2, 2016, at 2:15 p.m., an interview was conducted with the Social Services Director (SSD). The SSD stated they had done an investigation regarding the missing ring and were waiting for the daughter to give them documentation of an appraisal of the ring before responding to her. The SSD provided documentation, dated January 5, 2016, and signed by ADM 1 on February 29, 2016. The documentation indicated the administrator was aware a police report had been filed and the police knew who had allegedly taken the ring.
On June 2, 2016 at 2:30 p.m., LVN 1's employee file was reviewed. The file indicated LVN 1 had called in to resign from her position on March 16, 2016. The file did not indicate the exact date of rehire, but there was documentation of a salary increase on April 16, 2016.
In a concurrent interview with the Director of Staff Development (DSD), the DSD stated LVN 1 had worked on March 7, 2016, called off for five scheduled days and finally resigned on March 16, 2016. DSD stated the resignation was immediate and no reason was given. The DSD stated LVN 1 returned to work at the facility in April 2016. The DSD stated she was not part of the process for the rehiring of LVN 1. The DSD stated the rehiring was all handled by the former DON and ADM 1.
On June 3, 2016, at 10:45 a.m., LVN 1 was interviewed by phone. LVN 1 stated that any discussion regarding the alleged stolen ring must go through her lawyer.
On June 7, 2016, a report from the sheriff's office was reviewed. The report indicated LVN 1 had been arrested on March 9, 2016, for elder abuse and grand theft.
On June 13, 2016, at 10:25 a.m., a phone interview was conducted with FM 1. FM 1 stated she had attended the court proceeding on June 10, 2016 concerning LVN 1 and her mother's ring. FM 1 stated LVN 1 pled guilty to stealing the ring.
On June 14, 2016, at 3 p.m., Administrator 2 (ADM 2) was interviewed. ADM 2 stated LVN 1 was to be placed on administrative leave effective June 4, 2016, but had chosen to resign. ADM 2 stated that LVN 1 had referred him to her lawyer for any discussion regarding the alleged stolen ring. ADM 2 stated he had not been aware the former resident's ring had been missing prior to this investigation. ADM 2 stated he was not aware of any investigation that his predecessor may or may not have conducted.
Therefore, the facility failed to protect Resident A from the misappropriation of the resident's property by LVN 1 when Resident A's wedding ring was stolen and pawned by LVN 1.
This failure had a direct relationship to the health, safety, or security of residents. |
| 250001724 |
MURRIETA HEALTH AND REHABILITATION CENTER |
250012961 |
A |
22-Feb-17 |
USM711 |
12831 |
483.25 QUALITY OF CARE
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
On June 2, 2016, at 10:20 a.m., an unannounced visit was made to the facility for the investigation of a complaint.
It was determined that the facility failed to provide necessary care and services to ensure one resident (Resident A) maintained the highest level of physical well-being. This failure caused the resident to suffer from severe, unrelieved abdominal pain for approximately 12 hours and required the resident to be transported to an acute care hospital by a paramedic ambulance for further evaluation and treatment where the resident underwent emergency surgery for a ruptured duodenal ulcer (condition where an untreated sore of the lining of the small intestine breaks or bursts suddenly through the wall of the small intestine allowing digestive juices and undigested food to leak into the abdominal cavity; treatment generally requires immediate surgery) and peritonitis (inflammation of the lining that covers the abdominal organs).
On June 2, 2016, Resident A's record was reviewed. Resident A, an 83 year old male, was admitted to the facility on XXXXXXX, 2016, with diagnoses that included myasthenia gravis (weakness and rapid fatigue of the muscles under voluntary control), respiratory failure (not enough oxygen passes from lungs to the blood), transient cerebral ischemic attack (brief stroke like attack), and hypertension (high blood pressure).
A review of Resident A's, "History and Physical," (H&P) dated April 14, 2016, indicated, "This resident has the capacity to understand and make decisions." A review of Resident A's Minimum Data Set (MDS- a comprehensive assessment tool) dated April 21, 2016, in the section titled, "Brief Interview for Mental Status," (BIMS) indicated the resident's score was 13. A BIMS score is a reflection of a resident's mental status. A score of 13-15 indicates the resident is cognitively intact per the 3.0 Resident Assessment Instrument (a manual used with the MDS).
A review of Resident A's document titled, "Order Summary Report," indicated, "MONITOR FOR PAIN LEVEL 0-10 (0 -pain free; 10 -worst pain ever experienced) every shift for pain," ordered April 15, 2016. Further review of the summary report found two orders for Tylenol (acetaminophen - a pain reliever) for Resident A. The first order indicated, "Tylenol Tablet 325 MG (milligram, unit of measurement) Give 1 tablet by mouth every 4 hours as needed FOR MILD PAIN..." The second order indicated, "Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablets by mouth every 4 hours as needed FOR MODERATE PAIN..." Both were ordered April 15, 2016. No other orders for pain medication were found during Resident A's record review.
Review of Resident A's care plans found a care plan with the focus, "AT RISK FOR FURTHER EPISODES OF PAIN," initiated April 15, 2016. The care plan interventions indicated, "Assess level of pain based on pain management scale of 0-10, Attend to needs promptly...Monitor effectiveness of medication and refer to MD (Medical Doctor) if ineffective...Refer to MD if management is ineffective."
Review of Resident A's medication administration record (MAR) for May 2016, indicated, "MONITOR FOR PAIN LEVEL 0-10 every shift for pain." In the column designated for Tuesday May 3rd, the pain level was documented with zeros (no pain) for all three shifts. For the Wednesday May 4th column an, "8/10," was documented in the seven a.m. to three p.m. shift column only. (Day shift)
Further review of Resident A's MAR found only one entry to indicate Tylenol was given to Resident A. The documentation indicated the ordered medication was administered to the resident on Wednesday May 4, 2016, on the day shift for a pain level of, "8/10." The back of this document indicated, "Tylenol 325mg," had been given for, "C/O (complaint of) pain." The pain level for this entry indicated a seven. The result of the medication administration was documented as, "effective." An entry dated May 5, 2016, at 8:15 a.m., (The resident was discharged from the facility to the acute hospital on XXXXXXX 2016, at approximately 10:30 a.m.) indicated, "Tylenol 325mg (2 tablets)," given for, "C/O 10/10 ABD (abdominal) PAIN." The result was documented as, "INEFFECTIVE; SENT OUT TO (name of hospital)." No documentation was made by the LVN that indicated if the entry had been a late entry.
Further review of Resident A's record found nursing documentation titled, "Health Status Note," dated May 4, 2016, at 4:04 a.m. The note indicated, "...RESIDENT CONT (continued) TO C/O PAIN TO STOMACH, PM SHIFT GAVE PAIN PRN (as needed) INEFFECTIVE, RESIDENT RESQUESTED (sic) SLEEPING AID, INEFFECTIVE, RESIDENT NOTED TO HAVE ABD (abdominal) DESTENTION (sic)...DR NOTIFIED @ 1245 AM, AWAITING CALL BACK WITH ANY ORDERS..."
Resident A's, "Physician's Order Note," dated May 4, 2016, at 10:01 a.m., indicated, "Sent to ER Secondary to severe unrelieved RLQ (right lower quadrant) ABD pain..."
Resident A's, "Health Status Note," dated May 4, 2016, at 2:24 p.m., indicated, "...RESIDENT WAS SENT OUT TO ER AT (hospital name) SECONDARY TO C/O UNRELIEVED ABD PAIN TO RLQ. PT WAS (sic) C/O PAIN SINCE LAST NIGHTER (sic) PER NOC (night) SHIFT NURSE AND WAS UNRELIEVED EVEN THOUGH PAIN EDS (sic) WERE ADMINISTERED AND WITH INTERVENTION. DR. (2 physician's names) WERE CALLED SEVERAL TIMES DURING MORNING SHIFT DUE TO PATIENTS SEVERE C/O PAIN WITH NO ANSWER...DOCTOR CALL BACK TO NURSES ST (station) APPROX 0940 AND GAVE ORDER TO SEND PT OUT TO ER 911..."
Resident A was transferred from the facility to the acute hospital for unrelieved abdominal pain that began the evening of XXXXXXX 2016, and had increased to severe pain over approximately 12 hours when the resident was transported by ambulance at 10:29 a.m., on May 4, 2016.
On June 6, 2016, Resident A's acute hospital emergency department record was reviewed. A review of Resident A's hospital, "History and Physical," (H&P) dated May 5, 2016, indicated, "...ABD PAIN 10/10 LAST NIGHT..."
The section, "History of Present Illness," of the same H&P indicated, "...Patient was admitted with abdominal pain and he was found to have viscous rupture (forcible tearing or bursting of an abdominal organ which is an emergency condition that requires immediate medical attention) and he went to surgery yesterday...Currently patient is intubated (a breathing tube placed in the windpipe) on ventilator with sedation..."
In section, "Assessment/Plan," of the hospital's H&P for Resident A indicated, "...Bowel perforation (a hole that develops through the wall of the small intestine or large intestine) Evaluated by general surgery, was taking (sic) emergently to OR (operating room)..."
Review of Resident A's hospital, "Operative Report," dated May 4, 2016, indicated, "...Postoperative Diagnosis: Acute (experienced to a severe or intense degree) surgical abdomen, Perforated Duodenal ulcer (ruptured sore that occurs in the beginning of the small intestine), peritonitis..."
On June 2, 2016, at 1:28 p.m., an interview was conducted with a licensed vocational nurse (LVN 1) who works on the day shift (7a.m. - 3 p.m.). LVN 1 was asked about Resident A's medical condition. LVN 1 stated the NOC (night) shift nurse had reported to her that the PM (3 p.m. -11 p.m.) shift and NOC (11 p.m. - 7 a.m.) shift nurses had both attempted to reach the resident's physician but had received no response regarding Resident A's abdominal pain. LVN 1 stated she evaluated the resident at approximately 7:45 a.m., on May 4, 2016. LVN 1 stated the resident had a complaint of pain at eight out of 10 on the pain scale. LVN 1 stated she had attempted to call the physician three times but received no response. LVN 1 stated the physician called back to the nurse's station after the third attempt and gave orders for the resident to be sent out.
On June 2, 2016, at 1:51 p.m., an interview was conducted with a certified nurse's assistant (CNA 1) who works on the day shift. CNA 1 was asked if she had provided care for Resident A the day of May 4, 2016. CNA 1 stated, "Yes." CNA 1 stated the resident had continued to use his call light and complained to her about his abdominal pain.
A phone interview was conducted on June 6, 2016, at 2:42 p.m., with CNA 2 who works on the NOC shift. CNA 2 was asked if she had provided care for Resident A the night of May 3, 2016. CNA 2 stated, "Yes." CNA 2 stated the resident was in "bad abdominal pain" that night. CNA 2 further stated she thought that the resident should have been sent out to the hospital because of his pain. CNA 2 stated she had told the resident's LVN about his abdominal pain and had told another licensed nurse that evening. CNA 2 further stated the resident had used his call light approximately, "25 times," that night to report his abdominal pain. CNA 2 stated another CNA had also answered the resident's call lights because he had used it so often to ask for help for his pain. CNA 2 stated Resident A almost cried he was in so much pain
On June 9, 2016, at 3:04 p.m., a phone interview was conducted with the facility Administrator (AD), the Assistant Director of Nursing (ADON) and the Director of Staff Development (DSD). The AD was asked for the facility policy on how a physician was to be contacted with a resident's change of condition. The AD stated if there was an acute change in a resident's condition the physician was to be notified. The AD stated if the staff had not received a prompt response from the physician, the Medical Director should be called. The AD stated 30 minutes or less would be considered a prompt response.
On June 13, 2016, at 8:57 a.m., a phone interview was conducted with LVN 2 who works the NOC shift. LVN 2 was asked about Resident A's medical condition on the night of May 3, 2016. LVN 2 stated she was, "worried about the resident." When asked if she had notified the resident's physician about the change of condition, LVN 2 stated she had called the physician two times within an hour but stated she had not heard back from the physician. No additional attempts were made to contact the physician or to contact the Medical Director. LVN 2 was asked at what time she had called the physician. LVN 2 stated she could not remember exactly, but knew it had been earlier in her shift. (NOC shift is 11:00 p.m. to 7:00 a.m.)
On June 15, 2016, at 10:40 a.m., a phone interview was conducted with a registered nurse supervisor (RNS). The RNS was asked about Resident A. The RNS stated LVN 2 had come to her about Resident A's abdominal pain. The RNS stated she and LVN 2 had assessed Resident A and the resident had abdominal distention. The RNS stated she told LVN 2 to call the physician to get orders. The RNS was asked if she had called the physician for Resident A's change of condition. The RNS stated, "No." When asked if a physician should be notified of a resident's change of condition and ask if new orders were needed for the resident's care, the RNS stated, "Supposed to be."
Record review and interview with facility staff indicated no attempts were made to contact the Medical Director when Resident A's physician failed to respond in a timely manner.
Review of the facility's policy and procedure titled, "Acute Condition Changes-Clinical Protocol," revised December 2012, indicated: "...6. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less). 7. The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition or status.
a. The staff will notify the Medical Director for additional guidance and consultation if they do not receive a timely or appropriate response..."
Therefore, it was determined that the facility failed to provide necessary care and services to ensure Resident A maintained his highest level of physical well-being. This failure caused the resident to suffer from severe, unrelieved abdominal pain for approximately 12 hours and the failure required the resident to be transported to an acute care hospital by a paramedic ambulance for further evaluation and treatment where the resident underwent emergency surgery for a ruptured duodenal ulcer and peritonitis.
The above violation presented either an imminent danger that death or serious harm would result or a substantial probability of death or serious physical harm to the patient. |
| 250000077 |
MAGNOLIA REHABILITATION & NURSING CENTER |
250013266 |
B |
14-Jun-17 |
OKDW11 |
6785 |
HSC 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.
Facility staff witnessed multiple episodes of Resident 1?s abuse both physically and verbally by the resident?s significant other (SO). The facility failed to report these witnessed incidents to the California Department of Public Health (CDPH) until September 17, 2015, almost a year after the first witnessed and documented incident of abuse occurred.
On October 1, 2015, at 9:30 a.m., an unannounced visit was made to the facility to investigate an entity reported incident of witnessed abuse between Resident 1 and the resident?s SO.
On October 1, 2015, at 9:46 a.m., the Administrator (ADM) was interviewed. The ADM stated Resident 1 was out on the grass in the yard of the facility on September 17, 2015, and certified nursing assistant witnessed Resident 1 being slapped by her SO. The ADM stated the staff contacted the police on September 16, 2015, at approximately 11 p.m. Resident 1 declined to press charges or issue a restraining order.
A record review was conducted for Resident 1 on October 1, 2015. Resident 1 was readmitted to the facility on XXXXXXX, 2014, with diagnoses including lumbosacral spondylosis (lower back degenerative arthritis). A physician order dated September 21, 2015, indicated, ?Pt (patient) may leave facility out on pass (OOP) (with) responsible party. (Pt is her own responsible party).?
?Social Work Progress Notes,? dated October 8, 2014, at 9:34 a.m., indicated, ?Administrator and SSD (social services designee) had one-to-one room visit with resident regarding the incident last night. Resident is able to make decisions and she refused the option to report (to) the Ombudsman, Public Health, and APS (Adult Protective Services) against her ex-boyfriend for verbal abuse but Administrator will have a conversation with resident?s ex-boyfriend regarding his behavior and will make it very clear that his behavior is not acceptable at this facility and he needs to come during visiting hours??
In addition, the ?Social Work Progress Notes,? included the following entries made by the ADM:
June 22, 2015, at 5 p.m., ?Admin (Administrator) note: Called to nursing station about 11:30 a.m. by nurses to help calm down patient and boyfriend (boyfriend?s name). Was informed patient and (boyfriend?s name) were arguing and throwing things. I asked the boyfriend to leave building and not to come back until he calmed down. Explained to him there are certain expectations in how he can treat patient? he was escorted out of building. Boyfriend came back @ (at) 7:30 p.m. started fighting again. Once again asked boyfriend to leave, this time to not come back today. If he returned police would be called? and is refusing to leave; police called and waiting arrival.?
June 23, 2015, at 8:30 a.m., ?Admin Note: Police officer at building this morning again regards to (boyfriend?s name) patient?s boyfriend on premises. Boyfriend was gone prior to my arrival. Boyfriend is no longer allowed in building because he has been sleeping here, doing his laundry, drinking alcohol, and fighting with patient. Will continue to call police and have his escorted out of building each time. Did speak with patient last night about these issues and the fact he would not be allowed in building. She seemed to understand.?
June 23, 2015, at 12:30 p.m., ?Admin Note: (Boyfriend?s name) back again with belongings. Asked him to leave and take belonging with him. Explained again this is not his home and he could not leave his things in patient room. (Resident name) present during conversation, and informed her I would be calling the police again. Called police to ask for help. (Resident Name) and (boyfriend?s name) started to leave building, stopped them both again asked (boyfriend?s name) to remove his belongings (backpack, jacket, large black laundry bag full of what appears to be clothing). (Boyfriend?s name) refused informed him in front of (Resident?s name) and charge nurse I would be sending his belongings out of room. (Boyfriend?s name) stated, ?Go ahead?? Nurses informed me that this morning (boyfriend?s name) appeared under the influence of alcohol again and when female officer arrived could not wake him up and called for backup. Currently his belongings in administrator office, will call police again when he returns.?
September 17, 2015, at 12:35 p.m., ?Admin Note: Interviewed resident at approx. (approximately 8:45 a.m., in regards to incident at occurred during the night outside of facility. Asked resident what happen; she explained that her and her ex-husband had been arguing and had put his hand on her head and pushed it back. Explained to her that the staff had called me last (night) and witnessed him slap her. This is when she told me he did slap her on her face. Explained to her as a mandated reported I would need to call police, ombudsman, and Department of Public Health. Resident seemed to understand, she had stated she didn?t press charges last night because she didn?t want him to (go) back to jail??
During an interview conducted with the ADM on October 1, 2015, at 1:15 p.m., the ADM stated she notified the Department after Resident 1?s boyfriend slapped her face on September 16, 2015. The ADM stated he had not reported any of the other incidents with Resident 1?s boyfriend to the Department.
On October 1, 2015, the facility policy and procedure titled, ?Abuse Prevention Program,? was reviewed. The policy indicated, ??.Our facility will not condone resident abuse by anyone, including? family members? When an alleged or suspected care of mistreatment,? or abuse is reported, the facility Administrator, or his/ her designee, will notify the following persons or agencies of such incident (Note: by form SOC 341 (Report of Suspected Dependent Adult/ Elder Abuse) where applicable)? Notices to the above agencies/ individuals shall be made immediately after the occurrence of the incident or when the facility learns of the abuse? Any person who has knowledge or reason to believe that a resident has been a victim of mistreatment, abuse, or any other criminal offense SHALL report, or cause a report to be made of, the mistreatment or offense. Failure to report such an incident may result in legal/ criminal action being filed against the individual(s) withholding such information??
The facility failed to report multiple incidents of verbal abuse by Resident 1?s SO toward the resident to the Department immediately or within 24 hours.
The violation of this regulation has a direct or immediate relationship to the health, safety, or security of the patients. |
| 250000077 |
MAGNOLIA REHABILITATION & NURSING CENTER |
250013268 |
B |
14-Jun-17 |
OKDW11 |
6045 |
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 failed to ensure Resident 1, a resident at the facility for more than five years, was free from multiple incidents of verbal and physical abuse from the resident?s significant other (SO). The SO was witnessed committing verbal and physical abuse toward Resident 1 on several occasions. The facility did not take steps to ensure Resident 1 was protected from the SO and permitted the SO to continue with unsupervised visits to the facility.
On October 1, 2015, at 9:30 a.m., an unannounced visit was made to the facility to investigate an entity reported incident of witnessed abuse between Resident 1 and the resident?s SO.
On October 1, 2015, at 9:46 a.m., the Administrator (ADM) was interviewed. The ADM stated Resident 1 was out on the grass in the yard of the facility on September 17, 2015, and a certified nursing assistant witnessed Resident 1 being slapped by her SO. The ADM stated the staff contacted the police on September 16, 2015, at approximately 11 p.m. Resident 1 declined to press charges or request a restraining order against the SO.
On October 1, 2015, at 10 a.m., an interview was conducted with Resident 1. The resident stated she wanted to continue to see and interact with her SO outside the facility. Resident 1 stated her SO had acted violently before, but had never injured her.
A record review was conducted for Resident 1 on October 1, 2015. Resident 1 was readmitted to the facility on XXXXXXX, 2014, with diagnoses including lumbosacral spondylosis (lower back degenerative arthritis). A physician order dated September 21, 2015, indicated, ?Pt (patient) may leave facility out on pass (OOP) (with) responsible party. (Pt is her own responsible party).?
?Social Work Progress Notes,? dated October 8, 2014, at 9:34 a.m., indicated, ?Administrator and SSD (social services designee) had one-to-one room visit with resident regarding the incident last night. Resident is able to make decisions and she refused the option to report (to) the Ombudsman, Public Health, and APS (Adult Protective Services) against her ex-boyfriend for verbal abuse but Administrator will have a conversation with resident?s ex-boyfriend regarding his behavior and will make it very clear that his behavior is not acceptable at this facility and he needs to come during visiting hours??
In addition, the ?Social Work Progress Notes,? included the following entries made by the ADM:
June 22, 2015, at 5 p.m., ?Admin (Administrator) note: Called to nursing station about 11:30 a.m. by nurses to help calm down patient and boyfriend (boyfriend?s name). Was informed patient and (boyfriend?s name) were arguing and throwing things. I asked the boyfriend to leave building and not to come back until he calmed down. Explained to him there are certain expectations in how he can treat patient? he was escorted out of building. Boyfriend came back @ (at) 7:30 p.m. started fighting again. Once again asked boyfriend to leave, this time to not come back today. If he returned police would be called? and is refusing to leave; police called and waiting arrival.?
June 23, 2015, at 8:30 a.m., ?Admin Note: Police officer at building this morning again regards to (boyfriend?s name) patient?s boyfriend on premises. Boyfriend was gone prior to my arrival. Boyfriend is no longer allowed in building because he has been sleeping here, doing his laundry, drinking alcohol, and fighting with patient. Will continue to call police and have his escorted out of building each time. Did speak with patient last night about these issues and the fact he would not be allowed in building. She seemed to understand.?
June 23, 2015, at 12:30 p.m., ?Admin Note: (Boyfriend?s name) back again with belongings. Asked him to leave and take belonging with him. Explained again this is not his home and he could not leave his things in patient room. (Resident name) present during conversation, and informed her I would be calling the police again. Called police to ask for help. (Resident Name) and (boyfriend?s name) started to leave building, stopped them both again asked (boyfriend?s name) to remove his belongings (backpack, jacket, large black laundry bag full of what appears to be clothing). (Boyfriend?s name) refused informed him in front of (Resident?s name) and charge nurse I would be sending his belongings out of room. (Boyfriend?s name) stated, ?Go ahead?? Nurses informed me that this morning (boyfriend?s name) appeared under the influence of alcohol again and when female officer arrived could not wake him up and called for backup. Currently his belongings in administrator office, will call police again when he returns.?
September 17, 2015, at 12:35 p.m., ?Admin Note: Interviewed resident at approx. (approximately 8:45 a.m., in regards to incident at occurred during the night outside of facility. Asked resident what happen; she explained that her and her ex-husband had been arguing and had put his hand on her head and pushed it back. Explained to her that the staff had called me last (night) and witnessed him slap her. This is when she told me he did slap her on her face. Explained to her as a mandated reported I would need to call police, ombudsman, and Department of Public Health. Resident seemed to understand, she had stated she didn?t press charges last night because she didn?t want him to (go) back to jail??
On October 1, 2015, the facility policy and procedure titled, ?Abuse Prevention Program,? was reviewed. The policy indicated, ??.Our facility will not condone resident abuse by anyone, including? family members? ?
The facility failed to ensure Resident 1 was not subjected to verbal and physical abuse from her SO.
The violation of this regulation has a direct or immediate relationship to the health, safety, or security of the patients. |
| 970000143 |
MID-WILSHIRE HEALTH CARE CENTER |
910008985 |
B |
08-Feb-12 |
BOLN11 |
6527 |
? 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. ? 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 or by telegraph to the local health officer and the Department. Based on interview and record review, the facility failed to follow State regulations and failed to follow their policy and procedure titled, ?Incidents, Accidents, and Injuries of Unknown Origin? that indicated to report unusual occurrences to the Department within 24 hours by failing to: 1. Report Patient 4?s fall incident on November 5, 2009, wherein the patient sustained laceration to the right eyebrow and right hip fracture. Patient 4 underwent hip surgery. 2. Report Patient 10?s fall incident on October 2, 2009, wherein the patient sustained fracture to the left clavicle.a. During the course of the facility?s annual recertification survey on March 20, 2010, Patient 4?s clinical record was reviewed. According to the admission face sheet, Patient 4 was a 93 year old female, admitted to the facility on June 21, 2007, with diagnoses that included dementia (a progressive and degenerative disorder of the brain characterized by multiple cognitive deficits that include impairment in memory), diabetes, agitation, and osteoporosis (a disease in which the density and quality of bones are reduced with increased risk of fracture).A Minimum Data Set (MDS), an assessment and care screening tool, dated February 25, 2010, indicated Patient 4 had long and short term memory problems, required cues/supervision because of poor decision-making and had difficulty making her needs known. The MDS indicated the patient required extensive assistance (staff to provide weight bearing support) with all activities of daily living. The facility?s investigative report, dated November 15, 2009, indicated Patient 4 fell from her bed on November 15, 2009. The patient took off her bed alarm and got out of bed over raised side rails. The patient sustained a laceration to her right eyebrow (measurement not indicated) and was transferred to the acute hospital where she was also diagnosed to have a fractured right hip. Patient 4 underwent surgical repair for her right hip fracture. The investigative report indicated the Department was not notified about the fall incident.During an interview with the administrator on March 20, 2010 at 11:45 a.m., he stated he did not report Patient 4?s fall incident to the Department. The administrator stated the incident happened over the weekend and he was not informed or given the incident report until late Monday, November 16, 2009. He stated he forgot to report the incident to the Department because he was dealing with Patient 4?s upset family members.b. On March 20, 2010, Patient 10?s clinical record was reviewed. According to the admission face sheet, Patient 10 was an 81 year old male, originally admitted to the facility on June 19, 2009. He was readmitted to the facility on October 15, 2009, with diagnoses that included status post left clavicular (clavicle) fracture and diabetes.The MDS dated December 21, 2009, indicated Patient 10 had short term memory problem, made poor decisions in new situations, and had no difficulty making his needs known. Patient 10 required extensive assistance with all activities of daily living.According to an undated interdisciplinary team investigative report, the director of nursing (DON) interviewed Patient 10 on October 2, 2009, during the 7-3 shift. Patient 10 stated he went to the bathroom by himself, lost his balance and slid to the floor, hitting his left shoulder against the toilet bowl. The patient stated he was not sure what time the incident occurred. He further stated to the DON that he did not call for help, got up by himself, and went back to bed without notifying any staff member since he felt he was all right until he felt the pain later that night. During an interview with the administrator on March 20, 2010 at 2:30 p.m., he stated he did not report Patient 10?s fall incident to the Department because there was no staff member that witnessed the incident and it was not clear what actually happened. However, during a review of the Investigation of Incident, dated October 2, 2009, the form contained the following: ?Conclusion: After evaluating the above data, conclude if it can be logically determined how the resident (patient) became injured. If this cannot be determined, it will be necessary to file a report with DHS (Department of Health Services) and the Ombudsman, as an Alleged Abuse Report.?The facility?s policy and procedure titled, ?Incidents, Accidents and Injuries of Unknown Origin? dated August 2005 indicated that it is the policy of the facility that resident incidents are properly documented, reported and evaluated. The policy defined an incident as an unusual event or happening involving a resident with unintended, undesirable, and/or unexpected results or outcomes. The policy further indicated that following completion of an incident report involving a patient, an Investigative Form is to be completed when it has been determined that a serious incident/injury, unusual occurrence, or injury of unknown origin has occurred. The policy also indicated unusual occurrences that threaten the welfare, safety or health of residents, personnel or visitors will be reported by the facility within 24 hours and confirmed in writing to the local health officer of the Board of Licensure and Certification. Therefore, the facility failed to follow State regulations and failed to follow their policy and procedure titled, ?Incidents, Accidents, and Injuries of Unknown Origin? that indicated to report unusual occurrences to the Department within 24 hours by failing to: 1. Report Patient 4?s fall incident on November 5, 2009, wherein the patient sustained laceration to the right eyebrow and right hip fracture. Patient 4 underwent hip surgery. 2. Report Patient 10?s fall incident on October 2, 2009, wherein the patient sustained fracture to the left clavicle.The above violation had a direct or immediate relationship to the health, safety, or security of Patients 4 and 10. |
| 970000143 |
MID-WILSHIRE HEALTH CARE CENTER |
910009972 |
B |
26-Jun-13 |
PW1H11 |
6986 |
Title 22 Section 72311 Nursing Service ? General 72311(a) Nursing service shall include, but not 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 with 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.Based on interview and record review, the facility failed to ensure Patient 1?s complaints of not being able to sleep at night, and being lethargic (drowsy; sluggish) during the day were addressed by failing to: 1. Assess and identify the reason why Patient 1 was unable to sleep at night. 2. Ensure Patient 1?s physician was notified of the patient?s inability to sleep at night, for the physician?s interventions as needed. 3. Develop a plan of care that had specific/measurable interventions that included monitoring Patient 1?s hours of sleep and activity in between rest/nap periods. On October 20, 2010, at 10 a.m., Patient 1 fell from her wheelchair and hit her head on another patient?s wheelchair while attending the morning activity in the activity room. Patient 1 sustained two lacerations (cuts), one on the middle forehead that measured 2.5 centimeters (cm) by 1 centimeters cm and on the upper scalp area that measured 0.5 cm by 0.5 cm that required stiches. Patient 1 was transferred to a general acute care hospital (GACH), the lacerations were sutured and the patient was returned to the facility on the same day, October 20, 2010.According to the admission record Patient 1 was admitted to the facility on October 12, 2009, with diagnoses that included osteoarthritis (occurs when the protective cartilage [the tough, elastic, fibrous connective tissue] on the ends of the bones wears down over time and affects the joints in the hands, neck, lower back, knees and hips).According to the Minimum Data Set (MDS), an assessment and care screening tool dated October 25, 2009, Patient 1's cognitive skills for daily decision making were independently modified, and she had the ability to make herself understood. The patient required extensive assistance from the nursing staff with transferring and locomotion on and off the nursing station. The patient attended activities in the day activity room and her preferred activities included exercise, music and watching television.A review of the Fall Risk Assessment forms dated October 13, 2009, January 29, 2010, April 23, 2010 and July 22, 2010, indicated the patient was a high risk for falls. The plan of care dated October 13, 2010, for at risk for fall due to left shoulder weakness and pain revealed that the patient was encouraged to attend and participate in activity programs for increased supervision.The plan of care dated October 19, 2010, indicated during the past months, the patient complained she was unable to sleep at night which was causing her to be more lethargic during the day, and interferred with her ability to participate in recreational programs. The approaches included the recreational department would invite and assist the patient in group activities of interest after the patient?s scheduled nap. There was no documented assessment of the patient?s inability to sleep at night. Also, there was no documented nap schedule nor activity schedules for this patient.The Nurse?s Notes (note) dated October 20, 2010, at 10 a.m., indicated Patient 1 fell from the wheelchair and hit her head on another patient?s wheelchair while sleeping. The note indicated the patient had a deep cut to the middle forehead and upper head. The physician was notified and the patient was transferred to a GACH at 10:45 a.m. A review of the GACH clinical record dated October 20, 2010, at 3:18 p.m. indicated Patient 1 sustained a forehead/scalp laceration, status post fall. Patient 1 underwent a bilateral facial repair procedure to the forehead/scalp area. The laceration was irrigated with normal saline (a sodium chloride or salt solution). The total length of the laceration was 4.0 cm; the outer skin layer was closed with non-absorbable sutures (sides of the wound are stitched together), and the lower most layer of skin was closed with two absorbable sutures.During an interview with the activity director (AD) on November 3, 2010, at 11:30 a.m., she stated on October 20, 2010, Patient 1 was sitting in her wheelchair in the activity day room, fell completely out of her wheelchair and hit her head. The AD stated she was alone in the activity room when the patient fell forward from her wheelchair, and when she saw the patient she was already on the floor. According to the AD, the patient stated she was unable to sleep during the night because her roommate kept her up at night. The AD stated the patient had been falling asleep during the activities and she would try and keep the patient awake during activities by touching the patient or calling her name. During an interview on November 3, 2010, at 12 p.m., with registered nurse (RN 1), she stated the AD informed her that Patient 1 had been falling asleep during activities. RN 1 stated she did not document the patient had been falling asleep during activities, and was unable to sleep at night, nor did she notify the physician. In an interview on November 3, 2010, at 12:30 p.m., with registered nurse 2 (RN 2), she stated the patient's physician should have been notified that she was unable to sleep at night.The facility failed to ensure Patient 1?s complaints of not being able to sleep at night, and being lethargic during the day were addressed by failing to: 1. Assess and identify the reason why Patient 1 was unable to sleep at night. 2. Ensure Patient 1?s physician was notified of the patient?s inability to sleep at night, for the physician?s interventions as needed. 3. Develop a plan of care that had specific/measurable interventions that included monitoring Patient 1?s hours of sleep and activity in between rest/nap periods. On October 20, 2010, at 10 a.m., Patient 1 fell from her wheelchair and hit her head on another patient?s wheelchair while attending the morning activity in the activity room. Patient 1 sustained two lacerations (cuts), one on the middle forehead that measured 2.5 centimeters (cm) by 1 centimeters cm and on the upper scalp area that measured 0.5 cm by 0.5 cm that required stiches. Patient 1 was transferred to a GACH, the lacerations were sutured and the patient was returned to the facility on the same day, October 20, 2010.The above violation had a direct relationship to the health, safety, or security of Patient 1. |
| 970000143 |
MID-WILSHIRE HEALTH CARE CENTER |
910009997 |
B |
05-Jul-13 |
Q2VU11 |
6994 |
Code of Federal Regulations F323 ? Free of Accident Hazards/Supervision/Devices 483.25(h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility failed to ensure one of one sampled residents (Resident A), who was assessed as requiring total assistance during transfers, was transferred by two staff members using a Hoyer lift (a mechanical hydraulic lift) in accordance with the facility's policy and procedure. Resident A sustained a proximal (near the center of the body) left tibia/fibula (lower leg bones) fracture.On May 16, 2013, at 2 p.m., an unannounced visit was made to the facility to investigate an entity self-reported incident (CA00353521).According to Resident A's clinical record, she was a 92 year old, admitted to the facility on September 19, 2012. Her diagnoses included dementia (a loss of brain function that affects memory, thinking, language, judgment, and behavior), diabetes mellitus (high blood sugar), and osteoporosis (a disease in which bones become fragile and more likely to fracture). The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated March 29, 2013, indicated the resident was severely impaired in her cognitive skills for daily decision making and had short-term and long-term memory problems. According to the MDS, Resident A had impairment for range of motion (the distance and direction a joint can move to its full potential) on both sides of the upper (shoulder, elbow, wrist, and hand) and lower (hip, knee, ankle, and foot) extremities. The MDS also indicated she required extensive assistance (full staff performance) with bed mobility and transferring.There was a care plan, titled, "Activities of Daily Living" (ADL) functioning with self-care deficit requiring assistance with bed mobility and transfer, updated March 20, 2013. The goal was for Resident A to be assisted with ADLs daily, with interventions that included to assist with ADL care and bathing as scheduled. The interventions did not address how the resident would be transferred from one surface to another surface (bed to shower chair).During an interview with CNA 1 on May 16, 2013, at 2:20 p.m., he stated that he transferred Resident A from the bed to the shower chair without any problems using the Hoyer lift. However, during the shower when he rubbed the resident's left lower leg, she complained of pain and he noticed the leg was slightly swollen. CNA 1 stated he stopped the shower, returned the resident back to bed, using the Hoyer lift, and reported the resident's complaint of pain to the registered nurse supervisor (RN 1). When asked why he used the Hoyer lift to transfer the resident, CNA 1 replied, because the resident was a total assist. CNA 1 was asked if he had assistance with the Hoyer lift transfer, and he stated CNA 2 assisted him.During an interview with CNA 2 on May 16. 2013, at 3:05 p.m., she stated she did not assist CNA 1 transfer Resident A to the shower chair on May 4, 2013.During an interview with director of staff developer (DSD) on May 16, 2013, at 2:55 p.m. she said during her investigation of the incident she interviewed CNA 1 and 2. CNA 1 said he used the Hoyer lift to transfer the resident and CNA 2 assisted him with the transfer. However, when she interviewed CNA 2, CNA 2 denied assisting CNA 1 with the transfer. She also stated that all CNAs are supposed to get assistance when using the Hoyer lift to transfer residents. The DSD provided in-service records on the use of the Hoyer lift, dated August 9, 2011, with CNA 1?s signature for attendance. The July 11, 2012, in-service was not attended by CNA 1, according to the signatures of attendance. During an interview with the director of nursing (DON) on May 16, 2013, at 3:30 p.m., she stated the nursing staff are to use the Hoyer lift to transfer residents that require extensive to total assistance with bed mobility and transfer. The facility's policy and procedure titled, "Mechanical Lift", dated August 2009, indicated at least two people are present while resident is being transferred with the mechanical lift. During a review of the ?situation, background, assessment, request? (SBAR) dated May 4, 2013, at 8:00 a.m., RN 1 documented that there was no skin tear, no discoloration, no redness noted. The resident was medicated with Tylenol 640 milligrams for pain rated 3 out of 10 (pain scale of 1 to 10, 1 being the least, and 10 being the worst pain). The resident?s left leg was elevated on one pillow and immobilized. The physician and responsible party were informed of the swollen left lower leg. The physician ordered to elevate and monitor the left lower leg every shift daily for 14 days.Review of the physician's orders indicated on May 5, 2013, at 11 a.m., the physician ordered a stat (now) x-ray of the left lower leg. Review of the Final X-ray Report taken on May 5, 2013, on Resident A's left leg indicated a left nondisplaced (a break in the bone in which the bone remained aligned) comminuted (crushed) fracture of the proximal tibia epiphysis (round end of a long bone) as well as a nondisplaced fracture of the proximal fibula metaphysis (widest part of a long bone). Review of the Nurse's Notes dated May 5, 2013, at 7:30 p.m., indicated the physician was informed of the results of the X-rays and ordered the resident to be transferred to an acute care hospital for evaluation and treatment. The History and Physical (H & P) from the general acute care hospital dated May 6, 2013, indicated Resident A had both knees swollen with severe tenderness in the left tibial area. The impression was proximal left tibia/fibula fracture. Etiology (cause) was unclear. A review of the right knee x-ray report dated May 6, 2013, indicated a nondisplaced fracture of the proximal patella (knee cap). No surgical procedure was performed. On May 7, 2013, at 9 p.m., the resident was transferred back to the skilled nursing facility (SNF) with orders to continue previous SNF orders for medication and treatment, keep bilateral (both) leg immobilizers in place, and monitor both legs for circulation and sensation every shift.A review of the final investigation report received from the facility dated June 7, 2013, revealed the facility determined that CNA 1 had provided a false statement regarding CNA 2 assisting him with the Hoyer Lift transfer of Resident A on May 4, 2013.CNA 1 was terminated on June 6, 2013. The facility failed to ensure Resident A, who was assessed as requiring total assistance during transfers, was transferred by two staff members using a Hoyer lift (a mechanical hydraulic lift) in accordance with the facility's policy and procedure. Resident A sustained a proximal (near the center of the body) left tibia/fibula (lower leg bones) fracture. The above violation had a direct relationship to the health, safety, or security of Resident A. |
| 910000060 |
MARYCREST MANOR |
910010490 |
A |
04-Mar-14 |
VD5S11 |
7666 |
F333 ?483.25(m) Medication Errors The facility must ensure that-- (2) Residents are free of any significant medication errors. On March 28, 2011, an unannounced visit to the facility was made to investigate an entity reported incident (ERI) that Resident 1 was administered a narcotic medication at a dose ten times greater than the prescribed dose.Based on interviews and record reviews, the facility failed to administer Duragesic, in patch form, to Resident 1 at the dose and strength ordered by the physician. Resident 1 subsequently experienced difficulty in breathing, stopped breathing and died. According to the Resident 1?s clinical record, Resident 1was an 87 year-old female who was admitted to the facility on February 22, 2011, with diagnoses that included left common femoral artery occlusion with left foot gangrene, advanced dementia, stroke (a medical condition when blood flow to part of the brain stops), an acute myocardial infarction (heart attack) and hospice. The resident had an advance directive of DNR (do not resuscitate) and was on comfort measures only. According to the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated March 4, 2011, Resident 1 had severely impaired cognitive skills in daily decision making and was totally dependent on staff for activities of daily living. Resident 1 had a physician?s order dated March 11, 2011, for Duragesic patch 12.5 mcg to be applied to her chest wall every 72 hours.According to the Prescription Delivery Receipt, from the pharmacy, the facility received medications on March 11, 2011, at 5:54 p.m. The pharmacy delivered two boxes of Duragesic patches with a total of ten patches. One box contained five patches of 50 mcg each and the second box had five patches of 75 mcg each. The dispensing pharmacy instruction was to apply one patch of each strength together as one dose, to deliver 125 mcg per dose, to the chest wall every 72 hours. A review of the Medication Administration Record (MAR) for the month of March 2011, indicated the physician?s order for a Duragesic patch was transcribed as ?Duragesic patch 12.5 mcg every 72 hours.?According to the MAR dated March 12, 2011, at 9 a.m., the resident was administered Duragesic medication to her left chest. According to the Charge Nurse Evaluation notes there was no documented change in the resident?s respiratory condition from March 12, 2011, at 9 a.m., until March 13, 2011, at 12:10 p.m.At 12:10 p.m., the notes indicated Resident 1 was noted with shortness of breath with oxygen saturation of 68 percent (normal range is 95 to 100 percent) while on room air, with a pulse rate of 138 to 140 beats per minute (normal 60 to 100). It was documented the resident was started on oxygen (no amount of oxygen indicated) and was suctioned due to excess secretions. At 12:20 p.m., it was documented the resident had labored breathing with a respiratory rate of 24 breaths per minute, and had an oxygen saturation of 97 percent on oxygen at five liters per minute through a nasal cannula (tubes in the nose). At 2:25 p.m., the resident stopped breathing and was pronounced dead at 2:30 p.m. On March 28, 2011, at 11:35 a.m., during a telephone interview with the dispensing pharmacy, the pharmacist in charge (PIC) stated the dispensing pharmacist did not see the decimal point on the faxed order and attempted to clarify the order with the prescribing physician. However, the PIC stated there was no documentation of any order clarification. A review of the faxed physician?s order to the pharmacy, provided by the dispensing pharmacy, revealed there was no decimal point in the prescribed Duragesic dose and it appeared as 125 mcg instead of 12.5 mcg. According to the prescribing information (package inserts), Duragesic contains a high concentration of fentanyl, a potent Schedule II opioid substance with the highest potential for risk of fatal overdose due to respiratory depression (slowing down of breathing). Duragesic should be used with caution in elderly or debilitated patients. Duragesic is not available in 125 mcg patches, only in 12.5 mcg, 25 mcg, 50 mcg, 75 mcg, and 100 mcg patches. Based on the dosing conversion tables listed in the Duragesic package insert, the maximum dose for Resident 1 would be 25 mcg. On March 28, 2011, at 12:20 p.m., during an interview, Staff 1 stated the licensed vocational nurse 1 (LVN 1) administered the Duragesic patches to Resident 1 on March 12, 2011, at 9 a.m. Staff 1 also stated the nurses should double verify with another nurse before administering Schedule II narcotics. Staff 1 said it was not a common facility practice to double verify with another nurse, however after this incident they would start verifying. On March 28, 2011, at 2:23 p.m., during a telephone interview, the physician confirmed that he had prescribed Duragesic 12.5 mcg, not 125 mcg. A review of LVN 1?s personnel file, the Progressive Discipline Memo, dated March 18, 2011, revealed LVN 1 had provided a hand-written statement indicating she interpreted the physician?s order as 125 mcg. The memo also revealed there were four patches of Duragesic 75 mcg and four patches of 50 mcg remaining in the narcotic drawer, which indicated a total of 125 mcg (75 mcg and 50 mcg together) had been administered to Resident 1. LVN 1 was terminated on March 18, 2011, and was not available for interview.According to the amended Certificate of Death dated July 2, 2011, the resident?s cause of death was cardiomegaly with aortic atherosclerosis and other undetermined factors, with the significant contributing condition of peripheral vascular disease with left foot gangrene. It was documented there was a medication error by history and there was a limitation in testing/interpretation of post mortem toxicology due to embalming.A review of the Los Angeles County Coroner Autopsy Report dated October 29, 2011, for the autopsy performed on March 22, 2011, indicated the primary cause of death was cardiomegaly (enlarge heart) associated with aortic atherosclerosis and peripheral vascular disease with left foot gangrene. The deputy medical examiner documented that according to the resident?s medical record an error occurred in administration of the amount of Fentanyl (Duragesic) with more medication delivered than prescribed. The medical examiner also documented that ?due to the embalming process the levels of Fentanyl cannot be interpreted and the manner of death is therefore undetermined.? According to the Department of Coroner, County of Los Angeles, Forensic Science Laboratory Analysis Summary Report dated March 22, 2011, the decedent?s vitreous fluid (a fluid within the globe of the eye, between the retina and the lens) had a Fentanyl level of 11 nanograms per milliliter (ng/ml). The test for Fentanyl level on the decedent?s blood was not performed. During a phone interview with the medical examiner Department of Coroner of Los Angeles County, on February 19, 2014, at 9:30 a.m., he interpreted Fentanyl level of 11 ng/ml in the decedent?s vitreous fluid as high and stated that in blood it would be even higher. The Medical Examiner stated level of Fentanyl at 11 ng/ml would constitute an overdose of medication which would lead to respiratory distress and possible death. The facility failed to administer Duragesic patch to Resident 1at the dose and strength ordered by the physician. Resident 1 subsequently experienced difficulty in breathing, stopped breathing and died. This violation presented either imminent danger that death or serious harm would result, or a substantial probability that death or serious physical harm would result to Resident 1. |
| 910000059 |
MARINA POINTE HEALTHCARE & SUBACUTE |
910011809 |
B |
30-Oct-15 |
IIHQ11 |
6741 |
F226 Abuse Policy and Procedure Development and Implementation42 CFR 483.13 (c) The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences.F309 Quality of Care42 CFR 483.25 Each resident must receive and the facility must provide the necessary care and services to attain or maintain that the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.On July 16, 2015, at 7 a.m., a complaint allegation regarding a certified nursing assistant 1 (CNA 1) physically abused Resident 1 was investigated.Based on observation, interview, and record review, the facility failed to implement their abuse policy and procedures, and a plan of care by not ensuring the following: 1. CNA 1, a suspected perpetrator, was suspended pending the results of investigation. 2. Report the incident to the Department of Public Health (DPH), Licensing and Certification program. 3. To conduct a thorough investigation of an allegation of physical abuse. 4. CNA 1 would handle Resident 1 gently as care planned.According to the admission record, Resident 1 was 76-year old female who was admitted to the facility on March 15, 2004, with diagnoses which included paralysis agitans (disorder of the central nervous system that affects movement, often including tremors) due to Parkinson's disease, osteoporosis (weakening of the bones), and degenerative joint disease (DJD, a form of arthritis which can be painful).According to the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated June 4, 2015, Resident 1 had an intact cognitive skills for daily decision making and required extensive assistance from staff for bed mobility, transferring, ambulation, dressing, hygiene and was incontinent (lost control) of bowel and bladder functions.There was a care plan dated March 19, 2014, for a potential/actual injury related to osteoporosis and degenerative joint disease. One of the interventions included to handle the resident gently during care.On July 16, 2015, at 9 a.m., Resident 1 was observed with blueish/yellowish skin discoloration (bruise) on both arms. During concurrent interview the resident stated on July 5, 2015, on 3 p.m., to 11 p.m., shift, after dinner, CNA 1 wanted to weight her again. The resident stated she asked CNA 1 to come back later but CNA 1 forced the resident by grabbing the resident?s hands. The resident then demonstrated by grabbing her own wrists real hard showing how she was grabbed. The resident stated that was how she got bruised. During an interview, Resident 1 was not consistent with the story of the incident. A review of the facility?s Investigation Report dated July 6, 2015, at 10:13 a.m., indicated according to Resident 1 on July 5, 2015, after dinner on 3 p.m., to 11 p.m., shift CNA 1 came to her room to weigh her but the resident insisted she had already been weighed. Resident 1 told the facility the reason she was bruised was because CNA 1 forced and grabbed her hands and wrists, even when the resident told CNA 1 to come back later. A review of the Incident Investigation Report indicated the resident had bruises to both hands. The right wrist bruise measured at 0.5 centimeters (cm) by 10 cm, the right hand bruise measured 3 cm by 3.5 cm, and the left hand bruise measured 2 cm by 2.5 cm. The resident denied any pain or discomfort.A review of the facility's Investigation Interview Form dated July 6, 2015, indicated CNA 1 stated she was in the resident?s room with CNA 2 on July 5, 2015 at 3 p.m. to 11 p.m., shift. CNA 1 further stated Resident 1 was soiled and needed to be changed so she held the resident's hands and wrists to get a good grip to lift her. The investigation corrective actions were to educate CNA 1 on how to improve the customer service by using therapeutic communication, introducing herself to the resident, and explaining the procedures in order to build rapport and gain trust. There was no documented evidence CNA 1 was suspended during the investigation as indicated in the facility?s policy and procedures. Also, there was no documented evidence the facility conducted a thorough investigation which would include an interviews with the potential witnesses such other staff members, other residents assigned to CNA 1 and resident?s roommates. The facility's Investigation form dated July 10, 2015, indicated the administrator in training (AIT) left several messages for CNA 2 but not until July 10, 2015, at approximately 3:15 p.m., did the AIT spoke to CNA 2 regarding the incident involving Resident 1. CNA 2 told the AIT she felt they provided good customer service and there was nothing out of the ordinary.On July 16, 2015, at 3:20 p.m., during an interview with AIT, he stated he did not conclude the allegation of physical abuse involving Resident 1 and CNA 1 until he spoke to CNA 2. The AIT stated the allegation of abuse was not substantiated and confirmed he should have suspended CNA 1 until the investigation was completed. The AIT also confirmed he did not report the alleged physical abuse to the DPH Licensing and Certification program.On July 16, 2015, and September 10, 2015, at 2:58 p.m., CNA 1 was not available for interview and did not return telephone messages.On September 10, 2015, at 3:40 p.m., CNA 2 was not available for interview, phone message was left for CNA 2, with no return call.A review of the facility's policy and procedure titled Abuse Prevention revised January 2013, indicated that all incidents of resident abuse, mistreatment, neglect and injuries of unknown origin will be promptly and thoroughly investigated by the Administrator and or his/her designee, and to prevent further potential abuse while the investigation is in progress, the suspected employee will be removed and suspended immediately from the care or vicinity of the residents during investigation.The facility failed to implement their abuse policy and procedures by failing to: 1. Ensure CNA 1, a suspected perpetrator was suspended pending the results of investigation. 2. Report the incident to the Department of Public Health, Licensing and Certification program. 3. Conduct a thorough investigation of an allegation of physical abuse. 4. Ensure CNA 1 handled Resident 1 gently.The above violation presented had a direct relationship to Resident 1 health, safety, or security. |
| 920000052 |
MAYFLOWER GARDENS CONVALESCENT HOSPITAL |
920009726 |
B |
04-Feb-13 |
ZQIJ11 |
4083 |
Title 22, Division 5, Chapter 3, Article 6 - 72601((a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter 1, Division 17, Part 6, Title 24, California Administrative Code and requirements of the State Fire Marshal. On March 3, 2012, at approximately 10:30 am, during the Life Safety Code survey, the evaluator conducted an investigation 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 requirement from OSHPD, the authority having jurisdiction for alterations to existing buildings licensed as skilled nursing facilities by: 1. Installed a natural gas generator, Automatic Transfer Switch (ATS), and appurtenances without required OSHPD approval, inspections or permits. 2. Installed several replacement water heaters without required permits, plan approval, inspection, testing or approvals from OSHPD. 3. Altered the existing fire alarm system without the required review, inspection, acceptance testing and/or approvals from OSHPD. This deficient practice was documented on the last two Life Safety Code surveys on August 24, 2009 and December 05, 2010.4. Installed a computer patient monitoring system without required permits, plan approval, inspection, testing or approvals. During an interview, the maintenance supervisor stated she was not aware these projects required OSPHD permit and/or approval. She provided a fire alarm system plan approved by the Los Angeles County Fire Department. She also stated she had sent a copy of the fire alarm system plan to OSHPD through certified mail but not sure if they received it.A review of the OSHPD Fire Marshal Field Visit Report dated 10/19/2011, indicated: 1. 10/8/09- Noted an apparent natural gas generator, ATS, and appurtenances installed on site without required OSHPD approval, inspections or permits.2. 10/19/11- Noted the installation of several replacement water heaters that have already been placed in service without required permits, plan approval, inspection, testing or approvals from OSHPD.3. 10/19/11- Noted the installation and/or upgrade to the existing fire alarm system without required review, inspection, acceptance testing and/or approvals from OSHPD. The OSHPD fire marshal reminded the facilities representative that Los Angeles County does not have jurisdiction for construction and alterations in healthcare facilities.4. 10/19/11- Noted the installation of an apparent computer patient monitoring system without required permits, plan approval, inspection, testing or approvals. Video monitors associated with the system were observed mounted in the corridor side of the exit access corridor, as well.During an interview, the administrator stated these projects were being handled by corporate personnel. The facility failed to comply with the requirement from the Office of Statewide Planning Health Planning and Development, the authority having jurisdiction for alterations to existing buildings licensed as skilled nursing facilities by: 1. Installing a natural gas generator ATS (Automatic Transfer Switch) and appurtenances without required OSHPD approval, inspections or permits. 2. Installing of several replacement water heaters that have already been placed in service without required permits, plan approval, inspection, testing or approvals from OSHPD 3. Installing and/or upgrading the existing fire alarm system without the required review, inspection, acceptance testing and/or approvals from OSHPD. This deficient practice was cited on the previous two Life Safety Code surveys on August 24, 2009 and December 05, 2010.4. Installing an apparent computer patient monitoring system without required permits, plan approval, inspection, testing or approvals. These violations had a direct relationship to the health, safety, and security of all patients of the facility. |
| 920000007 |
MOUNTAIN VIEW CONVALESCENT HOSPITAL |
920010177 |
B |
02-Oct-13 |
NTP511 |
6967 |
Title 22 Section 72311 (a)(2) (a) Nursing services shall include, but not limited to, the following: (2) Implementing of each patient?s care plan according to the methods indicated. Each patient?s care shall be based on this plan. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Based on interview and record review, the facility failed to provide a patient with protective clothing to prevent the development of skin tears as care planned, failed to implement measures to prevent the reoccurrence of skin tears and to update the care plan with approaches directed to eradicate the cause of the patient?s injuries. Patient 1, who was totally dependent on staff for activities of daily living, was found to have a very deep laceration to the right lower leg which required Patient 1?s admission to the acute care hospital for suturing. On May 3, 2011 at 1 p.m., an unannounced visit was made to the facility to investigate a complaint alleging Patient 1 had a severe laceration to a right lower leg. The patient was no longer in the facility at the time of investigation. According to the admission record, the patient was admitted to the facility on March 6, 2011, with diagnoses that included cerebro-vascular accident, systemic lupus erythematosus, difficulty in walking, abnormal posture and status post left hip replacement. The Minimum Data Set (MDS), dated March 17, 2011, indicated the patient had severely impaired cognitive skills for daily decision making and was totally dependent on staff for activities of daily living. The MDS indicated the patient required two plus person physical assistance with transfer to and from bed and the patient used a wheelchair for mobility. The Nursing Admission Assessment, dated March 6, 2011, indicated the patient had multiple skin discolorations and skin tears. There was a care plan, dated March 6, 2011, for the presence of skin tears. The goal was for the patient to be free from further skin tears. One of the approaches was to provide protective clothing. A review of the patient?s clinical record indicated there was no documented evidence the patient was provided with protective clothing as care planned. On April 16, 2011, the patient sustained a deep laceration on her right lower leg. According to the investigative report dated April 16, 2011, the patient was found to have a laceration to her right leg shin that was measured to be 9 cm by 8 cm long and 1 cm deep. It was documented the patient could not provide staff with the information on how she sustained this laceration. During an interview with Certified Nursing Assistant 1 (CNA 1) on May 3, 2012 at 2 p.m., she said on April 16, 2011 at 7:15 a.m., she brought a tray with the breakfast to the patient?s room and observed CNA 2 attending to the needs of the patient?s roommate. CNA 1 asked CNA 2 to help to position the patient for breakfast. CNA 1 said the patient was covered with one sheet and a patient?s blanket was folded and placed at the foot of bed. CNA 1 said she saw a part of the wheelchair foot rest under the blanket. When CNA 1 removed the blanket she saw two foot rests at the foot of bed, she picked them up and placed them on a wheelchair. Then CNA 1 uncovered the patient?s sheet and noticed the patient laying on her right side with a pillow under her right leg. There was a bloody stain on a pillow case approximately the size of a human palm which appeared wet but with no active bleeding on the leg. CNA 1 then stated she reported the incident to the Licensed Vocational Nurse 1 (LVN 1). During an interview with CNA 2 on May 3, 2011 at 1:30 p.m., he reported the patient had a bad cut on her right lower leg, which appeared fresh with no active bleeding, but the blood on the pillow case looked fresh. The patient was on air loss mattress without side rails, with a bolster wedge on each side of the patient to prevent her from falling out of bed and the patient had short fingernails. CNA 2 said the patient did not have any protective clothing on her arms or legs and she appeared uncomfortable. Both CNAs said that wheelchair foot rests were clean without any blood stains. During an interview with LVN 1 on May 3, 2011 at 3:15 p.m., she said when she went to assess the situation with the patient on April 16, 2011, at approximately 7:25 a.m., the patient had a big laceration to right leg shin area. There was no bleeding from the wound and the blood looked coagulated. There was a bloody stain on a pillow case which was under the patient?s right leg. The stain looked fresh and was the size of a human palm. LVN 1 said the patient could not provide any information on how she obtained this laceration. LVN 1 called LVN 2 to provide the patient with first aid treatment and called a nursing supervisor Registered Nurse 1 (RN1). During an interview with LVN 2 on May 3, 2011 at 3:45 p.m., she stated on April 16, 2011 at 7:30 a.m., she was summoned to the patient?s room to provide first aid treatment. LVN 2 said the patient had a large laceration with depth on her right leg shin area. She reported she cleaned the wound with Normal Saline solution, patted it dry, applied steri-strips (thin adhesive strips which used to close small wounds) and wrapped it with Kerlix gauze. LVN 2 said that some parts of the wound she could not bring wound edges together to apply steri-strips. She went on saying that in her opinion the patient sustained laceration during the night shift. The patient?s physician was informed and the patient was transferred to the acute care hospital as ordered by the physician on April 16, 2011, for further evaluation. A review of the CNA 3?s personal file revealed she was suspended on April 16, 2011, and terminated on April 18, 2011.The reason for termination was failure to report an incident that occurred to a patient on April 16, 2011, that resulted in the patient?s right leg laceration. According to the acute care hospital emergency department physician?s documentation, dated April 16, 2011, the patient sustained a ?very large 21 centimeters total length, deep, very irregular, zigzag shaped complex laceration?, to the right leg shin. The patient?s laceration required 12 sutures.The facility failed to provide a patient with protective clothing to prevent the development of skin tears as care planned, failed to implement measures to prevent the reoccurrence of skin tears and to update the care plan with approaches directed to eradicate the cause of the patient?s injuries. Patient 1 was totally dependent on staff for activities of daily living and transfer, was found to have a very deep laceration to the right lower leg which required Patient 1?s admission to the acute care hospital for suturing. The above violation had a direct relationship to the health, safety and security of Patient 1. |
| 920000007 |
MOUNTAIN VIEW CONVALESCENT HOSPITAL |
920010224 |
A |
2-Mar-17 |
KQ3I11 |
10628 |
Title 22 Section 72311 (a)(1)(A)(B)
(a) Nursing services 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.
Based on observation, interview and record review, the facility failed to identify patient care needs to prevent injury when a patient was turned to the side to have his linen sheets smoothed, was grabbed on the right forearm by the Certified Nursing Assistant (CNA) 1 to prevent from falling when he rolled back toward her which resulted in a fracture by failing to:
1. Ensure that a patient, who was assessed as requiring two-plus person physical assist in bed mobility, was provided the same when turned to the side.
2. Develop a plan of care based on the comprehensive assessment information with intervention to prevent injury.
On September 12, 2011, at 2:20 p.m., an unannounced visit was made to the facility to investigate a complaint alleging Patient 1 sustained a fracture of the right arm.
On September 12, 2011, at 2:30 p.m., Patient 1 was observed in bed in a vegetative state and was not able to provide any information. Patient 1 had a feeding tube in place, was dependent on a ventilator and was noted to have a brace to the right upper arm and shoulder.
According to the admission record, Patient 1 was admitted to the facility on XXXXXXX 2008, with diagnoses that included encephalopathy (degenerative brain disease), respiratory failure, status post tracheostomy [tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs], and hypertension.
There was a plan of care dated January 24, 2011, for actual self-care deficit. The intervention was to assist with transfers between surfaces by using mechanical lift, assist in locomotion as needed and daily complete bed bath. There was no intervention on how the facility?s staff would assist and care for the patient during bed bath and the use of two-plus person physical assist in bed mobility.
The quarterly Minimum Data Set (MDS ? a standardized comprehensive assessment of a resident?s problems and condition) assessment dated July 22, 2011, indicated Patient 1 had severely impaired cognitive skills for daily decision making and totally dependent on staff for activities of daily living requiring two-plus persons physical assist in bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). Patient 1 had contractures on both upper and lower extremities.
According to the Sub-acute Daily Charting dated August 15, 2011, at 2:15 p.m., CNA 1 reported that while repositioning Patient 1 who was turned on the side facing the wall, Patient 1 suddenly moved toward CNA 1. CNA 1 grabbed the patient?s right forearm and heard a cracking sound. CNA 1 made the patient comfortable and notified the nursing supervisor. At 2:30 p.m., it was documented that the Occupational Therapist (OT) evaluated the patient due to the reported incident and ordered exercises with Restorative Nursing Assistant (RNA) to both upper extremities and splinting to both elbows. At 3 p.m., it was documented that RN 2 assessed Patient 1 and noted a slight swelling on the right wrist. The physician was informed and ordered STAT (immediate) x-ray of the right wrist.
During an interview with CNA 1 on October 27, 2011, at 12:30 p.m., she said that on August 15, 2011, on the 7 a.m. to 3 p.m. shift, she went to Patient 1?s room to render incontinence care. CNA 1 stated that CNA 2 assisted her in providing Patient 1 a bed bath. When they were finished, CNA 2 left Patient 1?s room. CNA 1 said she noted that the patient?s incontinence pad was wrinkled and wanted to make it smooth and even. CNA 1 said Patient 1 was on his left side facing a wall when she pulled the incontinence pad and the patient suddenly moved toward her. CNA 1 quickly grabbed the patient?s right forearm to prevent him from falling and heard a cracking sound. CNA 1 said she stopped doing anything and reported to the nursing supervisor right away. CNA 1 went on to say how she always had a second person assisting her with Patient 1?s bed mobility, transfer, bed bath, and care, but did not think that she would not be able to fix the incontinence pad by herself.
During an interview with RN 1 on September 12, 2011, at 3 p.m., she confirmed that on August 15, 2011, at 2 p.m., CNA 1 reported an incident to her. RN 1 said that the OT was asked to evaluate Patient 1 and that the physician was informed of the results.
In the Skilled Therapy Progress Note dated August 15, 2011, (time not indicated) the OT documented that Patient 1?s right wrist was assessed with no signs and symptoms of pain or deformity were noted, no crepitus was noted with PROM. The OT recommended taking an x-ray of the right wrist.
According to the record review there was a physician?s order dated August 15, 2011, at 2:30 p.m., for RNA to provide passive range of motion (PROM) to both upper extremities daily for one week as tolerated and for the application of elbow splint to both elbows for four to six hours daily for one week as tolerated. At 3:00 p.m., an order for stat (immediately) x-ray of the right wrist was received.
The x-ray report of the right wrist dated August 15, 2011, indicated there was no fracture.
A review of the restorative nursing assistant (RNA) flow sheet for August 2011, indicated Patient 1 was provided with the PROM on August 15 and 16, 2011.
According to the Sub-acute Daily Charting dated August 16, 2011, at 8:30 a.m., Patient 1 had slight swelling to the right wrist and had a splint on. At 3:15 p.m., it was documented that CNA 3 reported Patient 1?s right upper arm was swollen with discoloration noted near right elbow and that the patient?s right arm was flaccid (lacking muscle tone). The physician was notified with new order obtained and OT was informed of the upper arm swelling.
The x-ray report dated August 16, 2011, for the right humerus two views indicated there was an acute right humerus fracture. On August 16, 2011, at 6 p.m., there was a physician?s order to transfer Patient 1 to the acute care hospital for evaluation secondary to a right humerus fracture.
A review of the clinical record from the acute care hospital revealed that on August 16, 2011, at 9:50 p.m., Patient 1 had an x-ray of the right humerus. The x-ray report indicated Patient 1 had spiral complete fracture of the midshaft of the humerus.
The clinical course for the patient was to leave his arm in a splint and let it heal naturally on its own in a comfortable position.
XXXXXXX7, 2011, at 12:20 a.m., Patient 1 was readmitted to the facility.
During an interview with the OT on December 21, 2011, at 2 p.m., she said she provided Patient 1 with PROM in the morning of August 15, 2011, before the incident took place. On August 16, 2011, Patient 1 had PROM in the morning (no specific time was given). The OT said she did not notice any signs and symptoms which could indicate the patient had a fracture on his right arm. The OT stated that Patient 1 did not have any swelling or discoloration on his right arm with the exception of a noted decreased resistance on the right elbow when provided with PROM. The OT went on to say that the primary goal was to open Patient 1?s elbow and to decrease resistance. Decreased resistance was a desirable goal for the patient and therefore, would not be an alarming sign. She also pointed out that the x-ray report dated August 15, 2011, revealed there was no fracture to the right wrist so it was safe to continue to provide PROM with the application of elbow splint.
On August 18, 2011 at 11:55 a.m., the orthopedic physician saw the patient at the facility and ordered to have a right humeral brace placed by Orthotics/Prosthetics vendor and a follow up x-ray with brace on.
According to the orthopedic physician?s progress note dated August 28, 2011, there was no humeral fracture brace available and the patient had been fitted with a right elbow brace which stopped at fracture site and poorly fitted on the upper arm. It was documented that according to the x-ray dated August 24, 2011, the fracture was not well reduced. There was an order dated August 28, 2011, at 1:50 p.m., to contact orthotic/prosthetic person and fit the patient with ?Sarmiento? type humeral fracture brace.
During an interview with the OT on December 21, 2011, at 2:30 p.m., she said the initial order for the brace dated August 18, 2011, did not specify what type of brace for humeral fracture the patient needed. The facility?s orthotic vendor provided Patient 1 with a common type of brace for humeral fracture based on the patient?s measurements. OT said that on August 28, 2011, the orthopedic doctor clarified what kind of brace Patient 1 needed. OT said the patient was provided with ?Sarmiento? humeral fracture brace after August 28, 2011, as was ordered. OT verbalized an agreement that it was the rehabilitation department?s responsibility to clarify an order to provide Patient 1 with the right orthotic brace from the start.
The facility failed to identify patient care needs to prevent injury when a patient was turned to the side to have his linen sheets smoothed, was grabbed on the right forearm to prevent from falling when he rolled back toward the Certified Nursing Assistant 1 (CNA 1) which resulted in a fracture by failing to:
1. Ensure that a patient, who was assessed as requiring two-plus person physical assist in bed mobility, was provided the same when turned to the side.
2. Develop a plan of care based on the comprehensive assessment information with intervention to prevent injury.
The above violation presented an imminent danger that serious physical harm would result and was a direct cause of serious physical harm to Patient 1. |
| 920000009 |
MACLAY HEALTHCARE CENTER |
920010936 |
B |
15-Aug-14 |
TMQZ11 |
6147 |
CLASS B CITATION ? PROBLEM TRANSFER If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or the patient?s representative. Upon admission of the patient to the skilled nursing facility and upon transfer of the patient of a skilled nursing facility to a general acute care hospital, the skilled nursing facility shall inform the patient, or the patient?s representative, in writing of the right to exercise this bed hold provision. No later than June 1, 1985, every skilled nursing facility shall inform each current patient or patient?s representative in writing of the right to exercise the bed hold provision. Each notice shall include information that a non-Medi-Cal eligible patient will be liable for the cost of the bed hold days, and that insurance may or may not cover such costs. A licensee who fails to meet these requirements shall offer to the patient the next available bed appropriate for the patient?s needs. This requirement shall be in addition to any other remedies provided by law. Based on interview and record review, the facility failed to inform Patient 1, or his representative, in writing of the right to exercise the seven day bed hold provision, when he was discharged to a general acute care hospital (GACH) on October 6, 2011, and failed to readmit Patient 1 within the seven day bed hold period when he was ready to be discharged from the GACH on October 10, 2014. A complaint was received by the Department and initiated on October 19, 2011, alleging Patient 1 was discharged to the acute hospital on a 5150 (involuntary psychiatric hold) and the facility refused to readmit him.On October 19, 2011, at 8:30 a.m., during an interview with the Director of Nursing (DON), she stated the patient was transferred to the acute care hospital because of aggressive behavior. Patient 1 was violent and was hitting the staff. At 10:30 a.m., during an interview with the Administrator, he stated that Patient 1 was combative, grabbed the maintenance staff and assaulted him. He stated the police department came in twice, and Patient 1 was a threat to himself, to the staff, and to other residents. Patient 1 was transferred to the acute care hospital on a 5150, and the Administrator stated he would not readmit anyone who was a threat.According to the admission records, Patient 1 was admitted on September 29, 2011, with a form of epilepsy and recurrent seizure, dementia with behavioral disturbances, and unspecified reactive psychosis. The primary payer for the patient was private pay. The guarantor, substitute decision-maker and emergency contact number was the ex-wife.The Bedhold Informed Consent signed by the ex-wife dated September 30, 2011, did not indicate on admission if the patient or the responsible party would like the bed to be held upon transfer to the acute hospital. In addition, the sections indicating confirmation of transfer and 24 hours notification to hold the bed for seven days were left blank. The History and Physical Examination dated October 4, 2011, indicated the patient does not have the capacity to understand and make decisions.The physician?s telephone order dated October 4, 2011, indicated pending evaluation by the acute hospital for 5150, aggressive behavior. Transfer to the acute psychiatric unit.On October 6, 2011, at 1:30 p.m., there was another physician?s order to transfer the patient to the acute psychiatric unit 5150 for evaluation and treatment.A review of the Nurse?s Notes from October 4, 2011 to October 6, 2011, revealed no documentation that the resident or the responsible party was notified of the bed hold during and after the transfer of Patient 1 to the acute hospital.A review of Patient 1?s clinical record did not indicate that the responsible party was notified of the patient?s transfer or plan to transfer to the acute hospital.The Discharge Summary indicated Patient 1 was discharged on October 6, 2011, on a 5150 due to aggressive behavior. On October 19, 2011, at 11:30 a.m., during an interview with the DON, she stated they did not take Patient 1 back to the facility because of his aggressive behavior even though the hospital told the facility that the patient was evaluated and was able to go back to the skilled nursing facility.On November 2, 2011, at 1:55 p.m., during an interview with the Business Office Manager, she stated the facility does not hold a bed for a patient on a private pay. She also stated she did not notify the patient or the family regarding the bed hold policy. The facility?s policy and procedure titled ?Preparing a Resident for Transfer or Discharge? dated April 2007, indicated the business office will be responsible for informing the resident, or his or her representative (sponsor) of our facility?s readmission appeal rights, bed-holding policies, etc. In addition, the facility?s policy and procedure titled ?Documentation of Transfers/Discharges? dated April 2007, indicated documentation from the Care Planning Team concerning all transfers or discharges must include, as a minimum, and as they may apply that an appropriate notice was provided to the patient and/or representative (sponsor).A review of the hospital records dated October 10, 2011, indicated the social worker contacted the staff at the skilled nursing facility and received notice that Patient 1 would not be accepted back to the facility due to extreme combative behavior and multiple instances of fleeing the facility without regard to safety. Therefore, failure of the facility to inform Patient 1, or his representative, in writing, of the right to exercise the seven day bed hold provision when he was discharged to a GACH on October 6, 2011, and failure to readmit Patient 1 within the seven-day bed hold period, when the GACH called for readmission on October 10, 2011, had a direct and immediate relationship to the health, safety and security of Patient 1. |
| 920000009 |
MACLAY HEALTHCARE CENTER |
920011080 |
AA |
29-Dec-14 |
YU7X11 |
16577 |
483.25(j) F327Sufficient Fluid To Maintain Hydration The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. The facility failed to ensure Resident 1 was provided sufficient fluids to prevent dehydration, including but not limited to failures to: 1. Ensure that Resident 1, who was admitted to the facility with diagnoses of urinary tract infection (UTI), dysphagia (swallowing difficulties) and dehydration, was provided and consumed 2010 cubic centimeters (cc) of fluid as indicated in the nutritional assessment.2. Ensure that the licensed nursing staff monitored Resident 1's hydration status by means of accurate and continuous intake and output (I&O) records, with prompt communication between nursing staff, as indicated in the facility's policy and procedures for the prevention of dehydration.3. Promptly notify the physician when Resident 1's 24-hour fluid intake was not met for several days, and inquire of further medical interventions as necessary to prevent dehydration. These deficient practices resulted in Resident 1's hospitalization on June 18, 2014, at 2: 35 p.m., nine days after being admitted from the general acute care hospital (GACH 1). Resident 1 became unresponsive and was transferred via paramedics (emergency personnel) to GACH 2. She was diagnosed with hypovolemia (decreased fluid volume of the blood), dehydration (condition in which the total body fluid volume is reduced or depleted), fecal impaction (accumulation of feces in the bowel which may be caused by poor fluid consumption), and kidney failure. Resident 1 died on June 23, 2014, five days after she was transferred to GACH 2.On August 26, 2014, the Department received a complaint that alleged Resident 1 was unresponsive, with fast breathing, low blood pressure, and was transferred to GACH 2 by paramedics (emergency personnel) on June 18, 2014.A review of the skilled nursing facility (SNF) admission record indicated Resident 1 was admitted from GACH 1 on June 9, 2014, with diagnoses that included UTI, swallowing difficulties, decreased oral intake, and a dehydration.The discharge instructions sent with the resident to the SNF from GACH 1 indicated upon discharge, Resident 1 had diagnoses of dehydration and UTI, had to be monitored for dehydration and UTI, and needed to drink enough fluids to keep the urine clear or pale yellow in color.A review of the Resident 1's Dehydration Risk Assessment Tool dated June 9, 2014, indicated she had a moderate risk for dehydration, and the tool indicated a plan of care was required. However, on August 18, 2014, at 3: 50 p.m., during a record review and an interview, Registered Nurse 1 (RN 1) was asked to provide a plan of care to address interventions for Resident 1's risk for dehydration. RN 1 stated there was a nutritional care plan developed by the Registered Dietician (RD), but the licensed nursing staff did not develop a plan of care that included interventions to prevent dehydration. A review of the Registered Dietician's Nutritional Assessment dated June 16, 2014, indicated Resident 1 had a height and weight of 65 inches and 149 pounds respectively. The RD's assessment also indicated the resident was confused, had swallowing difficulties and her daily fluid requirement (fluids needed to maintain proper hydration) was 2010 cc of fluid per day. There was no indication on the assessment of the resident's moderate risk for dehydration.There was a care plan for "Alteration in Nutrition" dated June 16, 2014, that indicated to maintain adequate hydration for 3 months. The approaches included to monitor meal intake, offer/encourage fluids, and to assist/feed as needed. The care plan was not specific for dehydration and did not incorporate the June 16, 2014, fluid needs assessment of 2010 cc per day, completed by the RD.For example, the licensed nursing staff did not incorporate interventions that indicated how the 2010 cc of fluid per day would be provided to Resident 1; there was no indication as to the responsible persons to provide the fluids, and how the resident's intake of fluids would be monitored. The care plan did not indicate alternative interventions to be taken if the resident did not consume the 2010 cc of required fluid needs as assessed by the RD.A review of the Minimum Data Set, a comprehensive assessment tool, dated June 18, 2014, indicated the resident had long and short-term memory problems, and was totally dependent on staff for toileting, eating, and drinking.On July 15, 2014, during an interview with Family Member 1 she stated she is a registered nurse and knew the conditions of Resident 1 when discharged from GACH 1 to the skilled nursing facility on June 9, 2014. According to FM 1, Resident 1 had normal vital signs and no fever. FM 1 stated that on June 18, 2014, she received a call from the facility informing her Resident 1 was transferred to GACH 2 because she was unresponsive, had a low blood pressure and fast breathing. When FM 1 arrived at GACH 2 she was informed by the physician the resident was unresponsive and had abnormal labs. The labs were: Sodium was 176 (normal range is 135 to145), BUN (blood urea nitrogen test shows how well the kidneys and liver are working) was 93 (normal range is 8 to 20), Creatinine 4.41 (test to show how well your kidneys work), and had dehydration and kidney failure. During the interview, FM 1 stated that in her entire career as a registered nurse, she had never seen a sodium level that high. The intake and output record [(I&O) a record to monitor how much liquid was consumed and eliminated as urine] initiated on June 9, 2014, was reviewed with RN 1. The I&O record from June 9, to June 18, 2014, indicated the resident did not receive and consume 2010 cc of fluid per day in accordance with the RD's assessment. According to the I&O record Resident 1 consumed between 1050 cc and 1320 cc of fluids per day.For example, the intake from June 10 through June 19, 2014 was as follows according to documentation on the I&O sheet: June 10 was 1340 cc; June 11 was 1320 cc; June 12 was 1080 cc; June 13 was 1100 cc; June 14 was 1050 cc; June 15 was 1070 cc; June 16 was 570 cc with no 7 a.m. to 3 p.m. intake recorded, and no 24 hour total recorded; June 17 was 1120 cc; and June 18 was 1170 cc. The total fluids consumed daily was recorded between 690 cc to 960 cc per day less than what Resident 1 required for her daily hydration needs according to the RD's assessment. The comment section indicated "adequate". There was no indication the physician or RD had been notified of the intake. In addition, the I&O record under the section of Weekly Evaluations did not indicate the licensed nursing staff consistently recorded the resident's fluid output to ensure the resident's hydration status was adequate. The urine output was recorded as the number of times the resident urinated, such as 2 X, however the totals were not totaled correctly to ensure an accurate evaluation. The consistency of the urine, the color and the odor were not recorded as indicated on the discharge instruction received from GACH 1.On August 18, 2014, at 3: 50 p.m., during an interview with RN 1, she was asked why the physician was not contacted when the resident wasn't getting the required fluids necessary as assessed by the RD. RN 1 stated there was lack of documentation or communication from the certified nursing assistants indicating the resident was not drinking the required fluids. She was unable to provide the reason why the resident's I&O record was incomplete and inaccurate.The Medication Administration Record for June 2014 indicated that Isosource 250 milliliters (nutritional drink supplement) was ordered June 9, 2014, to be given three times per day. It was signed off as being given, however there is no indication what amount was consumed. A review of the CNA - ADL Tracking Form from June 10 through June 18, 2014, revealed the daily documentation was illegible and inconsistent in the areas of "Dietary Supplement Offered" and "Fluids Offered". In the supplements area the documentation for all three shifts is either "0? or "8" meaning none or did not occur. The fluids offered and consumed was not legible for most days and did not match the I&O recording. The resident's refusal or inability to take fluids was not reported to a licensed nurse according to RN 1's statement on August 18, 2014. The facility's policy titled, "Resident Hydration and Prevention of Dehydration" dated 2013, indicated the RD will assess all residents for hydration adequacy, nursing will assess for signs and symptoms of dehydration during daily care, nursing will monitor and document fluid intake and output in the medical record. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be incorporated into the care plan, and the physician will be notified. The RD, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake. Orders may be written for extra fluids to be encouraged between meals. A specific minimum amount should be included ...., "force fluids" or "encourage fluids" are not adequate orders. There was no documented evidence in the clinical record that indicated the licensed nursing staff consistently monitored the resident's hydration status. This would include monitoring clinical signs and symptoms of hypovolemia /dehydration such as skin turgor (skin's ability to change shape and return to normal), dry skin, dry mucus membranes (moist openings such as the mouth, nose, eyes), coated tongue, irregular bowel movements and its consistency, and the urine output (color, amount, odor). Other monitoring would include consistent documentation and communication regarding the resident's refusal or inability to drink fluids, and notification of the physician to obtain alternative treatment instructions such as tube feeding and/or IV fluid replacement as indicated in the facility's undated policies and procedures (a set of principles, rules, and guidelines formulated or adopted by an organization to reach its goals) as stated above. On August 18, 2014, at 3: 50 p.m., during an interview RN 1 stated, on June 18, 2014, at approximately 2:30 p.m., Licensed Vocational Nurse 1 (LVN 1) called stat (a code for emergency) to the resident's room. On arrival to the room, Resident 1 was observed with excessive sweating, fast breathing, unresponsive but arousable. The vital signs were: blood pressure 99/74, pulse 76, respiration 32, and had a temperature of 102.2 taken under the arm; cooling measures were provided. Oxygen Saturation was not readable due to excessive sweating. Oxygen was given at 15 liters per minute via a non-re-breather mask.A review of the Licensed Nurse Progress Note dated June 18, 2014, at 2:30 p.m., indicated Resident 1 was diaphoretic (sweating), breathing too fast and unresponsive. The blood pressure was 99/74 (normal 120/80), temperature 102.2 degree Fahrenheit (normal 98.6øF) taken under the arm, respiration 32 breaths per minute (normal 16-20). The physician was notified of the resident's change of condition and an order was obtained to transfer the resident to GACH 2 via paramedics, which occurred at 2:35 p.m.A review of the Emergency Room Note (ER) obtained from GACH 2 dated June 18, 2014, indicated upon arrival Resident 1 had an altered mental status, no pulse, a fever of 104 øF, was hypovolemic and hypotensive (low blood pressure) requiring levophed drip (medication to raise blood pressure) and CPR [cardiopulmonary resuscitation- compressing over the chest and blowing air into the lungs]. Resident 1 was intubated (insertion of breathing tube into the windpipe) and placed on a ventilator (tube connected to a breathing machine to help breath). The resident was also given 6.4 liters of IV fluid replacement (to compensate fluid loss) and two units of fresh frozen plasma, and was admitted to an intensive care unit.A review of the History and Physical (H&P) examination record dated June 18, 2014, indicated the resident went into acute renal failure. The record indicated the x-ray of the abdomen results on June 20, 2014, indicated the resident had a very large fecal impaction [a large lump of dry, hard stool that stuck in the rectum (often seen in resident's with low fluid intake and constipated for a long time)] of at least "16 by 819 centimeters."A review of Resident 1's laboratory test results obtained from GACH 2 dated June 18, 2014, indicated the following: 1. An elevated blood sodium level of 176 mEq/L (reference range 135-145 mEq/L). A blood sodium level of more than 150 mEq is an indicator for dehydration (American Journal of Nursing June 2006, Vol. 106 No. 6 Pages 40-49). According to the history and physical examination record dated June 18, 2014, the hypernatremia (high sodium) was secondary to dehydration as the resident has been refusing on and off oral fluid intake at the SNF (skilled nursing facility). The H&P also indicated the resident had episodes of seizures secondary to high sodium.2. An elevated Creatinine (Cr) level of 4.41 mg/dl (reference range 0.60-1.30 mg/dL). Resident 1's BUN/Cr ratio (BUN divided by creatinine) was 26.3. [A BUN/Cr ratio of 20 to 24 is an indicator for impending dehydration and a BUN/Cr ratio of 25 and above is an indicator for dehydration ("Ranges of Laboratory Test Results for Determining Hydration Status," American Journal of Nursing June 2006, Vol. 106 No. 6 Pages 40-49)]. BUN and Cr are waste products in the blood filtered by the kidneys and removed in the urine. The decrease blood flow to the kidneys due to reduced blood volume would affect the filtration process which in turn causes the accumulation of waste products such as BUN and Cr leading to acute renal failure, sepsis, decreased cardiac output [heart failure-cardiac arrest (AJN diagnostic clinical indicators and laboratory values May 1999- Vol. 99-Issue 5 Pages 66-69,71,73,75). Delayed treatment or delayed hydration may lead to acute renal failure a sudden decrease in kidney function that can lead to irreversible tubular necrosis (premature death or damage to the kidney cells). American Journal of Nursing May 1999 Vol. 99- issue 5 Pages 66-69.3. An increased white blood cell count (WBC) of 18.7 (reference range 3.6-5.1 mg/dL). An increased WBC may be an indicator for infection. According to GACH 2's Physician's Progress Notes and the Discharge Summary Notes dated June 23, 2014, Resident 1 died on that date, the fifth day of hospitalization. The causes of death were cardiac arrest (heart failure), severe sepsis (infection), meningitis (brain infection), neuroleptic malignant syndrome (a condition where the body cannot regulate itself), and multiple organ failure (a life threatening condition when more than one body organ stops functioning). Based on the foregoing, the facility failed to ensure Resident 1 was provided sufficient fluids to prevent dehydration, including but not limited to failures to: 1. Ensure that Resident 1, who was admitted to the facility with diagnoses of urinary tract infection (UTI), dysphagia (swallowing difficulties) and dehydration, was provided and consumed 2010 cubic centimeters (cc) of fluid as indicated in the nutritional assessment.2. Ensure that the licensed nursing staff followed monitored Resident 1's hydration status by means of accurate and continuous intake and output (I&O) records, and prompt communication between nursing staff, as indicated in the facility's policy and procedures for the prevention of dehydration.3. Promptly notify the physician when Resident 1's 24-hour fluid intake was not met for several days, and inquire of further medical interventions as necessary to prevent dehydration. These deficient practices resulted in Resident 1's hospitalization on June 18, 2014, at 2: 35 p.m., nine days after being admitted from GACH 1. Resident 1 became unresponsive and was transferred via paramedics to GACH 2. She was diagnosed with hypovolemia, dehydration, fecal impaction, and kidney failure. Resident 1 died on June 23, 2014, five days after she was transferred to GACH 2.This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of Resident 1. |
| 920000087 |
MAGNOLIA GARDENS CONVALESCENT HOSPITAL |
920011270 |
AA |
09-Apr-15 |
X5RS11 |
15827 |
CFR 483.10(b)(11)(i)(B). (11) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is ?(B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); CFR 483.20(k)(3) Comprehensive Care Plans: The services provided or arranged by the facility must ? (i) Meet professional standards of quality; and (ii) Be provided by qualified persons in accordance with each resident?s written plan of care. 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(k) Special NeedsThe facility must ensure that residents receive proper treatment and care for the following special servicesCFR 483.25(k)(5) Standard: Tracheal Suctioning CFR 483.25(k)(6) Standard: Respiratory Care The Department received a complaint on March 23, 2012, alleging a resident (Resident 1) was extremely congested and struggling to breathe on January 21, 2012, and the facility?s nursing staff were informed but did nothing. Resident 1 went into cardiac arrest and died two hours later.On April 2, 2012 at 2:35 p.m., an unannounced visit was made to the facility to investigate the complaint.The facility?s staff failed to provide the necessary care and services to Resident 1, including but not limited to, failure to: 1. Follow the physician?s orders, including orders to suction the resident every two hours, and administer breathing treatments every four hours and as needed to maintain an open airway in accordance with the plan of care; 2. Notify the physician when the resident was having difficulty breathing, with signs of congestion and restlessness; and 3. Implement the facility policy and procedure for cardiopulmonary resuscitation (CPR) and follow Resident 1?s advance directive for CPR. These failures resulted in Resident 1?s change in condition for over six hours with excessive secretions, difficulty in breathing, and restlessness. She was found unresponsive, pale in color with dilated pupils, and was pronounced dead at 10:08 p.m. on January 21, 2012. A review of Resident 1?s Admission Record indicated the resident was a 77 year- old female, who was admitted to the facility on January 10, 2012. Her diagnoses included a right hip fracture, status-post right hip open reduction internal fixation (a surgical method of repairing a fractured bone, using plates and screws or a rod to stabilize the bone) done on January 5, 2012, leukocytosis (an elevated number of white blood cells), a gastrostomy tube (GT - a feeding tube placed directly through the skin to the stomach when a resident cannot eat or swallow safely) and Clostridium Difficile (C-diff - bacteria that cause symptoms ranging from diarrhea to life-threatening inflammation of the colon). There was an ?Advance Directive Acknowledgment? form dated and signed January 19, 2012, by the resident?s agent for health care decisions, physician, and social service designee, for a preferred intensity of care. The form indicated the resident wanted to have CPR, intravenous fluids, hospitalization, tube feeding, and no restriction of any medications or treatments. A review of a License Nurse Record dated January 10, 2012, and timed at 6 p.m., indicated upon admission the resident was non-verbal, had an indwelling urinary catheter (a flexible plastic tube used to drain urine from the bladder), was incontinent (unable to control) of bowel, was receiving feedings via a GT, and receiving antibiotics for C-diff for seven days. The breathing section documentation indicated the resident had no secretions, did not require suctioning and had a pulse oximetry (non-invasive method for monitoring oxygen in the blood) applied that read 96 percent (%) on room air (normal value is greater than 96%). According to the ?Record? the resident was placed in isolation (private room) for C-diff precautions. The Physician?s Order dated January 10, 2012, indicated the nursing staff should suction the resident?s mouth every two hours and as needed with a Yankauer (a bulb tip with a large tube for maximum suction without damaging surrounding tissues) due to the pooling of secretions at the back of the resident?s mouth, and give Robitussin DM liquid (cough syrup) five milliliter (ml) via GT every six hours as needed (PRN) for coughing. Another physician?s order dated January 12, 2012, indicated the staff should administer the breathing treatments of Albuterol/Atrovent (bronchodilator that relaxes muscles in the airways and increases air flow to the lungs) every four hours as needed (PRN) for shortness of breath. On January 14, 2012, the physician ordered oxygen at two liters per minute by nasal cannula (N/C) as needed for labored breathing and to monitor the resident?s oxygen saturation every shift. A review of the Medication Administration Record (MAR) for the month of January 2012, indicated Robitussin was not administered to the resident from January 10, 2012, through January 21, 2012. The Atrovent/Albuterol breathing treatments were administered only once on January 14, 2012, since admission January 10 through 21, 2012.There was no record of oxygen administration or oxygen saturation readings every shift as prescribed by the physician to assess the resident?s breathing status. A review of the nurse?s notes indicated the resident?s oxygen saturation was not recorded on the following days: January 12, 13, 15, 16, 17, and 21, 2012, as directed in the physician?s orders to be done every shift. On January 14, 2012, according to the Licensed Nurse Record, Resident 1?s oxygen saturation was 98%. However, it was recorded as 89% on the Multidisciplinary Progress Record. The physician was notified and a chest x-ray was ordered on January 14, 2012. The results of the chest x-ray indicated the resident had slight right lower lobe atelectasis (a collapse of lung tissue affecting part or all of one lung. This condition prevents normal oxygen absorption to healthy tissues), but no infiltration (a density in the lungs that is not normal and usually refers to a focus of infection).The resident?s lung sounds changed from being clear to having rales and crackles (can be associated with severe airway obstruction). On January 18, 2012, the resident?s oxygen saturation dropped again to 94%.A review of a plan of care, dated January 11, 2012, indicated the staff would provide medication and breathing treatments as ordered and notify the physician of signs and symptoms of congestion, shortness of breath, and labored breathing. There was no documented evidence the resident?s physician was notified of the resident?s change of conditions on January 21, 2012, when the resident was having difficulty breathing. A review of the facility's undated policy titled, ?Oral-Nasal Suctioning? indicated when a resident cannot voluntarily expectorate (to cough up and spit out) to prevent aspiration of secretions, the resident should be suctioned from the mouth.On April 2, 2012, at 2: 30 p.m., during an interview, the director of nurses (DON) stated she remembered Resident 1 very well, because she admitted the resident on January 10, 2012. The DON stated on admission the resident had a productive cough, so cough medication and breathing treatments were ordered. However, a review of a Licensed Nurse Record, with an assessment done upon admission, dated January 10, 2012, indicated the resident?s lung sounds were clear and had no secretions, and did not require suctioning.On April 2, 2012, at 3:10 p.m., during an interview, licensed vocational nurse 1 (LVN 1) stated that Resident 1 was awake, alert, and non-verbal, but responded to tactile (touching) stimuli, upon admission. LVN 1 stated there was pooling of secretions at the back of the resident?s mouth, which required suctioning every two hours or more. LVN 1 indicated the resident was congested and required breathing treatments and cough medicines frequently. She stated the certified nursing assistant (CNA 1) called her into the resident?s room on January 21, 2012, at 9:45 p.m., to check the resident because she looked pale. LVN 1 stated she found the resident unresponsive and attempted to check her vital signs, but there was no pulse (heartbeat) or blood pressure (the pumping action of the heart). LVN 1 stated she called the registered nurse supervisor (RN 1) into the room and RN 1 re-assessed the resident at 9:47 p.m., but there was no pulse.When LVN 1 was asked about CPR being performed, she stated neither she nor RN 1 suctioned the resident. LVN 1 stated, ?We did something, but I cannot remember if we gave her oxygen or did CPR.?LVN 1 could not provide written documentation of CPR being performed on Resident 1 upon the initial assessment by LVN 1 or RN 1, or while waiting for the paramedics to arrive. On April 2, 2012, at 4 p.m., during a telephone interview, RN 1 stated that sometime after 7 p.m., on January 21, 2012, CNA 1 reported to LVN 1 that Resident 1 ?was gone.? LVN 1 went into the room and observed that the resident was cyanotic (bluish discoloration of the skin and mucous membranes due to not enough oxygen in the blood) and cool to touch. LVN 1 called a Code Blue (a medical emergency in which a team of medical personnel work to revive an individual whose heart has stopped) and all the staff rushed into the room. LVN 1 checked the resident?s vital signs, but the resident had no pulse or blood pressure. RN 1 stated she was not sure if the resident was a Full Code (to be resuscitated in the event of a cardiac or respiratory arrest) or not at the time of the incident. She stated, ?I started light chest compression without opening the resident?s airway by using two fingers to compress the resident?s chest while the resident was in bed.? [According to the American Heart Association (AHA), a two-hand procedure should be used to press hard on the resident?s center chest, by placing the heel of one hand over the center of the chest and place the other hand on top and interlace your fingers]. When RN 1 was questioned about the accurate procedure to perform chest compression she stated, ?Cardiac compression can be done in two ways either by using a cardiac board or placing the resident on the floor.? However, according to RN 1, she did not use either method, or follow the AHA CPR guidelines. RN 1 stated she did not use an Ambu Bag (a resuscitator bag used to maintain ventilation) on the resident. She stated she did not suction the resident in an attempt to open the resident?s airway, or turn the oxygen on. On August 6, 2012, at 6:10 p.m., during an interview, CNA 2 stated that on January 21, 2012, the resident was having difficulty breathing and became very restless. CNA 2 stated LVN 1 suctioned the resident at 3 p.m., but the resident was very agitated and did not want to lie down in bed, because she could not breathe while in a lying position. CNA 2 stated the resident wanted to either sit up or stand up (orthopneic - a body position that enables a person to breathe easier). According to the National Institutes of Health (NIH), acute upper airway obstruction is a blockage of the airway, which can be in the trachea (a tube that connects the nose and mouth to the lungs), laryngeal (voice box), pharyngeal (throat) areas, which can be caused by foreign bodies; and common symptoms to all types of airway blockage include agitation or fidgeting, difficulty breathing, gasping for air, and cyanosis (a bluish color to the skin). According to the American Heart Association (AHA), 2005 edition, Adult Basic Life Support, CPR is an emergency medical procedure for cardiac arrest; consisting of artificial blood circulation and artificial respiration (chest compression and lung ventilation). AHA indicates CPR must be started at once when a person is in cardiac arrest and placed on a hard, flat surface.A review of a Multidisciplinary Progress Record, dated January 21, 2012, and timed at 8 p.m., indicated the resident?s family was at the bedside and the resident had no shortness of breath or distress noted. The note also indicated the resident was suctioned. However, on February 10, 2012, at 10:20 a.m., during a telephone interview and a review of a written declaration, the resident?s family care giver, stated she did visit the resident the evening of January 21, 2012. She stated once she arrived at the facility she found the resident in bed without pajamas and had to clean her up and put pajamas on the resident. She stated the resident had a lot of secretions around her eyes and mouth and she cleaned those areas. She stated the resident had a hard time breathing with fast labored breaths. She stated she notified the nurses and they stated the resident receives breathing treatments and they would come in and check on her, but they did not come, so she went to remind them. She stated they promised theywould go and check on her while she left the facility. The family care giver stated she left the facility after being reassured they would check on the resident and as soon as she got home, within two hours, the facility called her and stated the resident had a cardiac arrest and died. A review of the facility's undated policy titled ?CPR? indicated the staff would provide life support to an individual who needs to be resuscitated. The policy also indicated once CPR is initiated, it shall be continued until effective circulation and breathing are restored in the resident and or if the resident is transferred to the care of emergency medical services. A review of Resident 1?s Advance Directive dated and signed January 19, 2012, indicated CPR was selected as a preferred intensity of care authorized by the resident. A review of the Multidisciplinary Progress Record, dated January 21, 2012, and timed at 9:45 p.m., indicated the resident had no pulse or blood pressure. According to the Licensed Nurse Note dated January 21, 2012, at 9:55 p.m., RN 1 called 911, and at 10 p.m., the paramedics arrived and pronounced the resident dead at 10:08 p.m.According to the Multidisciplinary Progress Record, dated January 21, 2012, the paramedics arrived at 10 p.m., and at 10:08 p.m., they pronounced the resident dead. At 10:18 p.m., the family was notified of the resident?s death. At 10:29 p.m., two police officers arrived at the facility and the physician was notified of the resident?s death.The facility?s staff failed to provide the necessary care and services to Resident 1, including but not limited to, failure to: 1. Follow the physician?s orders, including orders to suction the resident every two hours, and administer breathing treatments every four hours and as needed to maintain an open airway in accordance with the plan of care; 2. Notify the physician when the resident was having difficulty breathing, with signs of congestion and restlessness; and 3. Implement the facility policy and procedure for cardiopulmonary resuscitation (CPR) and follow Resident 1?s advance directive for CPR. The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of death of Resident 1. |
| 920000009 |
MACLAY HEALTHCARE CENTER |
920011517 |
A |
21-Oct-16 |
WS6F11 |
12828 |
F309 42 CFR ?483.25 Quality of Care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. F323 42 CFR? 483.25 (h) ACCIDENTS The facility must ensure that ? (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide the necessary care and services to ensure Resident 1's environment was free of accident hazards, including but not limited to, failure to: 1. Provide adequate supervision and assistance devices to prevent recurrent falls and injuries, in accordance with Resident 1?s plan of care; and 2. Ensure the interdisciplinary team (IDT) members evaluated, monitored and revised Resident 1's individualized plan of care as necessary to prevent injury as indicated in the policies and procedures. As a result, Resident 1, who was assessed to be at high risk for falls, with a history of falls, and was receiving psychoactive medications (any chemical substance that changes brain function and results in alterations in perception, mood, or consciousness), fell and sustained a fractured femoral neck (top end of the leg) of the left hip that required surgical repair under general anesthesia, experienced unnecessary pain, and required several days of hospitalization. On March 7, 2014, the Department received an entity reported incident (ERI 390420) regarding a resident who jumped from her wheelchair and fell to the ground sustaining an acute femoral neck fracture. According to the Admission Record, Resident 1 was admitted to the facility on October 29, 2013, and readmitted on February 3, 2014, with the admission diagnoses that included pathological fracture of the vertebrae (spine), muscle weakness, diabetes (high blood sugar), leukocytosis (a condition characterized by an elevated number of white cells in the blood), abdominal pain, and high blood pressure. The initial Fall Risk Evaluation dated October 29, 2013, indicated Resident 1 had a score of 20 (10 or higher is at risk). The Fall Risk Assessment dated February 3, 2014, indicated the resident had a score of 25 with a history of 3 or more falls. The Bowel and Bladder (B/B) Assessment upon admission dated October 29, 2013, indicated Resident 1 was alert and oriented times 3, used a walker (assistive device), was continent prior to admission, and was on antipsychotic and antidepressant medication. The Three Day Assessment was not completed. There was no further assessment of the resident's bowel and bladder function. The Minimum Data Set (MDS), an assessment and screening tool, dated November 22, 2013, indicated Resident 1 was able to make herself understood and understands others; required extensive assistance with transfer and ambulation with one person physical assist; was not steady but able to stabilize with staff assistance in balance during transition (from sit to stand) and walking; was continent of both bowel and bladder; was prescribed antipsychotic medication; and had two fall incidents with no injury. Resident 1 had a care plan for at risk for falls dated October 30, 2013. Interventions included to assess degree of orientation, vision, safety awareness, mobility, and B/B status to determine safety needs; frequent (frequency not indicated) visual checks; and review of medications and side effects that cause falls/dizziness and report to the physician. The MDS Care Area Assessment (CAA) dated December 2, 2013, indicated falls was a concern area requiring further intervention due to Resident 1?s balance problem during transferring, mobility, and ambulation; had a recent fall incident secondary to impaired cognitive and physical functioning; and was at risk for further falls secondary to diagnosis of dementia (loss of memory), psychosis (mental disorder), difficulty walking, nerve pain, and received antipsychotic medication. On February 3, 2014, Resident 1 had physician orders as follows: 1. Seroquel 50 milligrams (mg) daily. [Seroquel is an antipsychotic medication used to treat mental disorders, with an adverse reaction including dizziness sleepiness or drowsiness)]. 2. Depakote 250 mg by mouth two times a day. (Depakote is an anticonvulsant medication with the side effects of drowsiness and dizziness). On February 27, 2015 at 2:30 p.m., a review of the Nurse?s Notes with the Director of Nurses (DON 1) revealed the following: On November 21, 2013 (3 p.m. to 11 p.m. shift), Resident 1 had a fall with no injury. There was no documentation in the nurses' notes on how the resident fell, as reviewed with DON 1. On November 22, 2013 (3 p.m. to 11 p.m. shift), Resident 1 was found sitting on the floor. According to the resident, she was trying to go to her bedside commode when she slid to the floor. The approaches/plans were: review of medications and side effects that causes falls/dizziness and report to the physician if noted, frequent visual checks, rehab evaluation after incidents of falls as ordered, remove bedside commode, but the resident refused, instruct resident not to use bedside commode without calling for assistance, and apply a pad alarm to the bed. On November 26, 2013, at 1:30 p.m., Resident 1 was found on her side in a lying position near her commode and bed. The resident stated she slid to the floor. The approach/plan was to remove the bedside commode. On December 7, 2013, noted at 2:30 p.m., at 9:30 a.m., CNA (certified nursing assistant) reported Resident 1 was found in the room in a kneeling position between the foot of her bed and the restroom. The resident was ?anxious?, cried and stated, ?I just want to go to the bathroom for bowel movement, but nobody came to help me.? On February 4, 2014, at 7:50 a.m., Resident 1 was found on the floor as she was trying to go to the bathroom by herself and she slipped. On February 7, 2014, (no time indicated) Resident 1 was up in a wheelchair with episode of bending forward or standing up and wanting to walk. At 7:15 p.m., staff heard a scream inside the room and found the resident on the floor near the landing pad on her right side. The resident was noted with superficial skin laceration on her right eyebrow measuring 1 centimeter in length with minimal bleeding. The resident was transferred to the general acute care hospital (GACH) because of the fall with skin tear on the right eyebrow. On February 7, 2014, Resident 1 had a physician's order for Seroquel 50 mg by mouth at night (used for behaviors of agitation/anxiety) and for a ?wheelchair and bed alarm? to alert staff when the resident attempted an unassisted transfer. There was no indication as to what type of alarm was to be applied. On February 12, 2014, at 7:50 a.m., the CNA stated she saw Resident 1 crawling from the floor back to bed. No bleeding or swelling noted. At 12:30 p.m., the resident was up in a wheelchair in the dining room to eat meals, observed with episode of confusion and forgetfulness. At 5 p.m., the resident was in bed complaining of severe pain to the left hip. The physician was called and ordered an immediate X-ray of both hips. On February 13, 2014, at 8 a.m., the physician was paged to inform of the X-ray results of acute left femoral neck (hip) fracture. The physician returned the call and ordered Resident 1 to be transferred to the GACH, where she had surgical repair of the left hip fracture. A review of the literature indicated the post-operative risk and complications associated with a surgery under general anesthesia included bleeding, infection, heart attack, pneumonia, kidney failure (during or after an operation), deep venous thrombosis (DVT - occurs when blood clots from in the large veins of the leg. If the blood clots in the veins break apart, they travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung, called a pulmonary embolism) [Save, Richard H., "Postoperative Care." Hospital Medicine, 2nd Edition, Philadelphia: Lippincott, Williams, & Wilkins, 2005, 261-269). On February 27, 2015, in an interview with DON 1 while reviewing Resident 1?s clinical record, she was not able to locate documentation in the nursing notes of Resident 1?s fall from her wheelchair on February 12, 2014. She could not provide documentation that the pad alarm that was supposed to be applied while in bed was consistently applied as care planned on November 22, 2013. DON 1 was unable to provide documented evidence the IDT met after each of Resident 1?s falls to evaluate the reason for the falls and to revise the care plan in accordance with the facility?s policy and procedure. Nor was there evidence documented that the Licensed Nurse completed an evaluation of the resident and the environment in which the accident or incident occurred as indicated in the facility?s policies and procedures. A review of the CNA - ADL Tracking Form from November 2013 through February 2014, indicated Resident 1 had periods of incontinence. Resident 1?s falls reviewed from November 2013 to February 2014 indicated that she fell while attempting to get to her commode or bathroom. There was no documentation that her bowel and bladder (B/B) status was reassessed to determine safety needs, including to monitor her voiding pattern to develop set time intervals to be toileted, in accordance with Resident 1?s care plan. This was confirmed with DON 2 on March 31, 2014, and with DON 1 on February 27, 2015. A review of the literature indicates "Falls frequently occur when residents get out of bed and go to the bathroom, walk to or from the bathroom, or experience an episode of incontinence. Frequent "structured" nursing rounds in which the nursing staff would perform specific tasks at set intervals could help reduce the incidence of falls. Studies have demonstrated the benefits of having structured frequent rounds and performing specific nursing actions, such as asking whether the resident needed anything and assisting with toileting at set intervals was associated with statistically significant reductions in the incidence of falls, and with an increase in resident satisfaction (Safe and Reliable Care, American Journal of Nursing, July 2009, Volume 109 No. 7, Pages 70-71). A review of the facility?s ?Fall Prevention and Management Program? policy revised May 2008, and the ?Fall Prevention and Incident Management? policy revised October 2014, indicated the policy is all residents? environment shall remain as free of accident hazards as is possible and all residents shall receive adequate supervision and assistive devices to prevent accidents. The definition of an incident is an incident/occurrence involving a resident with unintended, undesirable and/or unexpected results or outcomes. The above policies indicated the Interdisciplinary Team (IDT- a team of health professionals), based on the identified potential risk factors, develops and implements an individualized plan of care as necessary; the IDT evaluates, monitors and revises the individualized plan of care as necessary; the Licensed Nurse documents a factual account of the events in the Interdisciplinary Progress Note or electronic documentation equivalent; the Licensed Nurse completes an evaluation of the resident and the environment in which the accident or incident occurred; and the IDT conducts an evaluation of each incident/accident and implements appropriate interventions to protect the resident(s) and prevent recurrence. The facility failed to provide the necessary care and services to ensure Resident 1's environment was free of accident hazards, including but not limited to, failure to: 1. Provide adequate supervision and assistance devices to prevent recurrent falls and injuries, in accordance with Resident 1?s plan of care; and 2. Ensure the interdisciplinary team members evaluated, monitored and revised Resident 1's individualized plan of care as necessary to prevent injury as indicated in the policies and procedures. As a result, Resident 1, who was assessed to be at high risk for falls, with a history of falls, and was receiving psychoactive medications fell and sustained a fractured femoral neck (top end of the leg) of the left hip that required surgical repair under general anesthesia, experienced unnecessary pain, and required several days of hospitalization. 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 to Resident 1. |
| 920000007 |
MOUNTAIN VIEW CONVALESCENT HOSPITAL |
920011837 |
B |
12-Nov-15 |
BGZF11 |
20302 |
F425 42 CFR ?483.60 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in ?483.75(h) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.F428 42 CFR ?483.60(c) Drug Regimen Review (1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. (2) The pharmacist must report any irregularities to the attending physician, and the director of nursing, and these reports must be acted upon. F514 42 CFR ?483.75(l) Clinical Records (1) The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are-- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized. On July 17, 2015, the Department received a Complaint (CA00450948) that alleged Resident 1 was started on blood thinner medication without monitoring the adverse effects of the medication that resulted in high laboratory results. On July 30, 2015, at 4:00 p.m., an unannounced visit was made to the facility to investigate the complaint concerning high laboratory values of a resident. Based on interviews and record review, the facility failed to: 1. Accurately document and to maintain an accurate record related to the administration of the Warfarin [Coumadin- high-alert medication] to one of four sample residents (1). Licensed Nurse 1 made duplicate entries to Resident 1?s medication administration record (MAR) from July 3, 2015 to July 6, 2015.2. Accurately document on the Emergency Kit (E-Kit) Pharmacy Log and on the Medication Administration Record (MAR) when Licensed Nurse 2 administered to Resident 1 a high-alert medication Warfarin (Coumadin) 4 mg removed from the Emergency Kit on June 29, 2015.3. Accurately document the use of the high-alert medication Coumadin 1 mg. Licensed Nurse 3 made two entries in the E-Kit Pharmacy Log but only one entry in Resident 1?s Medication MAR and no billing record on June 29, 2015.4. Accurately document the source of the high-alert medication Coumadin 5 mg on June 30, 2015 and July 4, 2015. 5. Ensure the licensed nursing staff timely submitted a request and acquired the medication (Coumadin 5 mg) timely from the pharmacy ordered by a physician.6. Use a Warfarin (Coumadin) flowsheet or comparable monitoring tool, to follow the trend in anticoagulant [medication] dosage and response as required its policy and procedures. 7. Ensure to have policy and procedures on the frequency medication regimen reviews (MRR) for residents with a short-stay (less than 30 days) in the facility. According to the admission record, Resident 1 was admitted to the facility on June 24, 2015. The history and physical examination record indicated the resident was an 82 year-old who had a fall at home that resulted in a fractured leg, and was admitted to a general acute care hospital (GACH) emergency department (ER) before admission to the facility. The diagnosis history indicated Resident 1 had atrial fibrillation (abnormal irregular heart beat), and was on Coumadin (Warfarin - a blood thinning medication given for the prevention of blood clots). A review of Resident 1?s medication administration record (MAR), from July 3, 2015 to July 6, 2015, indicated Licensed Nurses 1, 2, and 3 made duplicate entries related to the administration of Coumadin that included the drug name, strength, date, time, nurses? initials, and notations of emergency use on two separate pages of Resident 1?s MAR over a four day period.On August 28, 2015, at 11:30 a.m. during an interview, Pharmacist 1 stated that the Coumadin record in Resident 1?s MAR ?is confusing?, commenting on the double entries and E-Kit (emergency kit) notations written on the MAR on July 3, 2015, July 4, 2015, July 5, 2015 and July 6, 2015. Pharmacist 1 stated that the only true way to know what was administered to Resident 1 was to see the medication card (drugs placed in ?bubble packs? by day of month and time) and, by now, the medication card could not be retrieved. On August 28, 2015, at 12:40 p.m., during an interview, Licensed Nurse 1 reviewed Resident 1?s MAR, saw the duplicate order entries, and verified the handwriting as her own initials on the duplicate entries on July 5, 2015, at 5 p.m., along with the duplicate notations ?E-Kit.? Licensed Nurse 1 could not answer why she wrote two entries on the MAR for Coumadin, nor could she explain why the duplicate entries continued until the next day. Licensed Nurse 1 further stated the note, ?Duplicate?see other page,? recorded on MAR was not her handwriting.On August 28, 2015, at 3:18 p.m., during an interview Licensed Nurse 2 reviewed Resident 1?s MAR, saw the duplicate order entries, verified the handwriting as her own initials on the duplicate entries on July 4, 2015, at 5 p.m. Licensed Nurse 2 stated, on July 4, 2015, it is not noted that the medication was taken from the E-Kit, when it should have been from the bubble pack. Licensed Nurse 2 stated that initials are written after medication is administered to the resident. She gave all the medications to the patient, then, signed the MAR. During an interview, on August 31, 2015, at 4:30 p.m., Licensed Nurse 3 reviewed Resident 1?s MAR, saw the duplicate order entries on start dates of July 2, 2015 and July 3, 2015, verified the handwriting as her own initials on the duplicate entries on July 3, 2015, along with the duplicate notations ?E-Kit,? and her own initials on the duplicate entries on July 6, 2015, at 5 p.m. Regarding the July 2, 2015, entry on Physician Order Sheet and July 3, 2015, continue order, Licensed Nurse 3 stated that the nurse supervisor asked her to transcribe the order to the MAR. Licensed Nurse 3 stated, ?Sometimes we forget to D/C (discontinue) it on the MAR?it was a duplicate entry, but, ?No one caught it? [the error]. During an interview, on August 31, 2015, at 5:05 p.m., the Director of Nursing (DON) was asked about the duplicate entries on Resident 1?s MAR, and saw the duplicate order entries made on July 2, 2015, and July 3, 2015. The DON stated, ?July 2, 2015, was an original order and July 3, 2015, is a duplicate;? The DON stated the July 2, 2015, entry should have been crossed out or the July 2, 2015, entry should have continued and the July 3, 2015, entry should not have been entered. Normally, the nurse would fax the order to pharmacy. If 5 p.m. dose is not available then nurse would call pharmacy to get it from E-Kit. If the duplicate was caught early, the duplicate initials would not be there. A new training will be implemented. A review of the facility?s policy and procedure, ?Medication Ordering and Receiving From Pharmacy, Emergency Pharmacy Services and Emergency Kits?, dated August 2014, indicated, ?Use of the emergency medication is noted on the resident?s medication administration record (MAR).? A review of the Physician and Telephone Orders for Resident 1, dated June 24, 2015, at 7:40 p.m., indicated Physician 1 ordered Coumadin 2 mg, one dose by mouth stat (immediately). During an interview, on August 28, 2015, at 5:10 p.m., Pharmacist 2 stated that Resident 1 was admitted on June 24, 2015, received a stat dose of Coumadin 2 mg, from the E-Kit billing only and the pharmacy did not deliver Coumadin to the facility.A review of the Physician and Telephone Orders for Resident 1, dated June 26, 2015, at 11 a.m., indicated Physician 1 ordered Coumadin 4 mg, one tablet by mouth daily at 5 p.m., for DVT prophylaxis (deep vein thrombosis, or blood clot prevention) for 3 days.A review of either the facility?s or pharmacy?s ?Emergency Kit Pharmacy Log? did not show an entry for Resident 1, on June 26, 2015, for any combination of Coumadin that totaled 4 mg. On August 31, 2015, from 3:10 p.m. to 4:10 p.m., inspection of the E-Kits, on Stations 1, 2 and 3, indicated that each kit contained ten Coumadin 1 mg tablets, ten Coumadin 3 mg tablets, and ten Coumadin 5 mg tablets supplied by the pharmacy.The source of the first dose of Coumadin 4 mg tablet, administered to Resident 1 on June 26, 2015, at 5 p.m., was not documented on the E-Kit Pharmacy Log or in the MAR, since the tablets were not delivered to the facility until June 26, 2015, at 11:30 p.m. During an interview, on August 28, 2015, at 5:10 p.m., Pharmacist 2 stated that, on June 26, 2015, the pharmacy sent three Coumadin 4 mg tablets.A review of Resident 1?s pharmacy?s dispensing record and billing records for Resident 1 indicated that the pharmacy sent, and the facility received, three Coumadin 4 mg tablets to be administered on June 26, 2015, June 27, 2015, and June 28, 2015. A review of the pharmacy?s Consolidated Delivery Sheets for Resident 1, dated June 26, 2015 at 7:54 p.m., indicated that the facility received three tablets of Warfarin (Coumadin) 4 mg tablets on June 26, 2015, at 11:30 p.m. However, a review of Resident 1?s MAR, indicated on June 29, 2015, at 5 p.m., Licensed Nurse 3 administered and initialed a fourth box for Coumadin ?4 mg? tablet, the fourth tablet in a four day period.Therefore, the source of the first dose of Coumadin 4 mg, on June 26, 2015, at 5 p.m., is unknown since the pharmacy delivery was made at 11:30 p.m. A review of the Physician and Telephone Orders, dated June 29, 2015, at 5 p.m., indicated Physician 1 changed the order from Coumadin 4 mg to Coumadin 5 mg, one tablet by mouth daily.A review of the MAR Nurse?s Notes for Resident 1, dated June 29, 2015, at 5 p.m., indicated that Nurse 3 wrote, ?Coumadin 1 mg?given 4 mg from bubble pack and took 1 mg from the E-Kit to give a total dose of 5 mg.? A review of Resident 1?s MAR, on June 29, 2015, at 5 p.m., indicated that Licensed Nurse 3 administered and initialed the fourth box for Coumadin ?4 mg? tablet, the fourth tablet in a four day period.A review of Resident 1?s MAR, on June 29, 2015, at 5 p.m., indicated that Licensed Nurse 3, on the Coumadin 5 mg line, initialed the box with the notation ?E-kit (1 mg)?, indicating that a Warfarin (Coumadin) 1 mg tablet was used from the E-Kit. A review for the facility?s Emergency Kit (E-Kit) Pharmacy Log Sheet indicated the removal of, ?Warfarin (Coumadin) 1 mg tablet, June 29, 2015, at 5 p.m.? with the note, ?4 mg available on cart,? initialed by Nurse 3. The facility?s second E-Kit Pharmacy Log Sheet indicated another entry, ?Warfarin (Coumadin) 1 mg tablet, June 29, 2015, at 5 p.m.?, indicating the removal of a second dose from the E-Kit, initialed by Nurse 3. A review for the pharmacy?s copy of the facility?s E-Kit Pharmacy Log Sheet indicated the information, ?Warfarin (Coumadin) 1 mg tablet, June 29, 2015 at 5 p.m.?, initialed by Nurse 3, and an E-Kit replacement label affixed to it. However, the pharmacy did not provide a copy of the second facility E-Kit log sheet. A review of the pharmacy?s dispensing record for Resident 1 indicated no record for either one or two Coumadin 1 mg tablets, taken from E-Kit on June 29, 2015, at 5 p.m. During an interview, on August 28, 2015, at 5:10 p.m., Pharmacist 2 stated that she was unaware of the Coumadin 1 mg dose taken from the E-Kit on June 29, 2015 at 5 p.m.During an interview, on September 1, 2015, at 5:25 p.m., Pharmacist 2 stated there was no billing for Coumadin 1 mg tablets removed from E-Kit on June 29, 2015, for Resident 1. During an interview, on September 3, 2015, at 1:20 p.m., the DON stated the facility did not have policies and procedures on documentation in the MAR and documentation for E-Kits. The record review indicated that two separate E-Kit Pharmacy Log sheets from the same E-Kit Station 3 each had an entry for one Coumadin 1 mg tablet, dated June 29, 2015, at 5 p.m., suggesting that two 1 mg tablets were potentially administered with one 4 mg tablet, for a total of 6 mg instead of 5 mg. There are conflicts in the documentation on the dosage of Coumadin administered to Resident 1. A review of the facility?s policy and procedure, ?Medication Ordering and Receiving From Pharmacy, Emergency Pharmacy Services and Emergency Kits,? dated August 2014, indicated, ?Use of the emergency medication is noted on the resident?s medication administration record (MAR).? A review of the Physician and Telephone Orders, dated June 29, 2015, at 5 p.m., indicated Physician 1 ordered Coumadin 5 mg, one tablet by mouth daily.A review of the facility?s Emergency Kit (E-Kit) Pharmacy Log Sheets, dated July 1, 2015, at 5 p.m., July 2, 2015, at 5 p.m., and July 3, 2015, at 5 p.m., that indicated the removal of one tablet of Coumadin 5 mg each with Licensed Nurse 3?s initials; dated July 5, 2015, at 5 p.m., that indicated the removal of one tablet of Coumadin 5 mg with Licensed Nurse 1?s initials; and a missing sheet for July 6, 2015. However, a review of the pharmacy?s copies of the facility?s E-Kit Pharmacy Log Sheets, indicated missing sheets for July 1, 2015, and July 3, 2015; the identical sheets dated July 2, 2015 and July 5, 2015; and an additional sheet dated July 6, 2015, at 5 p.m. that indicated the removal of one tablet of Coumadin 5 mg with Nurse 3?s initials. A review of all E-Kit Pharmacy Log Sheets indicated no records of E-Kit use for Coumadin 5 mg on June 30, 2015 and July 4, 2015. A review of the pharmacy dispensing reports did not indicate charges for the E-Kit medications taken on June 30, 2015, July 1, 2015, July 3, 2015, and July 4, 2015. On July 6, 2015, the pharmacy delivered three Coumadin 5 mg tablets to the facility, the same quantity that the facility released to Resident 1 upon discharge on July 7, 2015. During an interview, on August 28, 2015 at 5:10 p.m., Pharmacist 2 stated that the order for Coumadin 5 mg, dated July 3, 2015, was not sent to the pharmacy until July 5, 2015. Pharmacy filled the order on July 5, 2015, billed four tablets but sent three tablets due to ?minus one from E-Kit?. The July 5, 2015, tablets were meant for administration on July 5, 2015, July 6, 2015 and July 7, 2015. A review of the pharmacy?s ?Consolidated Delivery Sheets,? dated July 6, 2015, at 11:27 a.m., indicated a quantity of four Warfarin (Coumadin) 5 mg tablets, delivered by ?Mike? at 5:40 p.m., and received and signed by Nurse 3 on July 6, 2015. A review of the pharmacy label, allegedly attached to the medication card, had ?Fill Date: July 5, 2015, ?Qty (quantity) 4 tabs (tablets),? and ?(-1E-KIT)? (minus one from E-Kit)? During an interview on August 28, 2015, at 5:20 p.m., Pharmacist 2 stated that Resident 1 would have had two Coumadin 5 mg tablets leftover upon discharge on July 7, 2015. A review of Resident 1?s ?Post Discharge Plan of Care,? dated July 7, 2015, indicated the facility released three tablets to Resident 1 upon discharge. A review of the MAR indicated entries for E-Kit use of Coumadin 5 mg on July 3, 2015 and July 5, 2015. A record review of the E-Kit Pharmacy Logs indicated entries for E-Kit use of Coumadin 5 mg on July 3, 2015, July 5, 2015, and July 6, 2015. A review of the facility?s policy and procedure, ?Medication Ordering and Receiving From Pharmacy,? dated April 2008, indicated, ??New medications?are ordered as follows?if needed before the next regular delivery, inform pharmacy of the need for prompt delivery?? During a records request for a Warfarin Flow Sheet or equivalent, on July 31, 2015, at 7:46 a.m., the DON stated, ?it is tracked in the MAR?. A review of the facility?s policy and procedure, ?Anticoagulation ? Clinical Protocol, Monitoring and Follow-Up,? dated October 2010, indicated, ?The staff should use a warfarin [Coumadin] flow sheet or comparable monitoring tool to follow trends in anticoagulant dosage and response.?During an interview on July 31, 2015, at 10:52 a.m. the DON stated that Pharmacist 1 reviewed the residents? records once a month. During an interview, on September 3, 2015, at 1:20 p.m., the DON stated the facility did not have policy and procedures on short-stay residents. A review of the facility?s records, ?Consultant Pharmacist Reports, Medication Regimen Review,? for the period between June 1, 2015, and June 26, 2015, and between July 1, 2015 and July 29, 2015, did not show documentation that Pharmacist 1 reviewed Resident 1?s medication regimen. Resident 1 was admitted on June 24, 2015 and discharged on July 7, 2015. The dates that Pharmacist 1 conducted the other residents? MRRs were documented as June 24, 2015 and June 26, 2015, which overlapped Resident 1?s stay. A review of the facility?s policy and procedure, ?Consultant Pharmacist Reports?Medication Regimen Review (Monthly Report)?, dated April 2008, indicated, ?The consultant pharmacist or off-site pharmacist reviews the medication regimen of each resident at least monthly?a more frequent review may be deemed necessary, e.g., if the medication regimen is thought to contribute to an acute change in status or adverse consequences, or the resident is not expected to stay 30 days.? A review of the facility?s policy and procedure, ?Anticoagulation ?Clinical Protocol?Treatment/Management?, dated October 2010, indicated, ?The staff and physician will identify potential complications in individuals receiving anticoagulation (Warfarin): for example, someone with a fall risk?? A review of Resident 1?s Fall Risk Assessment, dated June 24, 2015, indicated that Resident 1 had a history of falls within the past 3 months and had predisposing diseases of osteoporosis and fractures. According to the drug information database, ?DailyMed?, hosted by the U.S. National Institutes of Health, the drug Warfarin (Coumadin) carries a boxed warning (for a drug that may lead to death or serious injury), ?bleeding risk?can cause major or fatal bleeding?? According to the nationally recognized organization, ?Institute for Safe Medication Practices (ISMP)?, the drug Warfarin (Coumadin) is a high-alert medication. ?High-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients?? The facility failed to implement their policies and procedures by failing to: 1. Accurately document and to maintain an accurate record related to the administration of the Warfarin [Coumadin- high-alert medication] to Resident 1, one of four sample residents. Licensed Nurse 1 made duplicate entries in the medication administration record (MAR) from July 3, 2015 to July 6, 2015.2. Accurately document on the Emergency Kit Pharmacy Log and on the MAR when Licensed Nurse 2 administered to Resident 1 a high-alert medication Warfarin (Coumadin) 4 mg removed from the Emergency Kit on June 29, 2015.3. Accurately document the use of the high-alert medication Coumadin 1 mg. Licensed Nurse 3 made two entries in the Emergency Kit (E-Kit) Pharmacy Log but only one entry in Resident 1?s Medication MAR and no billing record on June 29, 2015. 4. Accurately document the source of the high-alert medication Coumadin 5 mg on June 30, 2015 and July 4, 2015. 5. Ensure the licensed nursing staff timely submitted a request and timely acquired from the pharmacy Coumadin 5 mg ordered by a physician.6. Use a Warfarin (Coumadin) flowsheet or comparable monitoring tool, to follow the trend in anticoagulant [medication] dosage and response as required its policy and procedures. 7. Ensure to have policy and procedures on the frequency medication regimen reviews (MRR) for residents with a short-stay (less than 30 days) in the facility. These violations had a direct relationship to the health, safety, or security of patients. |
| 920000007 |
MOUNTAIN VIEW CONVALESCENT HOSPITAL |
920012006 |
A |
06-May-16 |
2UI511 |
14838 |
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. F-328 CFR 483.25 (k) The facility must ensure that residents receive proper treatment and care for the following special services: (6) Respiratory careOn 3/15/16, at 9:10 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Quality of Care.Based on interview and record review, the facility failed to ensure the resident is provided with the necessary care and services in accordance with the comprehensive assessment and plan of care and that Resident 1, who needed oxygen administration, was at risk of pulmonary aspiration (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach), and had shortness of breath, received the needed care and services, including: 1. Failure to monitor the resident?s oxygen saturation (a measure of the amount of oxygen that is carried in the red blood cells which indicates the oxygenation status. The normal range is 95 -100%) every shift (every eight hours) as ordered by the physician and as stated in the plan of care. The oxygen saturation was not measured for 42 hours. 2. Failure to monitor and document the resident?s vital signs as his deteriorating condition warranted and per facility?s protocol. The vital signs were not checked for 18 hours. 3. Failure to promptly transfer the resident to a general acute care hospital (GACH) when the resident?s condition required urgent medical evaluation and treatment. Given the resident?s condition, the licensed nurses did not timely contact the physician again to obtain an order to transfer via 911, or alternatively, call 911 directly.As a result, Resident 1?s transfer was delayed 1.5 hours from time it was ordered and interventions were delayed. The resident was assessed at GACH 2 Emergency Room (ER) to have an altered mental status, was not verbally responsive, was hypotensive (low blood pressure), tachycardic (rapid heart rate), tachypneic (rapid breathing), and febrile (fever) with altered mental status. The resident was diagnosed to have severe sepsis. A chest x-ray indicated pneumonia (healthcare-associated pneumonia versus aspiration). The resident was admitted to the hospital where he continued to deteriorate, was placed on comfort care and expired on 2/24/16. A review of the clinical record indicated Resident 1 was admitted to the facility on 2/19/16, at 5 p.m., with diagnoses including hypertension (high blood pressure), coronary artery disease (a buildup of cholesterol and other material called plaque on the inner wall of the arteries that supply blood to heart muscle become hardened and narrowed), cerebellar (a large part of the brain) stroke syndrome (a condition in which the circulation to the cerebellum is impaired), hemiplegia (paralysis of one side of the body), and hemiparesis (weakness of one side of the body) following an intracranial hemorrhage. The resident had dysphagia (difficulty swallowing) and had a gastrostomy tube (GT ? tube surgically inserted into the stomach through the abdominal wall) for nutrition, hydration and medication administration.The Nursing Admission and Assessment dated 2/19/16 indicated Resident 1 was awake, alert, verbally responsive, and cooperative. The resident's breath sounds were regular and clear. The physician's orders dated 2/19/16, included GT feeding formula Jevity 1.5 at 75 cubic centimeters (cc) per hours via enteral pump; oral diet with honey thickened liquids; monitor oxygen saturation at every shift; oxygen at two liters per minute (2 L/min) via nasal cannula (a lightweight tube used to deliver supplemental oxygen or airflow to a person in need of respiratory help) as needed for shortness of breath; suction (respiratory track) orally as needed for congestion; Zofran (to treat nausea and vomiting) 4 milligrams (mg) every six hours as needed for nausea/vomiting. All medications were ordered to be given by the GT. On 2/20/16, a plan of care was developed for the resident?s risk for respiratory distress due to diagnoses and the use of oxygen and the interventions included monitoring shortness of breath, irregular respiration, wheezing, crackles, rhonchi (coarse rattling respiratory sounds, usually caused by secretions in bronchial airways), excessive secretions, monitoring oxygen saturation as ordered and as needed (no frequency specified), and monitoring oxygen inhalation as ordered.On 2/20/16, a plan of care developed for the resident?s risk for adverse drug effects and interactions due to receiving nine or more medications and the interventions included monitoring the resident?s vital signs as ordered. On 2/20/16, a plan of care was developed for the resident?s risk for (pulmonary) aspiration (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach) due to dysphagia and GT feeding. The interventions included monitoring for signs and symptoms of aspiration (frequency was not specified). The signs and symptoms of aspiration were not specified.According to the Change of Condition SBAR (Situation, Background, Assessment, and Recommendation) form dated 2/20/16, timed at 2 a.m., Resident 1 vomited, Zofran was given as ordered. The documentation included the resident?s vital signs and the oxygen saturation rate. Physician 1 was notified of Resident 1?s episode of vomiting and ordered to stop the GT feeding. A nursing progress note documentation dated 2/20/16, timed at 3 p.m., indicated Physician 1 came at 11 a.m. The note included the resident?s vital signs but not the oxygen saturation.According to the Change of Condition SBAR form dated 2/21/16, timed at 8:30 p.m., indicated Resident 1's temperature was elevated [99. 8 degrees Fahrenheit (F)] and both right and left lungs were congested. The oxygen saturation was 92 %, the resident was receiving oxygen at 2 L/min., and the remaining vital signs (respiration, pulse and blood pressure) were within normal limits. Physician 1 was notified and ordered x-rays, breathing treatment, and suctioning (pulmonary secretions).There was no documented evidence the resident was monitored for oxygen saturation from 2/20/16, at 2 a.m. to 2/21/16, at 8:30 p.m., a total of 42 hours. Also, there was no documented evidence the resident's vital signs were monitored from 2/20/16, at 3 p.m. to 2/21/16, at 8:30 p.m., a total of 18 hours. According to the Change of Condition SBAR form dated 2/21/16, timed at 9:40 p.m., Resident 1?s respiratory (22 breaths per minute) and heart rate (93 beats per minute) were increasing and at 10:15 p.m., Physician 1 was called and the facility was ordered to transfer Resident 1 via regular transportation (not equipped to handle unstable patients or emergencies) to GACH 1 for evaluation of congestion, shortness of breath, and elevated temperature.According to the nursing progress record (while waiting for the regular transportation/ambulance) at 11 p.m., Resident 1's temperature increased to 100.7 degrees F from 99.8 degrees F; the blood pressure decreased to 127/63 millimeters of mercury (mmHg ? units used to measure the blood pressure) from 146/86 mmHg; the heart rate was 93 beats per minute (same as at 9:40 p.m.); the respiratory rate increased to 24 breaths per minute from 22 breath per minute; the oxygen saturation decreased from 92% to 90%, and oxygen was administered at 15 L/min. According to the nursing progress record at 11:40 p.m., the regular transportation arrived, Resident 1's blood pressure decreased to 88/56 mmHg, the heart rate increased to 111 beats per minute, the respiratory rate was 22 per minute, the temperature was 100.7 degrees F, and the oxygen saturation was between 86% - 89%. The transportation staff indicated they were not able to transfer the resident due to desaturation (low oxygen saturation) and 911 (paramedics) was called. At 11:49 p.m., Resident 1 was transferred to GACH 2 (closest to the facility) via paramedics. The resident was transferred 1.5 hours after Physician 1 ordered the transfer.On 3/15/16, at 11:30 a.m., during an interview, Registered Nurse 1 (RN 1) stated she was not able to provide documented evidence Resident 1 was monitored for oxygen saturation during the dates and times referenced for the 42 hour period. RN 1 stated she was not able to provide the documented evidence Resident 1's vital signs were monitored during the times referenced for the 18 hour period.A review of the facility's guidelines titled, "Pulse Oximetry," revised 10/ 2010, indicated the purpose of assessing oxygen saturation was to monitor arterial blood oxygen saturation and to review the physician's orders. A review of the facility's policy titled, "Acute Condition Changes - Clinical Protocol," revised 12/2012, indicated the nurse shall assess and document/report the vital signs. The policy did not indicate when and how often the resident's vital signs should be monitored. On 3/15/16, at 12:20 p.m. during an interview, the Director of Nursing (DON) stated the nursing staff should have monitored the resident's oxygen saturation rate per the physician?s order and the vital signs every shift for 72 hours from admission. The DON did not provide a policy on monitoring the residents? vital signs every shift for 72 hours from admission.A review of GACH 2 Emergency Room documentation dated 2/22/16 indicated Resident 1 was diagnosed to have severe sepsis, was hypotensive (low blood pressure), tachycardic (rapid heart rate), tachypneic (rapid breathing), and febrile (fever) with altered mental status. A chest x-ray indicated pneumonia (healthcare-associated pneumonia versus aspiration). The resident was admitted to the hospital. The facility failed to ensure the resident is provided with the necessary care and services in accordance with the comprehensive assessment and plan of care and that Resident 1, who needed oxygen administration, was at risk of pulmonary aspiration (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach), and had shortness of breath, received the needed care and services, including: 1. Failure to monitor the resident?s oxygen saturation (a measure of the amount of oxygen that is carried in the red blood cells which indicates the oxygenation status. The normal range is 95 -100%) every shift (every eight hours) as ordered by the physician and as stated in the plan of care. The oxygen saturation was not measured for 42 hours. 2. Failure to monitor and document the resident?s vital signs as his deteriorating condition warranted and per facility?s protocol. The vital signs were not checked for 18 hours. 3. Failure to promptly transfer the resident to a general acute care hospital (GACH) when the resident?s condition required urgent medical evaluation and treatment. Given the resident?s condition, the licensed nurses did not timely contact the physician again to obtain an order to transfer via 911, or alternatively, call 911 directly.As a result, Resident 1?s transfer was delayed 1.5 hours from time it was ordered and interventions were delayed. The resident was assessed at GACH 2 Emergency Room (ER) to have an altered mental status, was not verbally responsive, was hypotensive (low blood pressure), tachycardic (rapid heart rate), tachypneic (rapid breathing), and febrile (fever) with altered mental status. The resident was diagnosed to have severe sepsis. A chest x-ray indicated pneumonia (healthcare-associated pneumonia versus aspiration). The resident was admitted to the hospital where he continued to deteriorate, was placed on comfort care and expired on 2/24/16. 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. |
| 920000007 |
MOUNTAIN VIEW CONVALESCENT HOSPITAL |
920012129 |
B |
21-Apr-16 |
VLTT11 |
5930 |
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.Based on observation, interview, and record review, the facility failed to ensure that Resident 1 was readmitted to the skilled nursing facility, after being discharged from an acute care hospital. On May 15, 2013, the Department received a complaint from Resident 1, calling from a pay phone. The resident alleged a representative from the skilled nursing facility visitedhim on May 10, 2013, while he was still in the acute care hospital. The representative told the resident unless he signs a new readmission contract, with new conditions, he would not be readmitted back to the skilled nursing facility. On May 16, 2013 at 8:20 a.m., a telephone interview was conducted with Resident 1?s Family Member, who stated that he lost contact with the resident on May 12, 2013, while the resident was getting a psychiatric evaluation at the acute care hospital. After the psychiatric evaluation, Resident 1 was scheduled to be discharged from the acute care hospital.On May 16, 2013 at 1:20 p.m., an unannounced visit was made to the skilled nursing facility. At the skilled nursing facility, the room where Resident 1 resided was occupied by two other residents. A review of the daily census sheet for May 1, 2013, indicated Resident 1 was transferred to an acute care hospital and was placed on bed hold status. The clinical record also indicated Resident 1 was transferred to an acute care hospital for evaluation of his legs. The clinical record had an incomplete notification of bed hold dated May 1, 2013. The daily census sheet, dated May 10, 2013, indicated Resident 1?s bed was still vacant. A review of the admission record indicated Resident 1, a 59 year old male, was initially admitted to the skilled nursing facility on April 27, 2013, with diagnoses that included cellulitis (an infection of the skin and underlying issues) and abscess (a localized collection of pus that generally develops in response to infection) of the legs, anemia (a decreased level of oxygen carrying red blood cells), and chronic lower back pain. A review of a Minimum Data Set (MDS - a standardized assessment and care screening tool) dated May 1,2013 indicated the resident was independent for making decisions regarding tasks of daily life; required extensive assistance from staff with activities of daily living (ADL). There was no discharge plan for Resident 1 to return to the community. The licensed nurses notes, dated May 1, 2013, indicated the resident refused treatment to his legs and wanted to have his legs assessed at an acute care hospital. The physician was notified and the resident was transferred to the acute care hospital for evaluation.According to the acute care hospital records, dated May 1, 2013, Resident 1's legs were assessed, his condition was stabled, and he was to return to the skilled nursing facility.The nurse from the acute care hospital contacted the skilled nursing facility, but the skilled nursing facility staff refused to readmit Resident 1 back to the facility. The resident remained at the acute care hospital.On May 17, 2013 at 1:00 p.m., Resident 1 called the Department and stated a skilled nursing facility representative visited him at the acute care hospital on May 10, 2013. According to the resident, the facility representative told him that he could not return to the skilled nursing facility unless he siged a new contract. The contract contained specific conditions, about his behavior, and he had to agree with the terms of the contract. On May 17, 2013 at 1:10 p.m., an interview was conducted with the skilled nursing facility Administrator who stated Resident 1 needed a lower level of care. The Administrator also stated the resident requested to go to the acute care hospital. The Administrator could not present documentation that Resident 1 was given a written discharge plan for a lower level of care. On May 20, 2013 at 3 p.m., during a telephone interview, the Administrator stated she would find a shelter for Resident 1, but would not readmit him to the skilled nursing facility. The Administrtor stated Resident 1 was non-compliant with his treatment and the facility could not meet the resident?s care needs. On May 21, 2013 at 10 a.m., Resident 1 called the Department and stated since his discharge from the acute care hospital, and the skilled nursing facility?s refusal to take him back, he had been living on the street. The resident stated that he had not eaten well for a long time, he had no money, and he had to use the pay phone to make telephone calls. On May 23, 2013 at 3:30 p.m., during a telephone interview, Resident 1?s Family Member stated that the last time he spoke to Resident 1 (date uncertain), he told him his leg wounds were getting worse. The resident told the family member he was planning to call 911, so he could get admitted to an acute care hospital and have thewounds on his legs treated. On June 4, 2013 at 9:45 a.m., in an interview, the skilled nursing facility?s Director of Nursing (DON) stated Resident 1 was readmitted back to the facility on May 23, 2013. A receipt of the admission record indicated Resident 1 was readmitted on May 23, 2013, as indicated. The facility failed to provide Resident 1 with the required bed hold and failed to readmit the resident immediately upon the first availabile bed. The above violation jointly, separately,or in any combination had a direct or immediate relationship to resident health, safety, or security. |
| 920000009 |
MACLAY HEALTHCARE CENTER |
920012329 |
A |
29-Jul-16 |
SE2Q11 |
11663 |
F309 42 CFR ?483.25 Quality of Care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. F323 42 CFR? 483.25 (h) ACCIDENTS The facility must ensure that ? (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide the necessary care and services to Resident 1, who was assessed at a high risk for falls, to prevent recurrent falls, including but not limited to, failure to: 1. Provide adequate supervision to prevent recurrent falls and injuries, after Resident 1 had a change in condition and/or behavior. 2. Ensure the interdisciplinary team (IDT) members evaluated, monitored and revised Resident 1's individualized plan of care as necessary to prevent injury as indicated in the policies and procedures. As a result Resident 1 sustained a comminuted (in pieces) fracture of the proximal (near to attachment) right femur (thigh bone) with mild displacement and soft tissue swelling. On January 6, 2012, the Department received an entity reported incident (ERI) indicating Resident 1 was found on the floor mat next to her bed by a Certified Nursing Assistant (CNA). The CNA put the resident back to bed without taking any further actions. Resident 1 was observed and assessed for change of condition and probable injury to the right hip. A call was made to 911 and Resident 1 was transferred to the general acute care hospital (GACH). According to the admission record, Resident 1 was admitted to the facility on April 1, 2010, with diagnoses that included difficulty in walking, lack of coordination, essential hypertension (high blood pressure), dementia (memory problems), gastrostomy (artificial opening in the stomach for feeding purposes) and persistent mental disorder (complex mental illness). On April 1, 2010, Resident 1 had a physician?s order for fall precautions, was independent in locomotion (walking), and Tylenol (Acetaminophen) 325 milligrams (mg) two tablets (TABS) for mild pain. The Fall Risk Evaluation dated March 9, 2011, June 7, 2011, September 9, 2011, and December 5, 2011, indicated Resident 1 had a score of 12 (a score of 10 or higher is at risk for fall). According to the assessment, the resident had no falls during the last 90 days of each assessment date. However, Resident 1 had a fall on September 7, 2011. The Minimum Data Set (MDS), an assessment and care screening tool, dated September 5, 2011, indicated Resident 1 was usually able to make self understood, and had no signs and symptoms of delirium (confusion). Resident 1 required limited assistance with transfer and ambulation with one person physical assist; was not steady, and was only able to stabilize with staff assistance with moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet, and transferring surface to surface (transfer between bed and chair or wheelchair). Resident 1 was occasionally incontinent of bladder, continent of bowel, and had no history of falls. A care plan revised June 2011, indicated a problem for physical mobility impaired, related to weakness, cognitive impairment, poor balance and poor safety awareness, and being at risk for decline in function/fall/injury. The goal was for Resident 1 to be free of falls and injuries every shift, and to be in and out of bed and room safely. The interventions included to assist the resident with mobility, transfers, ambulation, toileting, and personal hygiene if needed, and evaluate risk for falls and steadiness/balance on a regular basis. A review of the Licensed Notes dated September 7, 2011, indicated the activity lady saw Resident 1 lying on the floor, no bleeding, no swelling noted. The resident said she wanted to go to the bathroom and was unable to explain what happened. Staff explained and reminded the resident that she has to use the call light. The physician was notified and an order for an X-ray was obtained and carried out. The x-ray result was negative for fracture. On September 7, 2011, noted at 12:20 p.m., there was a physician?s order for landing pads to bedsides for injury precaution, for neurological checks to be done for 72 hours (after the resident had a fall), and for a right hip x-ray. There was no documentation that the care plan had been updated to include the actual fall. The IDT did not do a fall assessment within 24 hours of the fall that included a review of the possible cause, in accordance with the facility's policy and procedure. The Nurse's Notes indicated on January 4, 2012, during the 3 p.m. to 11 p.m. shift, at 3:30 p.m., the licensed nurse documented Resident 1 was alert with confusion, disorientation, and poor safety awareness. Close monitoring done for safety secondary to the resident persistently trying to get out of bed and wandering inside her room and along the hallway with no assistance or assistive device in use. There was no documentation how frequently the resident was to be monitored to prevent injuries from falls. There was no indication a registered nurse assessed Resident 1 as to the reasons for this change in behavior. There was no documentation that the physician was notified regarding the resident's change in behavior for the possible need for medical intervention. The Nurse's Notes indicated at 7 p.m., Resident 1 was found lying on her landing pad. Initial assessment was done and the resident was found to have no apparent injuries. Resident 1 was assisted to get up, was taken to the bathroom then back to the bed. The resident?s range of motion was within normal limits and she was able to ambulate on her normal phase with no difficulties, no pain or discomfort, and the bed was placed at the lowest possible height, with the call light within reach. There was no documented evidence the physician or family member was informed of the resident's fall. A care plan dated January 4, 2012, indicated a problem for actual fall, fall risk potential for injury related to unsteady gait, cognitive deficits, impaired safety awareness, poor safety awareness, weakness, balance problem, risky behaviors, and wandering, as evidenced by history of falls, the last fall was documented as January 4, 2012. The interventions were not updated, but included to monitor the environment for appropriate lighting or obstacles that may obstruct field of vision, assist with transfers or ambulation as needed, frequent visual monitoring (no indication of frequency), attempt less restrictive devices to prevent falls and monitor effect, and to keep the bed in lowest position. The Nurse's Notes indicated on January 5, 2012, at 10 a.m., the Certified Nursing Assistant reported to the charge nurse that Resident 1 was found lying on the floor around 8:15 a.m. The registered nurse supervisor and the director of nursing (DON) were notified and upon assessment, shortening of right leg was noted (indication of a fracture) and swelling of the right hip. The resident was given Tylenol 325 milligrams two tablet via gastrostomy tube. According to the documentation on the medication administration record, the resident was assessed to have a pain level of 8 out of 10, on a pain scale of 0 (no pain) to 10 (most severe pain). A care plan dated January 5, 2012, indicated a problem for at risk for fall related to poor balance, unsteady gait, weakness, and history of fall due to diagnosis of coordination difficulty in walking; the dates of actual falls were documented as January 4, 2012, and January 5, 2012. The interventions included to assess degree of orientation, vision, safety awareness, bowel and bladder status, mobility and medications to determine safety needs; maintain a safe and hazard free environment. On January 5, 2012, there was a physician?s order to transfer Resident 1 to the GACH emergency room for right pelvis swelling and pain. On January 23, 2012, during a review of Resident 1?s clinical record with the DON, she was not able to provide documented evidence that the IDT members had met to evaluate Resident 1's falls, and revised the care plan, in accordance with the facility?s policy and procedure. There was no documentation to indicate the care plan interventions were revised to prevent Resident 1?s additional falls. There was no documentation the licensed nurse assessed Resident 1 in an attempt to find out why the resident was having a change in disorientation with a wandering behavior; or in an attempt of other interventions in use by the facility to alert staff when the resident attempted to get out of bed unassisted, such as applying a bed alarm. The DON confirmed that the CNA did not inform supervision on January 5, 2012, when she found the resident on the floor. Instead, the resident was put back into bed without an assessment. The DON stated that the involved CNA had been suspended, and was not available for an interview. The facility?s Fall Prevention and Management Program Policy and Procedure dated May 2008 indicated: ?? If a resident triggers a risk for falls, the IDT will further assess the fall risk factors utilizing RAP (Resident Assessment Protocol) guidelines and will discuss at the initial care plan meeting. The IDT, if indicated, will further update care plan to minimize the risks of falls. The IDT will re-evaluate all residents quarterly, annually or with a significant change of condition??. The Post Fall policy indicated: ?? Following a resident?s fall, the licensed nurse will assess the resident for injuries and necessary treatment??. ?? Complete neuro checks for all unwitnessed falls or known head injuries including level of consciousness, orientation, change in speech and communication, blood pressure, hand grip, dizziness, unsteady balance, pupils reaction to light. If fractured hip, back, or other injury is suspected, make resident comfortable until emergency medical unit arrives, if no apparent injury, assist off floor. Note: Do not move or leave an injured person. Summon help to call doctor and then carry out doctor?s order. Licensed Nurse will notify attending physician and responsible party?? According to the GACH emergency room x-ray report, dated January 5, 2012, Resident 1 sustained an angulated and comminuted fracture of the right femur. Therefore, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure Resident 1, who was assessed to be at high risk for falls and had history of falls was provided supervision and assistance to prevent fall and injuries, including but not limited to, failure to: 1. Provide supervision during transfer and ambulation as identified in the resident?s comprehensive assessment. 2. Ensure the interdisciplinary team (IDT) members evaluated, monitored and revised the individualized plan of care as necessary to prevent injury as indicated in the policies and procedures. As a result Resident 1 sustained a comminuted fracture (in pieces) of the right femur (thigh bone) with mild displacement and soft tissue swelling. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 920000007 |
MOUNTAIN VIEW CONVALESCENT HOSPITAL |
920012335 |
A |
15-Jul-16 |
3P4011 |
12091 |
F-309 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. On 3/15/16, at 9:10 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Quality of Care. Based on interview and record review, the facility failed to ensure the resident is provided with the necessary care and services in accordance with the comprehensive assessment and plan of care and that Resident 1, who needed oxygen administration, was at risk of pulmonary aspiration (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach), and had shortness of breath, received the needed care and services, including: 1. Failure to monitor the resident?s oxygen saturation (a measure of the amount of oxygen that is carried in the red blood cells which indicates the oxygenation status. The normal range is 95 -100%) every shift (every eight hours) as ordered by the physician and as stated in the plan of care. The oxygen saturation was not measured for 42 hours. 2. Failure to monitor and document the resident?s vital signs as his deteriorating condition warranted and per facility?s protocol. The vital signs were not checked for 18 hours. 3. Failure to promptly transfer the resident to a general acute care hospital (GACH) when the resident?s condition required urgent medical evaluation and treatment. Given the resident?s condition, the licensed nurses did not insist in obtaining an order to transfer via 911. As a result, Resident 1?s transfer was delayed 1.5 hours from time it was ordered and interventions were delayed. The resident was assessed at GACH 2 Emergency Room (ER) to have an altered mental status, was not verbally responsive, was hypotensive (low blood pressure), tachycardic (rapid heart rate), tachypneic (rapid breathing), and febrile (fever) with altered mental status. The resident was diagnosed to have severe sepsis. A chest x-ray indicated pneumonia (healthcare-associated pneumonia versus aspiration). The resident was admitted to the hospital where he continued to deteriorate, was placed on comfort care and expired on 2/24/16. A review of the clinical record indicated Resident 1 was admitted to the facility on 2/19/16, at 5 p.m., with diagnoses including hypertension (high blood pressure), coronary artery disease (a buildup of cholesterol and other material called plaque on the inner wall of the arteries that supply blood to heart muscle become hardened and narrowed), cerebellar (a large part of the brain) stroke syndrome (a condition in which the circulation to the cerebellum is impaired), hemiplegia (paralysis of one side of the body), and hemiparesis (weakness of one side of the body) following an intracranial hemorrhage. The resident had dysphagia (difficulty swallowing) and had a gastrostomy tube (GT ? tube surgically inserted into the stomach through the abdominal wall) for nutrition, hydration and medication administration. The Nursing Admission and Assessment dated 2/19/16 indicated Resident 1 was awake, alert, verbally responsive, and cooperative. The resident's breath sounds were regular and clear. The physician's orders dated 2/19/16, included GT feeding formula Jevity 1.5 at 75 cubic centimeters (cc) per hours via enteral pump; oral diet with honey thickened liquids; monitor oxygen saturation at every shift; oxygen at two liters per minute (2 L/min) via nasal cannula (a lightweight tube used to deliver supplemental oxygen or airflow to a person in need of respiratory help) for shortness of breath; Zofran (to treat nausea and vomiting) 4 milligrams (mg) every six hours as needed for nausea/vomiting. All medications were ordered to be given by the GT. On 2/20/16, a plan of care developed for the resident?s risk for respiratory distress due to diagnoses and the use of oxygen, included in the interventions monitoring shortness of breath, irregular respiration, wheezing, crackles, rhonchi (coarse rattling respiratory sounds, usually caused by secretions in bronchial airways), excessive secretions, monitoring oxygen saturation as ordered and as needed (no frequency specified), and monitoring oxygen inhalation as ordered. On 2/20/16, a plan of care developed for the resident?s risk for adverse drug effects and interactions due to receiving nine or more medications, included in the interventions monitoring the resident?s vital signs as ordered. On 2/20/16, a plan of care was developed for the resident?s risk for (pulmonary) aspiration (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach) due to dysphagia and GT feeding. The interventions included monitoring for signs and symptoms of aspiration (frequency was not specified). The signs and symptoms of aspiration were not specified. According to the Change of Condition SBAR (Situation, Background, Assessment, and Recommendation) form dated 2/20/16, timed at 2 a.m., Resident 1 vomited, Zofran was given as ordered. The documentation included the resident?s vital signs and the oxygen saturation rate. Physician 1 was notified of Resident 1?s episode of vomiting and ordered to stop the GT feeding. A nursing progress note documentation dated 2/20/16, timed at 3 p.m., indicated Physician 1 came at 11 a.m. The note included the resident?s vital signs but not the oxygen saturation. According to the Change of Condition SBAR form dated 2/21/16, timed at 8:30 p.m., indicated Resident 1's temperature was elevated [99. 8 degrees Fahrenheit (F)] and both right and left lungs were congested. The oxygen saturation was 92 %, the resident was receiving oxygen at 2 L/min., and the remaining vital signs (respiration, pulse and blood pressure) were within normal limits. Physician 1 was notified and ordered x-rays, breathing treatment, and suctioning (pulmonary secretions). There was no documented evidence the resident was monitored for oxygen saturation from 2/20/16, at 2 a.m. to 2/21/16, at 8:30 p.m., a total of 42 hours. Also, there was no documented evidence the resident's vital signs were monitored from 2/20/16, at 3 p.m. to 2/21/16, at 8:30 p.m., a total of 18 hours. According to the Change of Condition SBAR form dated 2/21/16, timed at 9:40 p.m., Resident 1?s respiratory (22 breath per minute) and heart rate (93 beats per minute) were increasing and at 10:15 p.m., Physician 1 was called and ordered to transfer Resident 1 via regular transportation (not equipped to handle unstable patients or emergencies) to GACH 1 for evaluation of congestion, shortness of breath, and elevated temperature. According to the nursing progress record (while waiting for the regular transportation/ambulance) at 11 p.m., Resident 1's temperature increased to 100.7 degrees F from 99.8 degrees F; the blood pressure decreased to 127/63 millimeters of mercury (mmHg ? units used to measure the blood pressure) from 146/86 mmHg; the heart rate was 93 beats per minute (same as at 9:40 p.m.); the respiratory rate increased to 24 breaths per minute from 22 breath per minute; the oxygen saturation decreased from 92% to 90%, and oxygen was administered at 15 L/min. According to the nursing progress record at 11:40 p.m., the regular transportation arrived, Resident 1's blood pressure decreased to 88/56 mmHg, the heart rate increased to 111 beats per minute, the respiratory rate was 22 per minute, the temperature was 100.7 degrees F, and the oxygen saturation was between 86% - 89%. The transportation staff indicated they were not able to transfer the resident due to desaturation (low oxygen saturation) and 911 (paramedics) was called. At 11:49 p.m., Resident 1 was transferred to GACH 2 (closest to the facility) via paramedics. The resident was transferred 1.5 hours after Physician 1 ordered the transfer. On 3/15/16, at 11:30 a.m., during an interview, Registered Nurse 1 (RN 1) stated she was not able to provide documented evidence Resident 1 was monitored for oxygen saturation during the dates and times referenced for the 42 hour period. RN 1 stated she was not able to provide the documented evidence Resident 1's vital signs were monitored during the times referenced for the 18 hour period. A review of the facility's guidelines titled, "Pulse Oximetry," revised 10/ 2010, indicated the purpose of assessing oxygen saturation was to monitor arterial blood oxygen saturation and to review the physician's orders. A review of the facility's policy titled, "Acute Condition Changes - Clinical Protocol," revised 12/2012, indicated the nurse shall assess and document/report the vital signs. The policy did not indicate when and how often the resident's vital signs should be monitored. On 3/15/16, at 12:20 p.m. during an interview, the Director of Nursing (DON) stated the nursing staff should have monitored the resident's oxygen saturation rate per the physician?s order and the vital signs every shift for 72 hours from admission. The DON did not provide a policy on monitoring the residents? vital signs every shift for 72 hours from admission. A review of GACH 2 Emergency Room documentation dated 2/22/16 indicated Resident 1 was diagnosed to have severe sepsis, was hypotensive (low blood pressure), tachycardic (rapid heart rate), tachypneic (rapid breathing), and febrile (fever) with altered mental status. A chest x-ray indicated pneumonia (healthcare-associated pneumonia versus aspiration). The resident was admitted to the hospital. The facility failed to ensure the resident is provided with the necessary care and services in accordance with the comprehensive assessment and plan of care and that Resident 1, who needed oxygen administration, was at risk of pulmonary aspiration (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach), and had shortness of breath, received the needed care and services, including: 1. Failure to monitor the resident?s oxygen saturation (a measure of the amount of oxygen that is carried in the red blood cells which indicates the oxygenation status. The normal range is 95 -100%) every shift (every eight hours) as ordered by the physician and as stated in the plan of care. The oxygen saturation was not measured for 42 hours. 2. Failure to monitor and document the resident?s vital signs as his deteriorating condition warranted and per facility?s protocol. The vital signs were not checked for 18 hours. 3. Failure to promptly transfer the resident to a general acute care hospital (GACH) when the resident?s condition required urgent medical evaluation and treatment. Given the resident?s condition, the licensed nurses did not insist in obtaining an order to transfer via 911. As a result, Resident 1?s transfer was delayed 1.5 hours from time it was ordered and interventions were delayed. The resident was assessed at GACH 2 Emergency Room (ER) to have an altered mental status, was not verbally responsive, was hypotensive (low blood pressure), tachycardic (rapid heart rate), tachypneic (rapid breathing), and febrile (fever) with altered mental status. The resident was diagnosed to have severe sepsis. A chest x-ray indicated pneumonia (healthcare-associated pneumonia versus aspiration). The resident was admitted to the hospital where he continued to deteriorate, was placed on comfort care and expired on 2/24/16. 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. |
| 920000009 |
MACLAY HEALTHCARE CENTER |
920013029 |
A |
10-Mar-17 |
HD1R11 |
13902 |
CFR 483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
483.25 (h) Accidents and Supervision
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
On 9/2/16, at 7 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 sustaining a fall at the facility, which resulted in progressively worsening back pain since the fall and a decline in mobility.
Based on interview and record review, the facility failed to provide its resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and failed to ensure that the resident?s environment remains as free of accident hazards as is possible and that each resident receives adequate supervision to prevent accidents and injuries, including:
1. Failure to implement Resident 1?s fall plan of care interventions including visual checks during care or during medication pass.
2. Failure to implement the cognitive loss plan of care interventions including monitoring Resident 1 for unsteadiness in gait and balance.
3. Failure to administer pain medication Morphine Sulfate in a timely manner, as ordered by the physician to Resident 1 who complained of severe pain on his lower back and both hips.
4. Failure to implement the facility's policy titled, "Falls - Clinical Protocol," dated 4/2013, to report a recent injury, pain, or precipitating factors and details on how Resident 1's fall occurred.
As a result, XXXXXXX 16, Resident 1 suffered a fall, with progressively worsening, severe pain, was transferred to a general acute care hospital (GACH), nine days after the complaints of severe pain, had a decline in mobility, became bed bound, unable to do most activities, and required total care.
A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on XXXXXXX16, with diagnoses of altered mental status (changes in brain function, such as confusion, memory loss, problems in perception, skills, and behavior), and diabetic neuropathy (condition caused by nerve damage from long-term high blood sugar levels, with symptoms such as pain, tingling, or loss of feeling in the extremities).
A review of the Fall Risk Assessment, dated 6/25/16, indicated Resident 1 received anti-hypertensive medications (used to treat high blood pressure), psychotropic medication (medication capable of affecting the mind, emotions, and behavior of a resident), and diuretics (medication that increases production of urine). The assessment indicated Resident 1 had difficulty in recalling the location of the facility, his room, staff names/faces, and days of the week. In addition, Resident 1 was unable to stand independently and had decreased muscle coordination. The fall risk assessment form indicated Resident 1 scored a 13 which indicated a moderate risk for fall.
A review of the Fall Plan of Care, dated 6/25/16, indicated Resident 1 was at risk for fall related to poor balance and weakness. The goal indicated not to have any incident of falls or injury. The plan of care approaches included providing visual checks during care and medication pass, to assist the resident with transfer as needed. However the Minimum Data Set (MDS - an assessment and care screening tool), dated 7/8/16, indicated Resident 1 required supervision during transfer and toilet use, and to encourage the resident to ask for assistance.
The MDS indicated Resident 1 had moderate cognitive impairment, required supervision during transfer and toilet use, and extensive assistance during personal hygiene / bathing with one person physical assistance.
A review of the SBAR Communication Form (SBAR - Situation, Background, Assessment, Recommendation), dated 8/19/16, indicated Resident 1 complained of pain on both sides of the hip related to an unwitnessed fall. The SBAR form indicated a neuro check (neurological assessment to identify early signs of trauma or brain injury) was initiated on 8/19/16, at 9:15 a.m.
A review of the Physician's Orders, dated 8/19/16, 9:15 a.m., indicated Resident 1 received x-rays of the lower back and both hips due to pain, and there was no fracture indicated from the results at 6:19 p.m.
A review of the Fall Plan of Care, dated 6/25/16, indicated there were no updated or revised goals or approaches / interventions to address the unwitnessed fall on 8/19/16. During an interview with Registered Nurse Supervisor 2 (RN 2), on 9/2/16, at 12:45 p.m., she stated Resident 1's care plan should have been updated or revised after the unwitnessed fall, but it was not done. RN 2 stated the revision should have included additional interventions to prevent Resident 1 from future falls.
A review of the clinical record for Resident 1 indicated there was no documentation of visual checks during care or during medication pass, per the plan of care. In addition, there was no documentation Resident 1 was being supervised during transfer and toilet use. During an interview with the Director of Nursing (DON), on 12/27/16, at 9:45 a.m., she stated providing visual checks to Resident 1 during care or medication pass, and providing supervision during transfer and toilet use should have been documented by the licensed nurses, but it was not. The DON stated it was important Resident 1 received the visual checks to assess for any changes in condition, provide prompt intervention, and to assess the safety of the environment, performed by the licensed nurses.
A review of the Cognitive Loss Care Plan, dated 6/25/16, indicated Resident 1 had potential for increasing confusion related to memory problem and impaired decision making. The goal was to be able to meet Resident 1's daily needs. The care plan approaches included to provide reality orientation while giving care, to provide verbal cues and reminders, to monitor for unsteady gait and balance, and to keep the environment free of hazard.
During an interview with LVN 1, 12/27/16, at 9 a.m., when asked if she provided reality orientation, verbal cues and reminders, she stated yes, however, a review of the clinical record for Resident 1 indicated there was no documentation of verbal cues or reminders provided to the resident. There was also no documentation that Resident 1 was monitored for unsteadiness in gait and balance. During an interview with the DON, on 12/27/16, at 9:48 a.m., she stated providing verbal cues or reminders and monitoring Resident 1 for unsteadiness in gait and balance should have been documented by the licensed nurses, but it was not done.
During an interview with Licensed Vocational Nurse 1 (LVN 1), on 9/2/16, at 12:40 p.m., she stated Resident 1 informed her that he fell on 8/19/16, at around 8:30 a.m. Resident complained of pain at this time, rated at 7 on a scale of 10 (moderate pain). LVN 1 stated she did not notify the supervisor of the fall, and was unable to explain her reasoning for not reporting. LVN 1 stated she should have reported it to her supervisor.
During an interview with RN 2, on 9/2/16, at 12:50 p.m., she stated LVN 1 informed her that Resident 1 was complaining of pain to the lower back and both sides of the hip. RN 2 stated there was no investigation or interviews conducted related to Resident 1's unwitnessed fall, that LVN 1 should have reported the unwitnessed fall. RN 2 stated the importance of reporting any fall incidents was to ensure facility staff performed an investigation to prevent further episodes of fall.
A review of the clinical record indicated there were no Interdisciplinary Team meetings conducted regarding Resident 1's fall on 8/19/16.
A review of Resident 1's Medication Administration Record (MAR), dated 8/9/16, indicated to administer Norco 5/325 milligrams (mg - a unit of measure), a narcotic medication used to relieve pain, one tablet by mouth every four hours as needed for moderate pain (rated five to seven out of ten). The Physician's Order, dated 8/9/16, indicated to administer Morphine Sulfate (a narcotic medication used to relieve severe pain) 0.25 milliliters (ml) every two hours as needed for severe pain (pain rated eight to ten out of ten).
A review of the Pain Assessment Flow sheet, dated 8/18/16, Resident 1 had no complaints of pain and did not receive any pain medication.
A review of the Pain Assessment Flow sheet, dated 8/19/16, indicated Resident 1 received Norco 5/325 milligram (mg) one tablet by mouth at 2 p.m. (over five hours after initial complaints of pain from the fall). The pain assessment form indicated Resident 1's pain was rated an eight out of ten on the pain intensity scale (ten being the worst possible pain). This indicated Resident 1 did not receive the physician ordered Morphine for severe pain after the fall.
During an interview with LVN 1, on 12/27/16, at 9:10 a.m., she stated she administered Norco as ordered after Resident 1 complained of moderate pain on 8/19/16 around 9 a.m., but she forgot to document it on the MAR. LVN 1 stated she should have documented it. LVN 1 stated she did not administer the appropriate medication which was the Morphine Sulfate 0.25 ml when the resident complained of eight out of ten pain indicating severe pain on 8/19/16 at 2 p.m.
A review of the Pain Assessment Flow Sheet, dated 8/19/16 through 8/28/16 (for 10 days) indicated Resident 1 had generalized pain, rated eight to nine out of 10, indicating very severe pain. The assessment flow sheet indicated Resident 1 received Norco 5/325 mg one tablet a total of six times and Morphine Sulfate 0.25 ml a total of 18 times.
A review of the Physician's Order indicated Resident 1 was transferred to the general acute care hospital (GACH) on XXXXXXX16 for further evaluation (nine days after the SBAR documentation of the unwitnessed fall).
During an interview with the DON, on 12/27/16, at 9:30 a.m., she stated LVN 1 should have documented in the MAR administration of the pain medication. The DON stated she reviewed the Incident Log Book and there was no incident report completed on Resident 1's unwitnessed fall and there was no investigation done.
The DON stated during an unwitnessed fall the resident should be assessed immediately for any injuries including the pain level. She stated appropriate pain medication should be administered immediately and pain reassessment should have been done. The plan of care should have been revised or updated indicating new goals and interventions. The DON stated LVN 1 should have reported the incident to the RN Supervisor and the DON to be able to conduct an investigation to prevent further episodes of fall.
A review of the GACH's History and Physical, dated 8/29/16, indicated Resident 1 was observed to have progressively worsening back pain since the fall on 8/19/16 with a decline in mobility. A review of the GACH's Performance Scale, dated 9/2/16, indicated Resident 1 was bed bound, unable to do most activities, and required total care.
A review of the facility's policy and procedure titled, "Falls - Clinical Protocol," dated 4/2013, indicated a licensed nurse shall assess and report any recent injury, pain, and precipitating factors and details on how fall occurred.
A review of the facility's policy and procedure titled, "Care Plans," dated 9/2010, indicated a licensed nurse and/or other Interdisciplinary Team member should develop, update and revise a care plan upon identification of a change of condition and/or any new needs.
A review of the facility's policy and procedure titled, "Pain-Clinical Protocol," dated 6/2013, indicated a licensed nurse should assess a resident whenever there was a significant change in condition and when there was onset of new pain or worsening of existing pain. Appropriate non-pharmacologic and medication interventions to address the pain should be provided and administered timely.
The facility failed to provide its resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and failed to ensure that the resident?s environment remains as free of accident hazards as is possible and that each resident receives adequate supervision to prevent accidents and injuries, including:
1. Failure to implement Resident 1?s fall plan of care interventions including visual checks during care or during medication pass.
2. Failure to implement the cognitive loss plan of care interventions including monitoring Resident 1 for unsteadiness in gait and balance.
3. Failure to administer pain medication Morphine Sulfate in a timely manner, as ordered by the physician to Resident 1 who complained of severe pain on his lower back and both hips.
4. Failure to implement the facility's policy titled, "Falls - Clinical Protocol," dated 4/2013, to report a recent injury, pain, or precipitating factors and details on how Resident 1's fall occurred.
As a result, on 8/19/16, Resident 1 suffered a fall, with progressively worsening, severe pain, was transferred to a general acute care hospital (GACH), nine days after the complaints of severe pain, had a decline in mobility, became bed bound, unable to do most activities, and required total care.
The above violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 920000007 |
MOUNTAIN VIEW CONVALESCENT HOSPITAL |
920013324 |
A |
8-Jul-17 |
MTWY11 |
15237 |
F281
42 CFR 483.20 (k)(3) The services provided or arranged by the facility must?
(i) Meet professional standards of quality; and
(ii) Be provided by qualified persons in accordance with each resident's written plan of care.
F309
?42 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.
F322
?483.25(g) Naso-Gastric Tubes
Based on the comprehensive assessment of a resident, the facility must ensure that
(1) A resident who has been able to eat enough alone or with assistance is not fed by naso gastric tube unless the resident?s clinical condition demonstrates that use of a naso gastric tube was unavoidable; and
(2) A resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills.
F328
?42 CFR 483.25 (k) Special Needs
The facility must ensure that residents receive proper treatment and care for the following special services
(2) Parenteral and Enteral fluids
On August 9, 2016, an unannounced visit was conducted to the skilled nursing facility 1 (SNF 1) to investigate a complaint regarding Resident 1?s quality of care.
Based on interview and records review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care and failed to ensure residents fed by a gastrostomy tube (GT - a tube surgically inserted through the abdominal wall into the stomach for feeding and medication administration) received the appropriate treatment and services, including:
1. Failure to ensure appropriate placement of the Resident 1's GT and to identify the GT was not in the right location.
2. Failure to hold Resident 1?s tube feeding water flushes of 200 cubic centimeters (cc) every six hours and medications given through the GT when Resident 1 had episodes of vomiting, and the physician had ordered to hold the feeding formula.
3. Failure to check Resident 1?s feeding for residual (fluid contents that remain in the stomach) before resuming the feeding formula as ordered by the physician.ÿÿÿ
4. Failure to implement the facility's policy and procedures on Confirming Placement of Feeding Tubes to check the pH (measure of acidity or alkalinity of a solution) level of the feeding residual.
As a result, on July 22, 2016, Resident 1 developed fever, septic shock (a potentially deadly drop in blood pressure due to the presence of bacteria in the blood), required transfer to a general acute care hospital 1 (GACH 1) where she underwent emergency surgery for removal of four liters of purulent (pus) liquid material from the abdominal wall. Resident 1 was placed on hospice care (comfort care) and subsequently expired at SNF 2 on XXXXXXX 2016.
A review of the clinical record indicated Resident 1 was admitted to the facility on XXXXXXX, 2016 with diagnoses including acute respiratory failure, ventilator (a machine that supports breathing) dependent, and had a gastrostomy tube for feeding.
The Minimum Data Set (MDS - a standardized assessment and care planning tool) dated May 3, 2016, indicated the resident was in persistent vegetative state (completely unresponsive to stimuli and no sign of brain function), and was totally dependent on staff for activities of daily living (ADLs ? bed mobility, bathing, dressing, toileting, and transferring).
A plan of care developed on a February 3, 2016 for Resident 1?s use of the GT feeding and risk of aspiration (entry of food/water to the windpipe and to the lungs) and infection of the GT site (opening on the abdomen). The care plan had goals for Resident 1 to tolerate the feeding without vomiting, aspiration, or diarrhea, and to be free of GT site infection. The interventions included:
- Provide the feeding formula as ordered;
- Monitor the feeding tolerance;
- Flush the GT with water as ordered;
- Flush the GT with 30 cc of water before and after medication administration;
- Check the GT tube placement and patency (free from obstruction); and,
- Check and record the GT residual every shift, and if a residual is 100 cc or more, hold the GT feeding for one hour and then re-check the residual.
The plan of care did not include in the interventions to hold the GT feeding if there was vomiting, aspiration, or diarrhea.
A review of Resident 1's physician?s orders on admission included:
- Check the GT placement and patency before administration of medication and/or fluids every shift;
- Check residual of feeding every shift and hold feeding for one hour, if residual is greater than 100 cc;
- Flush the GT with 30 to 50 cc of water before and after medication administration; and,
- Flush the GT with a minimum of 200 cc of water every six hours (scheduled at 12 midnight, 6 a.m., 12 noon, and 6 p.m.).
A physician?s order dated May 6, 2016, indicated to administer Zofran (to treat vomiting) 4 milligrams (mg) one tablet via GT every six hours as needed for vomiting.
A physician?s order dated May 20, 2016, indicated to give the feeding formula Glucerna (brand name) 1.5 at 60 cc per hour for 20 hours, via enteral pump (automated delivery system), to provide 1200 cc over 24 hours.
On July 20, 2017, the physician ordered to increase the rate of Glucerna to 65 cc per hour for 20 hours to yield 1300 cc over 24 hours.
A review of the Change of Condition/Situation, Background, Assessment, Recommendation form (COC/SBAR - framework for communication between members of the health care team about a patient's condition a technique used to facilitate prompt and appropriate communication) dated July 21, 2016, timed at 5:30 p.m., indicated Resident 1 vomited at 3 p.m., and Zofran was given via GT. Resident 1's vital signs were taken and the heart rate was 118 beats per minute (bpm ? above the normal range 60 to 100 bpm). The GT feeding was held and was resumed at 4 p.m. The medications scheduled for 5 p.m. were given. There was no documented evidence the GT residual was checked prior to resuming the GT feeding as indicated in the plan of care. Resident 1 vomited again at 5:30 p.m., the physician was called and ordered to hold the feeding formula for three hours. The GT feeding was resumed after three hours without documented evidence the GT residual was checked as indicated in the plan of care.
According to the Medication Administration Record (MAR), the GT was flushed with 200 cc at 6 p.m., scheduled (time the GT feeding was held).
A review of the COC/SBAR form dated July 22, 2016 timed at 7 a.m. indicated Resident 1 had small amount of vomit. There was no documentation the GT feeding formula was held when vomit is indicative of feeding intolerance (indicated in the plan of care goal). At 8 a.m. Resident 1's body temperature reading was 101.4 degrees Fahrenheit (normal range 98.6 to 99) and the feeding residual was less than 20 cc. At 8:30 a.m., Resident 1?s physician was called. At 11:15 a.m., the physician returned the call and ordered blood test, chest x-ray and intravenous (IV) fluids. At 12 p.m., the note indicated inability to start IV and the physician was called (message left). At 1:15 p.m., Resident 1 was sweating, pale, had abdominal breathing (breathing supplemented by abdominal wall muscles), the heart rate was 52 bpm, the respiratory rate was 28 breaths per minute (range 12-20), and the oxygen saturation (oxygen carried in the blood) reading was 81 to 85 percent (Normal 95-100%) on a ventilator. The physician was called again at 1:15 p.m., and at 1:20 p.m., the physician returned the call and ordered to transfer Resident 1 to a GACH via 911 (emergency number to summon paramedics). At 1:57 p.m., Resident 1 was transferred to GACH 1 by paramedics.
A review of the MAR for the 7 a.m. to 3 p.m. shift on the day of transfer, indicated the GT feeding, medications, and water flush were continued to be administered.
There was no documented evidence that on July 21 and 22, 2016 the GT feeding residual was checked for pH level as indicated in the plan of care.
Further review of the clinical record, including the treatment administration record, had no documented evidence the GT was replaced while the Resident 1 was at the facility.
A review of Resident 1's GACH - Emergency Room (ER) notes, dated July 22, 2016 timed at 2:32 p.m. indicated Resident 1 had septic shock with diaphoresis (sweating). A computerized tomography (CT ? a radiological test) of the abdomen and pelvis (lower part of the abdomen) was done and the result indicated a displaced GT (also named percutaneous endoscopic gastrostomy PEG) and significant abdominal abscess (pus collection)/food collection into the abdominal wall, likely the source of the septic shock. The plan was to take Resident 1 to the operating room (OR) in the morning for wash out.
A review of Resident 1's GACH - Surgical Documentation dated July 23, 2016, at 5:27 p.m., indicated a preoperative diagnosis of dislodged PEG tube and left rectus (muscle) abdominal wall abscess/retained tube feeds. The operation indicated an incision and drainage was made at resident's left abdominal muscle, placement of catheter tract for drainage and removal of the dislodged PEG tube. The resident was admitted to the intensive care unit (ICU) after surgery.
A review of Resident 1's GACH - Discharge Documentation dated August 11, 2016 indicated the resident met four out of four sepsis (potentially life-threatening complication of an infection that occurs when chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body) criteria. A CT of abdomen/pelvis showed soft tissue infection in the abdominal wall because the PEG tube (GT) had terminated within the wall (not into the stomach) and the facility had likely re-inflated the balloon with feeding and medication directly into the abdominal wall. General surgery was performed, during which four liters of purulent and liquid material were removed, the GT was removed, and a red robin tube (drainage tube) was left in place in place. The resident was discharged to another skilled nursing facility (SNF 2).
On August 26, 2016 at 12 p.m., during a telephone interview, Family Member 1 (FM 1) stated Resident 1 was placed in hospice care for comfort and later died on XXXXXXX 2016 at SNF 2.
According to Resident 1's Certificate of Death dated XXXXXXX 2016, Resident 1?s immediate cause of death was cardiac arrest (a condition in which the heart suddenly and unexpectedly stops beating), underlying cause anoxic encephalopathy (loss of oxygen to the brain), and coronary artery disease (narrowing of heart arteries).
On August 26, 2016 at 1:25 p.m., during an interview, Licensed Vocational Nurse (LVN 1) stated she performed GT treatments on Resident 1 and was not aware Resident 1's GT was dislodged.
On August 26, 2016 at 1:35 p.m., during an interview, LVN 2 stated she was the medication nurse, and did not notice anything wrong with Resident 1?s GT and checked for the GT patency and placement with stethoscope (medical equipment use to listen to the body sounds) and checked the GT residual, which was zero.
On August 26, 2016 at 1:40 p.m., during an interview, Registered Nurse (RN 2) stated on July 22, 2016, before Resident 1 went to the GACH, the GT residual was below 20 cc. RN 2 stated that she did not recall any issues with the GT, and she checked Resident 1's abdomen at 8 a.m. and it was soft and round, and had bowel sounds.
According to facility's policy and procedure titled, "Confirming Placement of Feeding Tubes," revised December 2011, its purpose is to ensure proper placement of the feeding tube to prevent aspiration during feeding.
The policy included the following method of checking the GT placement:
4. Check pH of aspirate GT feeding.
a. If feeding has been interrupted for a few hours, aspirate a small amount from the stomach or small bowel observe the aspirate and then measure the pH (using the pH strips).
(1) Fasting stomach acid will have a pH of five or less? (5) A pH of five or less suggests that the tube is placed in the stomach. However, a pH of six (6) or greater is not definite of placement outside the stomach. If any of the above suggests improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician.
On May 18, 2017 at 4:10 p.m., during an interview, DON 1 stated that after the residual is checked, it is documented in the MAR. DON 1 stated licensed nurses do not check the pH as indicated in the facility's policy.
On June 8, 2017 at 1:30 p.m., during a telephone interview, RN 3 stated she was not aware of the facility?s policy to check the pH level of feeding residual and had not seen any licensed nurse checking the pH level. RN 3 added the facility did not have the strips needed to check the pH level.
On May 19, 2017 at 1:45 p.m. during a telephone interview, ER Physician 1 stated when the GT is displaced or trapped, there is a high residual and a high resistance is expected.
The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care and failed to ensure residents fed by a gastrostomy tube (GT - a tube surgically inserted through the abdominal wall into the stomach for feeding and medication administration) received the appropriate treatment and services, including:
1. Failure to ensure appropriate placement of the Resident 1's GT and to identify the GT was not in the right location.
2. Failure to hold Resident 1?s tube feeding water flushes of 200 cubic centimeters (cc) every six hours and medications given through the GT when Resident 1 had episodes of vomiting, and the physician had ordered to hold the feeding formula.
3. Failure to check Resident 1?s feeding for residual (fluid contents that remain in the stomach) before resuming the feeding formula as ordered by the physician.ÿÿÿ
4. Failure to implement the facility's policy and procedures on Confirming Placement of Feeding Tubes to check the pH level of the feeding residual.
As a result, on July 22, 2016, Resident 1 developed fever, septic shock, required transfer to a GACH 1 where underwent emergency surgery for removal of four liters of purulent liquid material from the abdominal wall. Resident 1 was placed on hospice care (comfort care) and subsequently expired at SNF 2 on XXXXXXX 2016.
These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 920000007 |
MOUNTAIN VIEW CONVALESCENT HOSPITAL |
920013362 |
B |
20-Jul-17 |
8SNY11 |
10378 |
CFR 483.21 (b) Comprehensive Care Plans
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.
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(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 2/6/17, an unannounced visit was made to the facility to investigate a complaint regarding Quality of Care.
Based on interview and record review, the facility failed ensure its residents must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and failed to ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent falls and injuries, including:
1. Failure to ensure Resident 1, who was assessed as a high fall risk, had a history of falls, and was totally dependent on staff for transfers, was safely transferred from bed to a shower chair, utilizing a mechanical lift (an assistive device allows residents to be transferred by the use of electrical or hydraulic power) with two-person assistance, as indicated in the plan of care.
2. Failure to revise / modify the care plan after Resident 1's sustained a second fall to implement additional interventions to prevent future falls, per the facility policy.
As a result, on 1/24/17, Resident 1 suffered a third fall with injury when Certified Nurse Assistant 1 (CNA 1) attempted to transfer the resident without using the mechanical lift and without two-person assistance. Resident 1 fell to the floor and CNA 1 fell on top of the resident, who sustained a laceration (cut) on the right side of the head.
According to the Admission Face Sheet, Resident 1 was re-admitted to the facility, on XXXXXXX16, with diagnoses including anemia (a condition in which the blood doesn't have enough blood cells, hypertension (high blood pressure), and dementia (a group of thinking and social symptoms that interferes with daily functioning).
A review of Report of Incident SBAR form (Situation, Background, Assessment, and Response) indicated on 5/28/16, Resident 1 had an episode of fall with no injury. On 9/24/16, Resident 1 had another fall episode that resulted in redness to the right knee and right temple.
A review of the Fall Risk Assessment, dated 5/28/16 and 9/24/16, indicated Resident 1 had a score of 10 (10 or greater indicated high risk for falls).
A review of the Activities of Daily Living (ADLs) Functional / Rehabilitation Potential care plan, updated on 7/12/16, indicated Resident 1 was at risk for unavoidable decline secondary to self-care deficits, related to intermittent weakness, decreased strength and endurance, poor balance, and poor safety awareness. The care plan goal indicated to minimize risk of falls or injuries by 90 days. The interventions included nursing to assist the resident with transfers and utilizing the mechanical lift with two person assist. The care plan was not revised after Resident 1's fall on 9/24/16.
A review of the plan of care, updated on 7/12/16, indicated Resident 1 was at risk for falls due to dementia, poor safety judgement/awareness, and confusion/forgetfulness. The goal was to minimize the risk of falls and injury everyday by 90 days. The care plan interventions included assessing the resident's need for an assistive/supportive device and to anticipate the needs of the resident. The care plan was not revised after Resident 1 fell on 9/24/16.
According to the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 1/9/17, Resident 1 was totally dependent on staff for bed mobility and transferring from bed to chair or wheelchair. The MDS indicated Resident 1 required two or more person physical assistance with transfers, and had joint mobility problems on arms and legs.
A review of the fall risk assessment, dated 1/9/17, indicated Resident 1 had a score of 12 indicating high risk for falls.
According to the SBAR, on 1/24/17, Resident 1 had a (third) episode of fall, while being transferred from the bed to the shower chair, sustaining a laceration on the right side of her head. The physician when notified ordered triple antibiotic to be applied to the laceration.
On 2/6/17, at 10:45 a.m., an interview was conducted while reviewing Resident 1's clinical record and the director of nursing (DON) stated the plan of care for fall and ADL?s should have been updated after the resident fell on 9/24/16 to prevent further falls.
During an interview, on 2/6/17, at 11:45 a.m., the DON stated Resident 1 was totally dependent on staff for transfers and the ADL care plan indicated the resident should have been transferred by two people, using the mechanical lift. The DON stated the certified nursing assistant (CNA 1), transferred Resident 1 on his own, without using a mechanical lift, the resident fell onto the ground and CNA 1 fell on top of the resident. The DON stated Resident 1 sustained a laceration on the right side of the head and was treated with triple antibiotic ointment.
During a phone interview, on 2/6/17, at 12:30 p.m., CNA 1 stated the rest of the staff was too busy to help him so he transferred Resident 1 from the bed to the shower chair on his own. CNA 1 carried the resident by placing his arms under the resident?s axillary area (underarm). When CNA 1 attempted to place Resident 1 on the chair, the shower chair tilted back and the resident fell to the ground hitting her head. CNA 1 stated he fell on top of Resident 1. He further stated Resident 1 should have been assisted by two people when transferring the resident from bed to chair.
A review of the CNA ADL tracking form for January 2017 indicated the 7 a.m. to 3 p.m. shift and the 3 p.m. to 11 p.m. staff, transferred Resident 1 using one person on 1/1/17, 1/19/17, and 1/24/17.
During an interview, on 2/6/17, at noon, when asked about the CNA ADL tracking form, the DON stated Resident 1 should have been transferred by two person assist in accordance with the resident's care plan.
A review of the facility's policy and procedure titled, "Assessing Falls and their Causes," dated 10/2010, indicated the facility was to review the resident's care plan to assess for any special needs of the resident. When a resident falls, the facility staff was to fill out a falls risk assessment and document appropriate interventions to prevent future falls.
A review of the facility's policy and procedure titled, "Falls and Fall Risk, Managing," dated 12/2007, indicated the staff was to identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try and minimize complications from falling based on previous evaluations and current data. If falling recurs despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff would try various interventions, based on the nature or category of falling, until falling was reduced or stopped, or until the reason for the continuation of the falling was identified as unavoidable.
The policy indicated if the resident continued to fall, staff would re-evaluate the situation and whether it's appropriate to continue or change current interventions. The staff and/or physician would document the basis for conclusions the specific irreversible risk factors exist that continue to present a risk factor for falling.
According to the facility's policy and procedure titled, "Care Plans - Comprehensive," dated 9/2010, indicated assessments of residents were ongoing and care plans were revised as information about the resident and the resident's condition change. The Care Planning/Interdisciplinary Team was responsible for the review and updating of care plans when the desired outcome was not met and at least quarterly.
The facility failed ensure its residents must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and failed to ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent falls and injuries, including:
1. Failure to ensure Resident 1, who was assessed as a high fall risk, had a history of falls, and was totally dependent on staff for transfers, was safely transferred from bed to a shower chair, utilizing a mechanical lift (an assistive device allows residents to be transferred by the use of electrical or hydraulic power) with two-person assistance, as indicated in the plan of care.
2. Failure to revise / modify the care plan after Resident 1's sustained a second fall to implement additional interventions to prevent future falls, per the facility policy.
As a result, on 1/24/17, Resident 1 suffered a fall with injury when Certified Nurse Assistant 1 (CNA 1) attempted to transfer the resident without using the mechanical lift and without two-person assistance. Resident 1 fell to the floor and CNA 1 fell on top of the resident, who sustained a laceration (cut) on the right side of the head.
The above violations had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 930000904 |
MEMORIAL HOSPITAL OF GARDENA D/P SNF |
930011139 |
B |
02-Dec-14 |
L0LZ21 |
9397 |
The following represents the findings of the Department of Public Health during a Life Safety Code Survey.This facility was surveyed under the Life Safety Code NFPA 101, 2000 Edition, Chapter 19, Existing Health Care Occupancies, and other applicable codes. Representing the Department of Public Health: Evaluator ID #16281, REHS, HFE I A State Citation was issued at K 056. 42 CFR 483.70(a)(8) K 056 NFPA 101 LIFE SAFETY CODE STANDARD If there is an automatic sprinkler system, it is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It is fully supervised. There is a reliable, adequate water supply for the system. Required sprinkler systems are equipped with water flow and tamper switches, which are electrically connected to the building fire alarm system.19.3.5The facility failed to ensure the subacute unit (a distinct part skilled nursing facility) on the 6th and 7th floors was fully sprinklered by August 13, 2013 as required by Centers for Medicare & Medicaid Services (CMS) for all nursing homes participating in Medicare or Medicaid, and failed to meet 4 of 10 of the Immediate, Extraordinary, and Sustained Risk Mitigation measures as indicated in attachment four of CMS S&C-13-55-LSC letter. The census was 68, including one bedhold, and the deficiency affected 68 of 68 residents and four of four smoke compartments. Where installed and maintained properly, a sprinkler system can be the most effective device for protecting and safeguarding against loss of life and property. Findings: Between 10/14/14, at 8:45 a.m. and 10/16/14, at 11:23 a.m., during the life safety code component of the annual recertification survey the sub-acute unit was not completely sprinklered. The locations of the subacute unit that were not sprinklered included. 6th floor 20 of 20 resident sleeping rooms (51 beds). 20 of 20 bathrooms in the resident sleeping rooms. Nurse's station Medication room Nourishment room Soiled and clean utility room Resident showers Corridors Alcove Nurses lounge Office7th Floor 9 of 9 resident sleeping rooms (18 beds). 9 of 9 bathrooms in the resident sleeping rooms. Nurses station Medication room Nourishment room Soiled and clean utility room Resident showers Resident tub room Physical Therapy room/Rehabilitation gym Day room Corridors Alcove Nurse's lounge The facility did not meet the Immediate, Extraordinary, and Sustained Risk Mitigation measures for the following:1. The facility did not conduct at least monthly fire drills on each shift.On 10/15/14 at 9:30 a.m., a review of fire drills from 1/1/14 to 9/30/14 indicated that 10 of 27 fire drills were not conducted during this nine month period. Two drills were missing on the first shift, four drills were missing on the second shift, and four drills were missing on the third shift. During an interview, at the same time as the review of fire drills, the Security Manager/Disaster Coordinator stated he had just now become aware of the Immediate, Extraordinary, and Sustained Risk Mitigation measures, including the facility conducting fire drills in the not sprinklered areas at least monthly on each shift, as indicated in attachment four of CMS S&C-13-55-LSC letter. 2. The facility did not conduct at least monthly fire training of all staff.On 10/15/14 at 10:58 a.m., a review of fire training of staff, from 1/1/14 to 9/30/14, indicated that the training was scheduled with the fire drills, and that 10 of 27 trainings were not conducted during this nine month period. Two trainings were missing on the first shift, four trainings were missing on the second shift, and four trainings were missing on the third shift. During an interview, at the same time as the review of fire trainings, the Security Manager/Disaster Coordinator stated the missing trainings were not conducted because the trainings were scheduled with the fire drills, and he had just now become aware of the Immediate, Extraordinary, and Sustained Risk Mitigation measures, including the facility conducting monthly fire safety awareness, prevention, mitigation, protection of residents, and supervision of activities that present fire risk training of all staff in the not sprinklered areas at least monthly on each shift, as indicated in attachment four of CMS S&C-13-55-LSC letter. 3. Direct care staffing was not increased on each floor of the not sprinklered residential areas to ensure increased evacuation readiness. On 10/15/14 between 10:20 a.m. and 11:22 a.m., during an interview, the Director of Subacute Services stated the direct care staffing was not increased because the staffing levels more than met the required staffing. 4. Construction had not begun and there was no documented evidence the facility had filed or received permits and approvals with the local authority having jurisdiction (OSHPD) to begin installation of an automatic sprinkler system. On 10/15/14 between 10:58 a.m. and 4 p.m., during an interview the Associate Administrator stated that he was aware of the CMS S&C-13-55-LSC letter and also indicated the following: That construction work had not started on the sprinkler system and that construction was expected to start in the second quarter of 2015. That the architect stated it was the soonest they could start with construction. That the architectural project plan designs/drawings and construction documents were completed, and were submitted to OSHPD, but that the facility did not have a copy of the architectural project plan designs/drawings and construction documents that were submitted to OSHPD. That the facility was in the process of filing the necessary permits, and currently were at the phase of material testing. The Associate Administrator also stated that the facility plans are to keep the residents on the non-sprinklered 6th and 7th floors. The Associate Administrator provided an e-mail correspondence dated 7/21/14, between the architect and OSHPD, and a plan drawing that was not dated from the architect, as documentation that project plan designs/drawings were submitted to OSHPD. The e-mail correspondence indicated that the architect was working on the design of adding fire sprinklers to the 6th and 7th floors, but the correspondence did not indicate that the design was completed, submitted to, and accepted by OSHPD. The plan drawing indicated the OSHPD submittal date as xx/xx/14. Therefore, there was no documented evidence that project plan designs/drawings were submitted to OSHPD. On 10/15/14, between 10:58 a.m. and 11:22 a.m., the Director of subacute services provided the following acuity of the residents. 68 of 68 were bed bound, 68 of 68 were on oxygen therapy, 68 of 68 had tracheotomy tubes, 65 of 68 had gastrointestinal tubes, 44 of 68 had ventilators, No residents ambulated The subacute unit was located on the 6th and 7th floors of a 7 story building, plus basement, and has a mechanical penthouse on the roof. The facility is located in a type 1, concrete and steel constructed building. The rubbish chute, soiled linen chute, elevator pits, and basement were sprinklered. The 1st floor was the level of exit discharge, directly outside at grade.The subacute was compartmentalized into four smoke compartments. Two smoke compartments on the 6th floor, and two smoke compartments on the 7th floor. Each smoke compartment had two elevators and one exit stairway. There were eight portable fire extinguishers, two in each smoke compartment. The unit had battery powered smoke detectors in each room, including the resident rooms. The unit had hard wired smoke detectors throughout the corridor, including at the cross corridor doors, in front of the elevators, and at the nurses stations.The unit was under a continuous fire watch conducted by rotating dedicated security guards. The fire watch was posted at the unit, and a fire watch log maintained. There was documented evidence of monthly fire inspections of the subacute unit. CMS S&C-13-55-LSC letter dated August 16, 2013 and revised 12-20-13, indicated that on August 13, 2008 in a final rule entitled Medicare and Medicaid Programs: Fire Safety Requirements for Long Term Care Facilities, Automatic Sprinkler Systems. The regulation provided a five-year advance timeframe to achieve full sprinkler status by August 13, 2013, and that all nursing homes must be fully sprinklered as of August 13, 2013 in order to participate in Medicare or Medicaid. This is a repeat deficiency. On 10/25/13 during an annual recertification survey, the subacute unit received a deficiency for not being fully sprinkled.At the time of the previous annual recertification survey, during the follow-up visit, and during this recertification visit,the subacute unit was not fully sprinklered, and residents had not been vacated from the unit. Between the previous annual recertification survey on 10/25/13, and the current annual recertification survey on 10/16/14, 103 residents were admitted to the subacute unit. Failure of the facility to ensure the subacute unit was fully sprinklered had a direct relationship to the safety and security of the residents. |
| 930000904 |
MEMORIAL HOSPITAL OF GARDENA D/P SNF |
930011151 |
A |
05-Feb-15 |
L0LZ11 |
8915 |
42CFR 483.25 (h) (1) (2) 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 staff failed to ensure Resident 7 was safe from injury, when Resident 7 was placed in a shower trolley (gurney) and the safety belt that and had a hole the size of a quarter, snapped open resulting in Resident 7 falling off the shower gurney, landed on the floor, and caused her to have an open wound on the left side of the forehead with bleeding. Resident 7 went to the emergency room for a computerized tomography scan (CT scan combines a series of X-ray views taken from many different angles and computer processing to create cross-sectional images of the bones and soft tissues inside your body scan of the head with contrast for a evaluation). The CT scan result showed Resident 7 had a 5 millimeter (mm) right frontal convexity (means curving out or extending outward) subdural hematoma (collection of blood outside the brain).This deficient practice caused Resident 7 to have a 5 mm right frontal convexity subdural hematoma and an open area on the left frontal part of the head. Subdural hematoma symptoms are not noticeable immediately and may not appear for several weeks. The common symptoms of a subdural hematoma included inability to speak, weakness, and loss of consciousness or coma. The possible complications included brain herniation which is severe pressure on the brain that could cause coma and death (National Library of Medicine, National Institutes of Health). Also, Resident 7 received Norco (an narcotic analgesic) for pain after the incident and received treatment by cleaning the open area with normal saline solution, applying bacitracin ointment to the open area, and cover with dry dressing daily for 30 days.Findings: During the initial tour of the facility with Registered Nurse (RN) 3, on October 14, 2014, at 10 a.m., Resident 7 was lying in her bed and her hands were in a flexion position. RN 3 stated that Resident 7 had contractures (chronic loss of joint motion) to her upper and lower extremities and a left hand soft restraint to prevent pulling out her tube feeding. On October 15, 2014, at 11:05 a.m., Resident 7's clinical record was reviewed. The face sheet indicated Resident 7 was admitted to the facility on April 9, 2014 with the diagnosis that included respiratory failure (condition that is not enough oxygen passes from your lung into your body).The Admission Minimum Data Set (MDS), a standardized assessment and care planning tool dated April 21, 2014, indicated the resident was comatose (person exhibits a complete absence of wakefulness and is unable to consciously feel, speak, hear, or move). Resident 7 required total assistance from the staff for activities of daily living such as bed mobility, transfers, ambulation, dressing, personal hygiene, and bathing. Resident 7 had limitation in range of motion to her upper and lower extremities.The Change of Condition MDS dated June 5, 2014, indicated Resident 7 had a fall with injury since admission. During an interview on October 17, 2014 at 8:10 a.m., the MDS Coordinator reviewed the electronic medical record. She stated Resident 7 was a one person assist for bed mobility and was identified with upper and lower extremity weaknesses. A review of the care plan titled, "High Risk for Falls" dated April 10, 2014 at 4:47 a.m., indicated Resident 7 would not have episodes of fall every shift. The interventions included providing a safe and hazard free environment.According to a facility's "Event Report" documentation, Resident 7 had a fall incident on June 2, 2014 at 9:15 a.m. Resident 7 was on the shower gurney, in her room and was waiting for her bed to be made. The shower trolley (gurney) belt snapped opened and Resident 7 slipped from the shower gurney. Resident 7 had a head injury to her left forehead area with some swelling. Certified Nursing Assistant (CNA) 3 stated the strap belt was secured on the gurney. CNA 3 stated Resident 7 was lying on the shower gurney and was about 2 feet away from her bed. While the other CNA was preparing the bed, CNA 3 was standing on the right side of the gurney with Resident 7. The shower gurney "belt snapped open" and Resident 7 slipped off the gurney. Resident 7 was able to move her upper and lower extremities without facial grimacing. Resident 7 was noted with an open skin measuring 4.0 centimeters by 4.0 centimeters on the left side of her fore head with some bleeding. The bleeding was controlled with pressure. Resident 7 remained awake but was nonverbal and was noted with slight facial grimaces when affected area was touched. Resident 7 was medicated for pain. The family member and the physician were notified.During a telephone interview on November 4, 2014, at 10 a.m., CNA 3 stated she was assigned as a "shower person." She stated she took Resident 7 on the shower trolley to be showered and the licensed nurse ventilated the resident via the ambu bag (an ambu bag is a manual medical device used to provide assisted ventilation to people who are either not breathing or having trouble breathing. The ambu bag consists of a bag, adapter, one way value, and a mask. The ambu bag needs to be compressed to force a volume of air into the lungs). CNA 3 notified the other CNA to change Resident 7's bed. Upon returning to Resident 7's room, the other CNA was changing the linens on the resident's bed. The licensed nurse connected Resident 7 to the ventilator and left the room. CNA 3 stated she waited on the right side of the gurney by Resident 7. CNA 3 stated, "I used two belts. I saw the belt come loose." When CNA 3 was asked which belt, CNA 3 stated the top belt came loose as Resident 7 turned and fell to the floor. "I screamed. I couldn't do anything. The resident fell to the floor." CNA 3 immediately examined the belt. CNA 3 was asked what was wrong with the belt. CNA 3 stated there was a hole in the belt about the size of a quarter.During an interview on October 17, 2014 at 7:15 a.m., the clinical director of the sub acute unit stated the shower gurney was taken out of service due to the straps being were "worn out." She stated she told CNA 3 to inform her when such things like an equipment were worn out or broken. The clinical director further stated that had the CNA reported to her that the shower gurney belt had a hole, the gurney would have been replaced with the new gurney. The clinical director said, "Yes, Resident 7's fall was avoidable." The clinical director stated there was no policy and procedure for the use of the shower trolley (gurney).A review of the facility's policy and procedure titled, "Shower, Tub Bath Ventilator Dependent Resident," effective date April 2013, stipulated the purpose of the policy and procedure was to safely provide an out of bed shower for ventilator dependent residents and to ensure safe transport of the ventilator dependent resident. However, but the policy did not include procedures on the safe use of the shower trolley (gurney) or a safety inspection of the shower gurney.A review of the physician orders dated June 2, 2014, at 9:20 a.m., indicated to apply ice pack to the left frontal area of the head for five minutes. Cleanse with normal saline open area on the left frontal part of the head, apply bacitracin ointment, and cover with dry dressing daily, for 30 days.The treatment record dated June 2, 2014, indicated Resident 7 received treatments daily with cleaning the open area with normal saline solution, applying bacitracin ointment, and covering with dry dressing daily, for 30 days.A review of a Progress Note Inquiry dated June 2, 2014, at 5:45 p.m., indicated Resident 7 was given Norco (narcotic analgesic used for the relief of moderate to moderately severe pain) at 9:43 a.m. and at 5:20 p.m.The physician orders dated June 2, 2014, at 11:30 a.m., indicated an order for a stat (immediately) CT of head with contrast for evaluation status post slip from shower gurney (trolley) with open skin left side of forehead. A review of the CT scan without contrast dated June 2, 2014, at 4:10 p.m., indicated Resident 7 had a 5 millimeter (mm) right frontal convexity subdural hematoma.Failure of the facility to ensure Resident 7 was safe from injury, when Resident 7 was placed in a shower trolley (gurney) and the safety belt that had a hole the size of a quarter, snapped open, resulting in Resident 7 falling off the shower gurney, landed on the floor, and caused her to have an open wound on the left side of the forehead with bleeding and subdural hematoma. This failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 930000744 |
MOTION PICTURE & TELEVISION HOSPITAL D/P SNF |
930011723 |
A |
24-Sep-15 |
BD0Y11 |
10922 |
42 CFR 483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free for accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On February 9, 2011 at 10 a.m., an unannounced visit was made to the facility to investigate a complaint (CA000257469) of fall incident involving Resident 1, who was wheelchair bound, and was able to exit the facility through the doors leading to a stairway of an emergency exit.Based on observation, record review and interview, the facility failed to provide close supervision and a safe environment for Resident 1. The facility failed to place the alarm on the resident?s wheelchair and lock the facility?s gate leading to the street. Resident 1 who was wheelchair bound, had two incidents of falls. (1) On April 10, 2010, Resident 1 wheeled himself out of the activity room to a pathway leading to the street. Resident 1 opened the unlocked gate, got out of the facility, and fell on the street. There was no alarm on the wheelchair. Resident 1 sustained multiple abrasions (skin cut) to the face and left knee, avulsion to face (surface trauma where all layers of the skin have been torn away, exposing the underlying structures tissue), and closed head injury without loss of consciousness. (2) On November 16, 2010, Resident 1 wheeled himself through the doors leading to a stairwell of an emergency exit, fell down onto the staircase, and sustained a broken nose, facial lacerations, and required sutures. The resident did not have his wheelchair alarm on. 1. On February 9, 2011, the medical record for Resident 1 was reviewed. Resident 1 was admitted to the facility on October 13, 2009, and readmitted on November 21, 2010, with diagnosis of status post fractured (broken) nose.A review of Resident 1?s Minimum Data Set (MDS) [assessment and care planning tool] dated January 24, 2010, disclosed Resident 1 had short and long term memory problems and was moderately impaired in cognitive skills for daily decision-making. The resident required total assistance from the staff for transferring, toileting, bathing, and personal hygiene. Resident 1's mode of locomotion (move from one location to another) was cane, walker, and wheel chair. Resident 1 had a behavior of "wandering" (moved with no rational purpose). The MDS, Section J (4) ?Health Conditions/Accidents, indicated the resident had a fall in the past 31-180 days. According to the Resident Assessment Protocol (RAP) dated January 28, 2010, the problem area of falls was triggered. The RAP summary indicated the resident is encouraged to attend activities, use bed alarm and wheelchair alarm to decrease risk for falls.A review of the nurses? notes, written by Staff 3, dated April 10, 2010, at 4:01 p.m., indicated at 1:05 p.m., Resident 1 got out of the activity room from the patio door and fell on the street.A review of a long term care plan for Resident 1 titled, "Falls" dated as initiated on June 27, 2007 and "Rewritten on February 27, 2009," indicated Resident 1 had a history of falls. The resident's goals included no falls and no injuries daily. The staff's interventions included to check frequently, bed/wheel chair alarm, and anticipate needs. An additional notation written dated April 10, 2010, included frequent visual monitoring of resident's whereabouts when up in wheelchair and off unit secondary to wandering in wheelchair.A review of a Physician Progress Note dated April 10, 2010 (no time) indicated Resident had "possible open fracture versus depressed skull fracture (bone is pushed inward)." The plan was to send Resident 1 to the emergency room for an evaluation. A review of the Ambulance Flow Sheet dated April 10, 2010, indicated the resident was found lying in a hospital gurney. The chief complaint included status post fall with facial laceration above left eye.A review of the Acute Care Hospital Discharge instructions dated April 10, 2010, indicated Resident 1 had been evaluated for the following conditions(s): multiple abrasions to the face and left knee; avulsion (refers to a surface trauma where all layers of the skin have been torn away, exposing the underlying structures tissue); and closed head injury without loss of consciousness.During an interview on February 9, 2011, at 1:40 p.m., Staff 2 stated she was not in the facility [here] when Resident 1 fell on the street (on April 20, 2010), however; this is what she was told. Staff 2 stated Resident 1 was attending group activities on the 1st floor when another resident (no name) requested to go out. Staff (no name) opened the door. Resident 1 went out, wheeled himself down the walk-way, opened the gate latch leading to the street, and went off the curb. Staff 2 stated there was a camera which showed Resident 1 was outside the open gate. Staff 2 further stated the gate remained opened periodically. The activity door leading to the patio and gate was not locked at the time. Staff 2 stated Resident 1 did not have the alarm on the wheelchair. At 2:40 p.m., Staff 2 stated there was a volunteer that observed Resident 1 was sitting in the patio, and then a few minutes later, Resident 1 was gone. According Resident 1?s care plan dated June 27, 2007, and February 27, 2009, the wheelchair alarm was one of the care plan interventions. During an interview on February 10, 2011, at 12 p.m., Staff 3 stated Resident 1 would propel himself around and when he returned to his room he informed the staff. "We try to keep Resident 1 in our eye sight." Three cones were placed in front of the emergency exit door. A Velcro strap with a stop sign was also placed across the emergency exit door. The family member requested a wheelchair alarm for Resident 1 at all times. Resident 1's family member wanted Resident 1 to be in group activities. The activity staff usually informed us [Nursing] when Resident 1 returned. Staff 3 stated she did not see the activity staff bring back Resident 1 that day (April 10, 2010). She further stated even if she was busy, at change of shift, the activity staff would bring it to her attention that Resident 1 was back on the unit. When Staff 3 was asked who placed the wheelchair alarms on for Resident 1, Staff 3 stated the certified nursing assistant was responsible to place the alarm on the resident?s wheel chair. Staff 3 stated Resident 3 did not have the wheelchair alarm on April 10, 2010.2. A review of the nurses notes dated November 16, 2010, indicated Resident 1 was taken to activities at 2 p.m. for country music recital by activities staff. While giving a report to the oncoming shift, staff heard the maintenance staff screaming "Resident 1 had fallen down the staircase from the exit door that faces room 164." Staff went to the area and saw Resident 1 had fallen 2 steps down the stairs. Resident 1 was lying on his right side. Resident 1 had a bloody nose, and an ice pack was applied. Resident 1 was transferred to an acute care hospital via ambulance.A review of an acute care History and Physical Examination dated November 16, 2010, disclosed Resident 1 had a 3 millimeter (mm) falx hematoma (a bleeding between the two sides of the brain-hemispheres along the falx [The falx is a membrane that extends down from the skull and helps protect brain]) with a 3 mm bleed and a nasal fracture (broken nose). A review of two (2) Consultations from the acute care facility indicated the following:a. November 16, 2010 - indicated status post fall from wheelchair. The family member stated that the resident had a history of falls from the wheel chair. The resident had wheeled his wheel chair through a set of double doors, down a set of stairs, fell from the wheel chair, and landed on his face. The resident has a history of dementia, short term memory problems, and difficulty following conversation. The laceration (cut) to the nose was sutured (stitched). The resident also had intravenous pain control with morphine and nausea with Zofran.b. November 16, 2010 - indicated the reason for consultation was subdural hematoma (collection of blood on the surface of the brain). The initial evaluations showed bilateral nasal fractures and left sided subdural hematoma.During a tour of the stairway, with Staff 1, on February 9, 2011, at 10 a.m., Staff 1 stated Resident 1 had accessed this staircase. Staff 1 stated Resident 1 got out the second door, fell two steps, and fractured his nose. Staff 1 stated at the time of the incident (November 16, 2010) the door was not equipped with a door alarm.On February 9, 2011, at 10:15 a.m., the surveyor was accompanied by Staff 2 to the activity room. Resident 1 was in his wheel chair with no wheelchair alarm. The surveyor asked why there was no wheelchair alarm being used for Resident 1. Staff 2 responded there was no alarm because Resident 1 was with the activity staff in a group activity.A review a long term care plan tilted, ?Cognitive Loss due to status post craniotomy brain tumor? dated April 19, 2007, included wanders in wheelchair -poor safety judgement. The resident's goals included would attend activities. The staff's interventions included involve in activities, keep environment free of hazards, self-propelled (not motorized) wheel chair with supervision (only-with accompanied by family, staff, and companion), place in lounge chair for comfort after activities.Another care plan titled, ?Self Care deficit? dated April 19, 2007 indicated the staff's approaches included bed/chair alarm, may use regular wheel chair only if accompanied by staff, family, or companion. Monitor frequently.According to the facility's policies titled: a. "Care Plan- Resident," dated October 2003, stipulated the purpose was to provide a communication among health care providers regarding resident care issues. Care plans are reviewed and updated with each Interdisciplinary Care Plan meeting and as needed. Procedure indicated each care plan was individualized to reflect resident's status and needs. b. "Bed/Chair Alarms," dated August 2010 indicated the purpose was to provide a mechanism to alert staff of residents identified as "Fall Risk" who may be attempting unsafe behavior. Place the alarm on the resident as indicated. Care Plan the need for the bed/alarm. Hand off communication of use of safety device. c. "Resident at Risk for Wandering," dated October 2003 the purpose included residents who were identified to be at risk for harm because of wandering would have a care plan that addresses the issue. The Interdisciplinary Team will meet to determine the appropriate treatment care plan.The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 930000904 |
MEMORIAL HOSPITAL OF GARDENA D/P SNF |
930012207 |
B |
05-May-16 |
NLBU11 |
17910 |
CFR 483.25 Quality of Care Each patient must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Based on observation, interview, and record review, the facility licensed nurses failed to ensure Patient 8 and 14, who had a Stage III and IV pressure sores and were receiving a pressure sores treatment daily, would not experience pain during provision of a pressure sore treatment. The facility?s licensed nurses failed to:1. Administer, on a consistent basis, pain medication Tylenol 650 milligram (mg) as ordered for pain prior to a pressure sore treatment to Patient 8. Patient 8 was not administered pain medication prior to a pressure treatment for 44 out of 115 days. 2. Administer pain medication Tylenol 650 mg as care planned to Patient 14 prior to a pressure sore treatment for 53 out of 118 days. 3. Assess Patient 8 and 14 for pain prior to the provision of a pressure sore treatment by assessing patients for signs and symptoms of pain using the face, legs, activity, cry, consolability (FLACC) scale or Baker-Wong Scale (measurements used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain. The scale is scored in a range of zero to 10 with zero representing no pain, and 10 representing severe pain), as care planed.The failure to assess patients for pain and medicate prior to a pressure sore treatment resulted in Patient 8 exhibiting sign and symptom of pain and discomfort and had the potential to cause pain and discomfort to Patient 14.a. On January 22, 1016 at 6 p.m., during the initial tour of the subacute unit, Patient 8 was observed lying on a low air loss mattress (a special mattress that promotes wound healing, and relieves pressure on the body surface), and was breathing through a tracheotomy (a tube that is inserted into the trachea, or windpipe, for purposes of breathing, and removal of lung secretions), that was connected to a ventilator (a machine that assists in breathing, or completely breathes for someone). Patient 8's eyes were partially open and did not appear to be focusing. Patient 8 was receiving a feeding formula through a gastrostomy tube [(GT) a tube that is surgically inserted through the abdominal wall into the stomach for purposes of feeding and medication administration], and had an indwelling urinary catheter (tube to drain urine from the bladder) that was draining cloudy urine. A review of Patient 8's clinical record indicated Patient 8 was admitted to the facility on April 12, 2013, with diagnoses that included history of stroke (sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery), chronic encephalopathy (irreversible brain damage due to lack of oxygen to the brain cells), tracheostomy insertion and GT insertion. A review of the Minimal Data Set (MDS), a standardized assessment and care screening tool, dated January 22, 2016, indicated Patient 8 was in a persistent vegetative state (describes a condition during which a person in a coma may have some improvement, with automatic functions like breathing, heart-rate regulation, and sleep, as well as some brain-stem function, like eye opening or making sounds), was unable to walk or to talk, and was totally dependent on staff for activities of daily living. According to the MDS, under section J titled Health Conditions/ Pain Management, the patient was not on pain management regimen and was receiving pain medications as needed [(PRN) whenever necessary] and non-pharmacological (medicinal) intervention for pain. There was a physician?s order, dated January 3, 2016, to cleanse Patient 8?s sacral (buttocks area) pressure ulcer Stage III with Normal Saline solution, to apply Santyl ointment (a product that works by helping to break up and remove dead skin and tissue) and to cover with dry dressing daily for 30 days. According to the State Operation Manual Survey Protocol for Long Term Care Facilities (Appendix P, April 4, 2014, page 247) a Stage III pressure sore definition is a full thickness tissue loss, subcutaneous fat may be visible but bone, tendon and muscle is not exposed. Slough (a necrotic tissue in the process of separating from the viable portion of the body) may be present but does not obscure the depth of tissue loss. Stage III pressure sore may include undermining and tunneling. The assessment and treatment of pain are integral components of pressure sore prevention and management. The goal of pain management in the pressure sore is to eliminate the cause of pain and to provide analgesia. Pain can contribute to immobility and potentially delay healing or non-healing of already existing pressure sore. On April 1, 2015, there was a physician?s order to administer Acetaminophen (Tylenol) 650 milligrams (mg) every four hours through the GT as needed (PRN) for pain. A review of Patient 8's care plan, dated January 22, 2016, indicated Patient 8 was totally dependent on staff with care and bed mobility, and the nursing staff had to monitor the patient for signs and symptoms of pain using the FLACC scale or Baker-Wong Scale.A review of Patient 8's Medication Administration Record (MAR) from November 7, 2015, to January 23, 2016, indicated Tylenol 650 mg was not administered prior to sacral pressure sore treatment on the following dates: 1. On October 3, 4, 8, 9, 10, 19, 20, 21, 23, 26, 27, 28, 29, and 31, 2015, a total of 14 days. 2. On November 8, 12, 15, 25, 27, 29 and 30, 2015, a total of 7 days. 3. On December 2, 5, 6, 7, 8, 9, 12, 14, 17, 18, 22, 23, 24, 25, 27, 28 and 31, 2015, a total of 17 days. 4. On January 2, 6, 11, 14, 19, and 20, 2016, a total of 6 days.Patient 8 was not administered pain medication prior to a pressure sores treatment for 44 days out of 115 days total for October, November and December 2015, and January 2016. There was no documented evidence the licensed nurse assessed the resident for pain as care planned on those days when the resident was not administered pain medication before the pressure sore treatment. On January 23, 2016, at 4:05 p.m., during an observation of Patient 8's pressure sore care, the licensed vocational nurse 1 (LVN 1) was observed preparing the pressure sore treatment supplies. The LVN 1 was observed sanitizing her hands, donning a clean pair of gloves, removing the old sacral pressure sore?s dressing and irrigating the pressure sore with Normal Saline solution and then wiping the pressure sore dry with gauze. The LVN 1 then was observed applying Santyl ointment to the pressure sore and A&D ointment (a skin protectant) around the edges of the pressure sore, covering with sterile gauze dressing and securing the dressing in place with tape.Concurrently, during pressure sore treatment, Patient 8 appeared awake and was observed to have facial grimacing. Both, the LVN 1 and a certified nursing assistant 1 (CNA 1), who was assisting with repositioning the patient during treatment, would periodically tell the patient "It's okay", and the LVN 1 would tell the patient several times "We are almost done."A review of Patient 8's MAR indicated the most recent Tylenol 650 mg dose was administered at 8:20 a.m., on January 23, 2016, eight hours before actual pressure sore treatment was provided.According to the Nursing Drug Handboook (Lippincott Williams&Wilkins, 2015) Tylenol 650 mg dose is effective in the treatment of pain of mild to moderate intensity with onset (start) from 30 minutes to one hour, pick effect (most effective) from one hour to three hours and with duration (a continued effect until effect is no longer present) time from three to four hours.On January 23, 2016, at 4:40 p.m., an interview was conducted with the LVN 1 and the LVN 2 (medication nurse). Both LVNs stated Patient 8 should have been pre-medicated for pain prior to a daily pressure sore treatment. Both LVNs confirmed the patient was not pre-medicated with the pain medication at least 30 minutes before pressure sore treatment. On January 23, 2016, at 4:50 p.m., during an interview with CNA 1, when asked if Patient 8 was able to respond, CNA 1 stated the resident was able to respond at times by facial expression, and would sometimes attempt to indicate her needs by moving her eyes.b. On January 26, 2016, at 11:10 a.m., Patient 14 was observed lying on a low air loss mattress. Patient 14 was not verbally responsive and was breathing through a tracheostomy that was connected to a ventilator. Patient 14 had contractures (shortening of the muscle tissue, causing the muscle to become highly resistant to stretching, and can lead to permanent disability) of both upper and lower extremities, and was receiving feeding formula through a G-tube. A review of Patient 14's clinical record indicated the patient was admitted to the facility on December 28, 2004, with diagnoses that included chronic respiratory failure with ventilator dependency, tracheostomy insertion, gastrostomy insertion, and multiple pressure sores. A review of Patient 14's MDS, dated December 29, 2015, indicated the patient was in a persistent vegetative state, was receiving feeding through a GT, and was totally dependent on staff for activities of daily living. According to the MDS the patient had the following pressure sores: 1. A Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar-dead tissue may be present. Often includes undermining and tunneling) to coccygeal (tailbone) site A. 2. A Stage IV to left heel. 3. A deep tissue injury [(DTI) a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to a right heel. 4. A Stage II (partial thickness skin loss) to left buttock. 5. Stage III (full thickness tissue loss) to left first and fourth toes.There was a physician?s order, dated June 11, 2012, to administer Acetaminophen (Tylenol) 650 mg through the GT every four hours PRN for pain. A review of Patient 14's care plan for comfort, dated December 21, 2015, indicated alteration in comfort related to pain, secondary to presence of pressure sores and contractures of both upper and lower extremities. The approaches included to assess the resident for signs and symptoms of pain and to administer pain medication as ordered and as needed. A review of Patient 14's MAR indicated the patient was not pre-medicated for pain prior to a pressure sore treatment as follows: 1. On October 3, 4, 8, 9, 10, 19, 20, 21, 23, 26, 27, 28, 29, and 31, 2015, a total of 14 days. 2. On November 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 15, 17, 18, 23, 27, 28, 29, and 30, 2015, a total of 20 days. 3. On December 3, 6, 8, 9, 10, 14, 16, 17, 18, 22, and 23, 2015, a total of 11 days. 4. On January 2, 5, 6, 9, 10, 11, 19, and 20, 2016, a total of 8 days. Patient 14 was not administered pain medication prior to a pressure sore treatment for 53 days out of 118 days total for October, November and December 2015, and January 2016. There was no documented evidence the licensed nurse assessed the resident for pain as care planned on those days when the resident was not administered pain medication before the pressure sore treatment. On January 26, 2016 at 11:45 a.m., during an interview with LVN 5, she confirmed the resident was not consistently assessed for pain and medicated for pain before provision of the pressure sore treatment. LVN 5 stated she will ask the treatment nurse which patients were scheduled to receive pressure sore care, then would medicate those patients approximately one hour prior to the treatment. On January 27, 2016, at 8:45 a.m., during an interview with CNA 4, stated Resident 14 was able to respond by moving her right arm, then stated that during wound care, whenever she assisted the treatment nurse with holding and repositioning the patient, she could feel the patient's right arm tense up when the patient's coccygeal pressure ulcer was being treated. On January 27, 2016, at 10:55 a.m., an interview was conducted with the Pharmacist 1 and the Pharmacist 2 at the same time. The Pharmacist 1 stated the wound care nurse attended the monthly interdisciplinary team (IDT) meetings, and if there was any indication that a patient required pain medication, it would be discussed with the IDT members. The Pharmacist 2 further stated the subacute unit did not have a pain management program in place, and that the pharmacy department relied on the licensed nursing staff to keep them informed regarding patients? status. There was no discussion in IDT regarding Patient 8 and 14. The Pharmacist 1 stated that he would have to evaluate each patient individually in order to determine whether a patient was manifesting any non-verbal signs or symptoms of pain during pressure sore treatment. He would then address that patient's pain medications needs with the physician.The Pharmacist 2 stated that he will start a conversation with the physicians and the IDT members regarding individualizing pain management for patients on the subacute unit. On January 27, 2016 at 2:05 p.m., an interview was conducted with the subacute unit medical director 1 (MD 1). The MD 1 stated that he would assess patients for any potentially painful conditions and then would order pain management around the clock, would re-assess patients after two weeks and then would keep that plan if there would be an improvement.As the interview with the MD 1 continued, he indicated the subject of pain being discussed during the IDT meetings, but may not always be documented in the IDT meeting notes. MD 1 then stated that he will put a pain management plan together, and will give a lecture on pain management for the subacute staff.According to the online article on the National Pressure Sores Advisory Panel website (http://www.npuap.org/wp-content/uploads/2012/01/Pieper_2009_Feb1.pdf), titled, ?Pressure Sores Pain: A Systematic Literature Review and National Pressure Sore Advisory Panel White Paper", dated February 2009, indicated the following: "Pressure sore pain needs to be assessed and treated because it has widespread physical and psychosocial implications for the patient...Pressure sore pain may be caused by tissue trauma from sustained loads [refers to pressure at the site of the ulcer, adequacy of blood supply, and infection], inflammation, damaged nerve endings, dressing changes, debridement [the process of removing nonliving tissue from pressure sore, burns, and other wounds], operative procedures, and other treatments. The skin has more sensory nerves than any other body organ. As the pressure sore cellular damage expands, chemicals are released that irritate nociceptive [the encoding and processing of harmful stimuli in the nervous system] nerve [endings] ...The sore erodes through tissue planes [layers] and destroys nerve terminals. As peripheral nerves regenerate, the nocioceptive nerve terminals send out immature sprouts of nerve tissue that may be hypersensitive to both noxious (hurtful, injurious) stimuli, and non-noxious stimuli [stimuli that is not painful or annoying]... Pain, particularly acute pain, is also a stimulus to the stress response thus, at the cellular level [the most basic structural units of the human body], hypoxia [inadequate amount of oxygen] may develop because of limited painful breathing and peripheral vasoconstriction [constriction of blood vessels, which may result in decrease of flow of blood] and impede wound healing... [Studies of pressure sores pain have shown that] the most frequently used descriptors by pressure sore stage were: tender, hurting, sore (Stage II); burning, tender, hurting, sore (Stage III); and tender, hurting, sharp, sore, wretched (Stage IV)...Persons with either Stage III or Stage IV pressure sore had significantly more pain than persons with other wounds... Pain assessment scales... have been used in research to measure pressure sore pain...Clinicians should have a high index of suspicion of pressure sore pain in patients, including those who cannot respond..."According to the National Pressure Ulcer Advisory Panel (NPUAP): "Pressure Sore Pain-A Systematic Literature Review and NPUAP White Paper," dressing change and pressure sore treatments were among the most painful times for an individual with a pressure sore. Pressure sore pain should be assessed by the bedside clinician. Pain medication should be administered on a schedule that maximizes the patient's ability to be comfortable during pressure sore treatment.The facility?s licensed nurses failed to:1. Administer, on a consistent basis, pain medication Tylenol 650 milligram (mg) as ordered for pain prior to a pressure sore treatment to Patient 8. Patient 8 was not administered pain medication prior to a pressure treatment for 44 out of 115 days. 2. Administer pain medication Tylenol 650 mg as care planned to Patient 14 prior to a pressure sore treatment for 53 out of 118 days. 3. Assess Patient 8 and 14 for pain prior to the provision of a pressure sore treatment by assessing patient for signs and symptoms of pain using the face, legs, activity, cry, consolability (FLACC) scale or Baker-Wong Scale (measurements used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain. The scale is scored in a range of zero to 10 with zero representing no pain, and 10 representing severe pain), as care planed.The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 940000001 |
MIRADA HILLS REHABILITATION AND CONVALESCENT HOSP |
940008589 |
A |
09-Feb-12 |
W0HL11 |
14601 |
? 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. On 5/4/10, at 2:45 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1?s fall with injury. Based on interview and record review, the facility failed to implement Patient 1?s plan of care according to the methods indicated by failing to: 1. Provide closer eye (visual) supervision as stated in the plan of care. 2. Provide one to one supervision as recommended by physical therapy.Patient 1 fell from the wheelchair, after being left unsupervised in front of the nursing station, sustaining a right lower eyelid laceration (irregular tear-like wound) and a right maxillary sinus (air cavity in the body of the maxilla, behind the cheek) fracture. On 5/4/10, a review of the clinical record revealed Patient 1 was an 80 year old female, admitted to the facility on 2/4/10, with diagnoses that included dementia (a loss of memory, concentration, and judgment), paralysis agitans (Parkinson?s disease, a progressive disorder of the nervous system that affects movement), hypertension (high blood pressure), and intracranial hemorrhage (bleeding within the skull). The physician?s orders upon admission included the anti-anxiety medication Ativan (Lorazepam) 1 milligrams (mg) three times a day as needed for severe anxiety manifested by inability to relax, which was discontinued on 2/8/10, and Ativan 0.5 mg twice daily as needed for inability to relax. A plan of care dated 2/4/10, indicated the patient was at risk for falls and injuries related to the patient?s diagnoses, needing assistance with activities of daily living (ADLs), use of psychotropic (mind altering) medications, history of multiple falls at home and syncope (fainting) episodes. The goal was to minimize falls and injuries. One of the approaches was to give the patient verbal reminders not to ambulate or transfer without assistance. On 2/5/10, the physician ordered physical and occupational therapy (PT and OT) for four weeks. According to the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 2/10/10, Patient 1 was moderately impaired in cognitive skills for daily decision-making (decisions were poor and cues/supervision required), was usually able to make herself understood and understand others, exhibited repetitive physical movement (e.g. restlessness) up to five days a week, and also exhibited behavioral symptom of wandering (moved with no rational purpose and seemingly oblivious to needs for safety) that was not easily altered, one to three days in the last seven days. The MDS also assessed the patient as totally dependent on staff for toilet use and bathing, required extensive assistance with bed mobility, transfers, dressing and personal hygiene. The MDS indicated the patient used a wheelchair as the primary mode of locomotion, had an unsteady gait and fell in the past 30 days.A review of the Fall Risk Assessment dated 3/4/10, indicated the resident was at high risk for falls. Further review of the nurse?s notes, interdisciplinary notes, and investigation reports revealed during her stay in the facility, Patient 1 fell a total of eight times, 2/6/10, 2/8/10, 2/13/10, 2/19/10, 2/25/10, 4/6/10, 4/15/10, and 4/18/10. On 2/6/10, at 6 p.m., the patient was found sitting on the floor next to the wheelchair near the Nursing Station, complaining of pain to the left arm and an x-ray to the arm was negative for fracture. The physician ordered a motion alarm to the patient?s bed and wheelchair.On 2/8/10, at 5:45 p.m., the patient had an assisted fall, by the nursing station, after trying to stand up from her wheelchair unassisted, no injuries were noted. On the same day, the physician ordered a low bed with landing mats. According to the Rehabilitation Services Multidisciplinary Screen Tool form, dated 2/9/10, a physical therapist documented the patient required constant monitoring. On 2/10/10, the physician changed the ordered alarm in wheelchair to a pressure pad alarm in wheelchair to alert staff when trying to get up unassisted.On 2/13/10, at 3 a.m., the patient was found by her bed, lying on her right side on the right landing mat. There was bleeding on the right nostril, cold compresses were applied and neurological checks for 72 hours were done. The neurological checks were within normal limits and there was no further bleeding. On 2/15/10, the physician changed the ordered alarm in bed to a pressure pad alarm in bed. On 2/18/10, the physician ordered a lap buddy (foam cushion restraining device applied over the lap that prevents the patient from rising) for proper body alignment while in the wheelchair.On 2/19/10, at 10 a.m., the patient had an assisted fall while in the bathroom with the physical therapist. As a result of the fall, the patient developed pain/bruising to the left foot and left arm. The physician ordered x-rays of the left foot, left arm and the skull, which were negative for fracture. On the same day, the physician ordered to discontinue the pressure pad alarm in wheelchair due to the use of the lap buddy restraint. According to the Rehabilitation Services Multidisciplinary Screen Tool form, dated 2/19/10, a physical therapist documented the patient required close supervision. On 2/25/10, at 3:15 p.m., the patient had a fall, with no injuries, when trying to get out of the wheelchair removing the lap buddy. The care plan for risk for falls was revised including in the approaches to provide closer eye (visual) supervision. The physician ordered an anti-depressant medication Paxil 10 mg every night for depression manifested by crying episodes. According to the Rehabilitation Services Multidisciplinary Screen Tool form, dated 2/26/10, an occupational therapist documented nursing staff will continue to monitor the patient closely to prevent further falls. On 3/23/10, the physician ordered a psychiatric evaluation that was conducted the same day. The evaluation indicated the patient was confused, restless with constant attempts to get out of bed or wheelchair unassisted, very difficult to re-direct, easily agitated and continued to yell and scream for no apparent reason. She was easily distractible because of a short attention span. She was excited, irritable and labile (undergoing frequent change). She showed signed of hyperactivity. The psychiatric evaluation included an order to increase the Ativan 0.5 mg to every six hours as needed for inability to relax, added Namenda 5 mg daily for 14 days and then twice daily for dementia and the mood stabilizer Depakote Sprinkles 125 mg three times a day for psychosis manifested by poor impulse control and attempts to climb out of bed. A nurse?s note dated 4/5/10, indicated the patient had multiple attempts to get out of bed and wheelchair and she was placed on a one to one with a nurse aide for fall precaution.On 4/6/10, at 2 p.m., the patient was found by a staff member lying on her stomach, with nose bleeding, on the floor in front of the nursing station. The patient had been placed in front of the nursing station for close supervision; however, she was able to remove the lap buddy and had an unwitnessed fall. The physician ordered x-rays of the skull and maxilla which were negative for fracture. The physician discontinued the use of the lap buddy and ordered a lap belt restraint in the wheelchair for safety. According to the Rehabilitation Services Multidisciplinary Screen Tool form, dated 4/7/10, a physical therapist documented the patient was on one to one supervision. According to another Rehabilitation Services Multidisciplinary Screen Tool form, dated 4/8/10, a physical therapist documented the one to one supervision was reinforced and recommended continuous monitoring with one to one supervision. A Social Service Progress Notes dated 4/8/10, indicated it was explained to Family Member A that the placement of Patient 1 in the facility was not appropriate because the facility did not provide one to one care.On 4/15/10, at 5:35 p.m., the patient was found by the nursing station, on the floor, with the right side of the face down. The patient had slid under the belt and got out of the wheelchair. The physician ordered x-ray of both hips which were negative for fracture. An interdisciplinary progress note dated 4/16/10, indicted the care plan for risk for falls was revised with an approach to discharge the patient home or in a small group setting as the facility could not meet the patient?s needs. An Interdisciplinary Progress Notes dated 4/16/10, indicated staff would continue to provide all safety precautions.According to the Nurse?s notes, on 4/18/10, at 7 p.m., the patient started to become agitated. The lap belt was in place because the patient tried to get out of the wheelchair. She was closely monitored by placing her wheelchair in front of the nursing station. At 8 p.m., Ativan 0.5 mg was given. At 9 p.m., Certified Nursing Assistant 1 (CNA 1) went to attend to the needs of anther patient, so Registered Nurse 1 (RN 1) took over the monitoring of the patient in front of the Nursing Station. At 9:05 p.m., RN 1 went inside the medication room and upon return at 9:08 p.m., the patient was found on the floor next to her wheelchair in front of the nurse?s station with her face down. The right lower eyelid was bleeding, and first aid and pressure to the bleeding site were applied. At 9:10 a.m., paramedics were called and at 9:20 p.m., the patient was taken to Acute Care Hospital 1 for further evaluation. The Emergency Department Patient Care Record from Acute Care Hospital 1 dated 4/18/10, timed at 9:47 p.m., indicated the patient fell forward out of the wheelchair while wearing eye glasses. The physical assessment section indicated the patient had swelling to the right cheek with hematoma, laceration under the right eye and bruising to the abdomen.A facial bone computed tomography (CT) scan dated 4/18/10, indicated a depressed fracture of the anterior wall of the right maxillary sinus with soft tissue swelling and some fluid in the right maxillary antrum (cavity). The Emergency Department Physician Chart dated 4/18/10, timed at 9:58 p.m., indicated the diagnostic impressions included blunt head trauma, laceration to the right lower eye lid involving the lacrimal duct (also known as tear duct, a short tube in the inner corner of the eyelid through which tears drain into the nose) and right maxillary sinus open fracture. At 11:57 p.m., the ophthalmologist advised the patient needed an ocular/plastic specialist, which Acute Care Hospital 1 did not have. Patient 1 was transferred on 4/19/10 to Acute Care Hospital 2.A review of the Trauma Run from Acute Care Hospital 2 dated 4/19/10, timed at 8:08 a.m., the patient was transferred as an inter-facility transfer for higher level of care. Her physical examination showed she had a right periorbital ecchymosis (bruise around the right eye) with a medial canthus laceration (a cut at the corner of the eye situated medially or near the midplace of the face). The CT scan of head showed a maxillary sinus fracture. The patient was discharged home on 4/22/10. A review of the Opthalmology Specialties Exam Form from an outpatient visit dated 5/4/10, indicated the resident had status post right lower lid laceration repair with ectropion (a condition in which the eyelid, typically the lower lid, turns out, leaving the inner eyelid surface exposed and prone to irritation). An Ophthalmology Specialties Exam Form from an outpatient visit dated 5/12/10, indicated right lower lid ectropion with tear duct obstruction. Another Ophthalmology Specialties Exam Form from an outpatient visit dated 6/16/10, indicated the patient complained of blurred vision, tearing, wiping throughout the day, and the sunlight bother the patient. The patient was diagnosed with epiphora (overflow of tears) of the right eye and right lower lid retraction as a result of the traumatic fall.On 5/4/10, at 3:20 p.m., during a telephone interview, RN 1 stated Patient 1 was agitated prior to the fall from the wheelchair and Ativan was given around 8 p.m., but was not effective. RN 1 stated CNA 1 needed to assist another patient so the patient was wheeled in front of the Nursing Station for him to watch her. RN 1 stated staff took turns in closely monitoring the patient by keeping an eye on her. RN 1 stated he went to the medication room quickly around 9 p.m. to obtain a pain medication for another patient and when he came out of the medication room, the resident was already on the floor facing down. RN 1 stated the patient had a seat belt while in the wheelchair but could get out of the seat belt. On 5/4/10, at 3:50 p.m., during an interview, CNA 1 stated someone had to keep an eye on Patient 1 all the time and ?everybody? knew that. CNA 1 stated she saw the patient trying all the time to get out of bed and wheelchair with the seatbelt on.On 5/4/10, at 3:45 p.m., during an interview, the administrator stated RN 1 was already disciplined for his bad judgment call to go inside the medication room and leave the patient. A review of the facility?s policy and procedure titled ?Incident Management?, revised on 11/2008, indicated each resident receives adequate assistance and oversight as defined in an individualized plan of care that reduces the risks for incidents. If a resident has had an accident or fall, the facility investigates and provides focused review to minimize the potential for recurrence. The procedures indicated identify residents who are at risk for incidents and implement care-planned procedures designed to reduce the risks of incidents. The facility failed to implement Patient 1?s plan of care according to the methods indicated by failing to: 1. Provide closer eye (visual) supervision as stated in the plan of care. 2. Provide one to one supervision as recommended by physical therapy.Patient 1 fell from the wheelchair, after being left unsupervised in front of the nursing station, sustaining a right lower eyelid laceration (irregular tear-like wound) and a right maxillary sinus (air cavity in the body of the maxilla, behind the cheek) fracture.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 Patient 1. |
| 970000141 |
MAPLE HEALTHCARE CENTER |
940008692 |
A |
10-Feb-12 |
PFNX11 |
11386 |
72311. Nursing Service - General (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient?s needs with input, as necessary, from health professional involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed with seven days after admission.72501. Licensee ? General Duties. (e) The licensee shall employ an adequate number of qualified personnel to carry out all the functions of the facility and shall provide for initial orientation of all new employees, a continuing in-service training program and competent supervision.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.On 4/12/10, at 1:45 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1's fall resulting in his death. Based on observation, interview and record review, the facility failed to identify Patient 1?s care needs based upon initial and continuous assessment, implement written patient care policies and procedures, and employ qualified personnel by failing to: 1. Conduct an appropriate assessment after Patient 1 sustained a head injury. 2. Provide appropriate interventions and emergency care to prevent complications from Patient 1?s fall and injury. 3. Ensure that Licensed Vocational Nurse 1 (LVN 1), who was the only licensed nurse in charge during the 11 p.m. to 7 a.m. shift, with no registered nurse on site, had received training and was deemed competent to manage emergency situations, falls with injuries and head trauma. 4. Implement policy and procedures on fall prevention and incident management. Patient 1 fell on the floor, hitting his head against a wall and leaving a dent on the wall. The charge nurse, LVN 1, sat the patient up on a chair after the fall without immobilizing (restricting movements) his head/neck, placed a cold compress on his forehead and right eyelid and administered oxygen via mask when the patient became less responsive. The paramedics arrived to the facility and found the patient sitting in a chair without a blood pressure, pulse or respiration. The autopsy report indicated the cause of death was a neck fracture that interfered with his ability to breathe. The director of nursing, the therapist and the coroner's examiner stated the appropriate intervention during a head impact is to immobilize the head/neck and not to move the patient. A review of the Patient 1's closed clinical record revealed the patient was a 69 years old male, admitted to the facility on 6/14/07, with diagnoses that included insomnia (sleeplessness) and Alzheimer's with dementia (a brain disease that affects memory, thinking and behavior).The quarterly Minimum Data Set (MDS - standardized assessment and care planning tool) dated 9/13/09, indicated the patient was cognitively impaired for daily decision-making, was unable to make himself understood or understand others, exhibited daily wandering behavior that was easily altered and was independent in walking and locomotion on and off the unit. The LVN Personnel Weekly Progress Notes, documented by LVN 1, indicated on 10/31/09, at 2:20 a.m., the patient was seen by certified nursing assistant 1 (CNA 1) running down the hallway. CNA 1 ran after the patient, who went inside and across the dining room to the exit of another hallway. Before CNA 1 could reach the patient, he fell and hit his head on the wall opposite to the exit door of the dining room. The patient was lying on the floor, on his right side and a dent from the impact of the head was noted on the wall. LVN 1's nursing progress note dated 10/31/09, timed at 2:20 a.m., further indicated the patient, while lying on the floor, was able to open his eyes and look at LVN 1, CNA 1 and CNA 2, when his name was called. The vital signs were taken indicating the blood pressure was 107 millimeters of mercury (mmHg) over 68 mmHg (107/68), the pulse rate was 67 beats per minute and the respiration rate was 18 breaths per minute. Chest movement was noted and the patient was assisted to sit up on a chair because he tried to get up. While the patient was in the chair, a cold compress was placed on his forehead and right eyelid.There was no evidence in the clinical record that LVN 1 and CNAs 1 and 2 tried to immobilize the head and neck of the patient prior to moving him from the floor. LVN 1 documented on 10/31/09, at 2:30 a.m., the patient, while sitting in a chair, became less responsive, a weak pulse was still noted, 911 emergency services were called and the patient was given oxygen via mask. Upon arrival of the paramedics (a medical emergency response team), the patient was transferred to a gurney and cardiopulmonary resuscitation (CPR- lifesaving technique) was performed. According to the Emergency Medical Service Report, the paramedics arrived at the facility on 10/31/09, at 2:35 a.m., and found the patient sitting in a chair. At 2:36 a.m., the patient's vital signs (blood pressure, pulse, respiratory rate and oxygen saturation) were measured as zero. CPR and cardiac monitoring were provided and emergency fluid and medications were given. At 2:50 a.m., the patient's vital signs were re-checked and the values remained zero. At 2:59 a.m., the patient was pronounced dead at the facility. On 9/8/11, at 1:20 p.m., during an interview, a licensed registered occupational therapist (OTR/L) stated whenever a head impact/injury is involved, first aid should include protecting and immobilizing the head and neck first, not moving the patient until after the paramedics arrived and performing an appropriate assessment. The OTR/L stated the best position after a head impact is a neutral position, not hyper-flexed (flexion beyond normal range) or hyper-extended (forcefully extended). On 9/8/11, at 2:40 p.m., during an observation of the site of the fall, with the director of staff development (DSD) and restorative nurse aide 1 (RNA 1), the dent the patient left on the wall, was still noticeable and had been covered with paint. The dented area was 20 inches from the floor, and measured approximately seven inches in length by seven inches in width. On 9/8/11, at 3 p.m., during an interview, the current director of nursing (the director of nursing at the time of the patient's fall no longer worked in the facility) stated the facility did not have policies and procedures addressing immobilization of the head after an impact because that was a basic nursing approach. The director of nursing stated paramedics should have been called immediately after the fall and the patient should not have been moved until paramedics arrived. On 9/8/11, at 3:34 p.m., during an interview with the DSD and a review of LVN 1?s personnel file revealed LVN 1 no longer was employed by the facility. According to the DSD, LVN 1 left soon after the incident had occurred and did not give a written resignation. LVN 1 was hired on 8/21/06, and the personnel file lacked documented evidence of training on managing emergency situations, falls with injuries and head trauma. There was no evidence LVN 1?s competency was evaluated to be the nurse in charge of the patients without direct supervision of a registered nurse. Attempts to contact LVN 1 failed due to lack of current contact information. On 9/9/11, at 9:51 a.m., during a telephone interview, CNA 2 stated it was the decision of the charge nurse, LVN 1, to sit the patient up on a regular chair (dining room chair) after the fall. CNA 2 stated the patient was trying to get up. According the Autopsy Report by the Department of Coroner, dated 3/10/10, an autopsy was performed on 11/7/09, and the cause of death was a neck fracture. There was a markedly displaced hyperextension fracture of the cervical vertebra 4 (C4 ? one of the eight vertebrae of the cervical spine) which had hemorrhage (bleeding) within it. The examiner?s opinion indicated ??When the decedent (deceased) fell against the door and hit his forehead, his head snapped backward and thereby he broke his neck. This caused an injury to his spinal cord which was fatal because it interfered with his ability to breathe. The fall also caused a subdural hematoma (collection of blood on the surface of the brain) around the decedent's brain, which, although not fatal, gives evidence of the severe degree of force involved in the impact. When a person suffers a suspected neck fracture, the best treatment is not to move them, because this can exacerbate the fracture by causing movement of the broken bones against the spinal cord. One thing you certainly don't want to do is to sit the person up; that is highly likely to exacerbate the fracture However, I could not tell from the autopsy whether it exacerbated the fracture in this case. The fracture was markedly displaced as a result of the fall, so it was already a fatal injury." The facility's policy and procedure titled, "Fall Prevention and Incident Management," revised 9/8/09, revealed when a patient incident occurs, the employee making the discovery immediately notifies the licensed nurse to conduct appropriate assessment and provide interventions and/or emergency care as needed. According to the Incident/Accident Treatment, Investigation and Reporting Flow Chart; Incident Management, when an incident occurs, assess the patient and provide appropriate intervention and/or emergency care, if necessary. Pursuant to Medical-Surgical Nursing: Assessment and Management of Clinical Problems/2000 Mosby, Inc. Sharon M. Lewis, Margaret M. Heitkemper, Shannon R. Dirksen. 5th edition. Pages 1722, 1726: ?The most common causes of spinal cord injuries include motor vehicle accidents, falls... When spinal cord injury happens to older adults the result is more devastating. The initial goals for the patient with a spinal cord injury are to sustain life and prevent further cord damage. After stabilization at the accident scene the person is transferred to a medical facility. A thorough assessment is done to specifically evaluate the degree of deficit and to establish the level and degree of injury.?The facility failed to identify Patient 1?s care needs based upon initial and continuous assessment, implement written patient care policies and procedures, and employ qualified personnel by failing to: 1. Conduct an appropriate assessment after Patient 1 sustained a head injury. 2. Provide appropriate interventions and emergency care to prevent complications from Patient 1?s fall and injury. 3. Ensure that Licensed Vocational Nurse 1 (LVN 1), who was the only licensed nurse in charge during the 11 p.m. to 7 a.m. shift, with no registered nurse on site, had received training and was deemed competent to manage emergency situations, falls with injuries and head trauma. 4. Implement policy and procedures on fall prevention and incident management. The above violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Patient 1. |
| 970000109 |
Montecito Heights Healthcare & Wellness Centre, LP. |
940008992 |
B |
10-Feb-12 |
9IPW11 |
4123 |
Class B Citation Title 22, 72357. Pharmaceutical Service ? Labeling and Storage of Drugs.(f) Drugs shall be stored in appropriate temperatures. Drugs required to be stored at room temperature shall be stored at a temperature between 15øC (59øF) and 30øC (86øF). Drugs requiring refrigeration shall be stored in a refrigerator between 2øC (36øF) and 8øC (46øF). When drugs are stored in the same refrigerator with food, the drugs shall be kept in a closed container clearly labeled ?drugs.?On 9/14/11, an unannounced visit was made to the facility to conduct a standard recertification survey which was completed on 9/21/11.Based on observation, interview, and record review, the facility failed to ensure that all drugs shall be stored in appropriate temperatures by failing to: Maintain medications stored at room temperature between 59 degrees Fahrenheit (F) and 86 degrees F. The medication room temperature was recorded at 91.8 degrees F, 5.8 degrees F above the recommended temperature to maintain the integrity of the medications placing patients at risk for adverse effect from the administration of unsafe medications.On 9/14/11, at 2:50 p.m., during the initial tour of the facility, in the presence of Licensed Vocational Nurse 1 (LVN 1), the medication room on the South wing was noted to be warm. The temperature obtained by the maintenance supervisor with an infrared thermometer indicated a temperature of 91.8 degrees F.The following medications were observed:1. One bottle of Polyethylene Glycol 3350 NF (Miralax - a laxative).The manufacturer's recommendation is to store at 68 - 77 degrees F. 2. Two bottles of acetaminophen (Tylenol - pain reliever, fever reducer). The manufacturer's recommendation is to store at 59 - 86 degrees F. 3. Four bottles of Tactinyl (Tylenol). The manufacturer's recommendation is to store at 68 - 87 degrees F. 4. Two bottles of Diocto Liquid (stool softener). The manufacturer's recommendation is to store at 68 - 77 degrees F. 5. One bottle of Metoclopramide (aids in gastric motility). The manufacturer's recommendation is to store at 68 - 87 degrees F. 6. One box of Bisacodyl suppositories 10 milligrams (mg) (laxative). The manufacturer's recommendation is to store at 68 - 87 degrees F. 7. Four tubes of Instaglucose (a form of glucose/sugar used to treat low blood sugar in an emergency). The manufacturer's recommendation is to store at 59 - 87 degrees F.There were also several emergency medication kits in the medication room which contained various intravenous (IV), oral, sublingual (under the tongue), intramuscular (IM), and inhalant medications. These medications were intended for immediate use in the event of an emergency or when a drug needed to be initiated in a timely manner.During a concurrent interview, LVN 1 stated the medication room temperature had been warm for approximately three weeks. On 9/15/11, at 8:15 a.m., during an interview with the director of nursing and the administrator, the director of nursing stated he had initially noticed the high temperature in the medication room approximately three weeks ago. The administrator explained the air conditioning service technician had been in the facility two weeks ago and informed her a part for the air conditioning system had to be ordered to repair the cooling/heating system. The director of nursing and the administrator could not explain why the medications were not relocated to another room with appropriate holding temperatures to preserve the medications.The facility failed to ensure that all drugs shall be stored in appropriate temperatures by failing to: Maintain medications stored at room temperature between 59 degrees Fahrenheit (F) and 86 degrees F. The medication room temperature was recorded at 91.8 degrees F, 5.8 degrees F above the recommended temperature to maintain the integrity of the medications placing patients at risk for adverse effect from the administration of unsafe medicationsThe above violation had direct or immediate relationship to the health, safety or security of the patients. |
| 940000092 |
MAYWOOD SKILLED NURSING & WELLNESS CENTRE |
940009065 |
A |
07-Aug-12 |
VO3E11 |
11473 |
F323CFR 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 11/8/11, an unannounced visit was conducted to investigate an entity reported incident regarding Resident 1 who eloped from the facility and sustained a fatal (deadly) fall. Based on interview and record review, the facility failed to ensure Resident 1, who was assessed at risk for elopement (leaving without notice or permission), received adequate supervision by failing to: 1. Monitor the resident?s whereabouts and observing his activities when out of bed according to the plan of care. 2. Check the resident every two hours and observing him for safety according to the facility's policy and procedure. 3. Ensure the alarm system, that alerted staff when someone exited the front door, was on. On 11/8/11, Resident 1 eloped from the facility using his wheelchair for locomotion and was found outside a convenient store which was 0.37 miles away from the facility. The resident was found sitting in his wheelchair with a trauma to his forehead and unresponsive. The resident was pronounced dead on 11/8/11 by the paramedics. On 11/9/11, a review of the clinical record revealed the resident was a 61-year-old male, admitted to the facility on 9/29/11, and re-admitted on 10/23/11, with diagnoses that included abnormality of gait (deviation from normal walking), bipolar disorder (serious mental illness that causes shifts in a person's mood, energy, and ability to function), and end stage renal disease (progressive loss of renal function). The resident was self-responsible. The admission Minimum Data Set (MDS - standardized assessment and care planning tool) dated 10/6/11, indicated the resident was alert, able to understand others and make his needs known, required limited assistance with one person physical assist in locomotion on and off the unit and needed extensive assistance in activities of daily living (ADLs) which included walking in room and corridor. The MDS also indicated the resident used a wheelchair as mobility device. An Elopement Risk Assessment dated 10/23/11, indicated the resident had a score of 15, a total score of 9 to 16 represented some risk for elopement. A care plan was developed on 10/23/11, for the potential risk of elopement related to the elopement risk score of 15, included goals for the resident to remain in the facility and to maintain safe and independent mobility in a restraint-free environment. The interventions included monitoring his whereabouts, but the frequency of the monitoring was not indicated. A Fall Risk Assessment completed on 10/23/11, documented the resident had a score of 13 which represented high risk for potential falls. A plan of care developed on 10/23/11, for the resident's risk for falls and associated injury, had a goal for the resident not to have falls. The approach plan included visual checks and monitoring at least every shift; observing the resident's activities when out of bed and observing the resident's ambulation/gait balance and stability. A review of an interdisciplinary team (IDT) note dated 11/7/11, timed at 2:20 p.m., and signed by the director of nursing (DON), revealed Family Member 1 called the facility asking if the resident was appropriate for discharge since the resident had called her to pick him up from the facility. The DON informed Family Member 1 the resident was not appropriate for discharge.A Nurse's Notes dated 11/8/11, timed at 3 a.m., documented by Licensed Vocational Nurse 1 (LVN 1) indicated Certified Nursing Assistant 1 (CNA 1) reported the resident was not in his room, that she searched inside and outside the facility premises but the resident was not found. At 3:30 a.m., LVN 1 further documented that Registered Nurse (RN) supervisor 1 (RN 1) was informed and after further unsuccessful searching for the resident, the RN supervisor asked CNA 1 and LVN 1 to go beyond the facility to look for the resident. LVN 1 documented on 11/8/11, timed at 4:05 a.m., the resident was found outside a convenient store, by a phone booth, sitting in a wheelchair with blood on his forehead and RN 1 was called. Another nursing note entry by RN 1 timed at 4:11 a.m., indicated the resident was found outside a store sitting in the wheelchair, unresponsive and with blood on the forehead and LVN 1 asked her to go to the location to assess the resident. RN 1 documented at 4:15 a.m., she assessed the resident who had blood on his forehead and a weak pulse. The resident did not wake up and at 4:19 a.m., paramedics (911) were called and arrived with the police at 4:25 a.m. According to the facility's investigation report, CNA 1 saw the resident sitting on the sofa at the front lobby on 11/7/11, at 11:30 p.m., but did not see the resident after that time. Laundry Worker 1 saw the resident pushing his wheelchair crossing a street and going towards a convenient store on 11/8/11, between 3:20 a.m. and 3:30 a.m. After entering the facility, when Laundry Worker 1 learned the staff members were looking for the resident, at approximately 3:45 a.m., she reported seeing the resident.According to http://maps.yahoo.com, the distance between the facility and the convenient store was 0.37 miles. The facility?s investigation report further documented LVN 1 and CNA 1 found the resident on 11/8/11, between 4:02 a.m. and 4:06 a.m. outside a convenient store sitting in the wheelchair near a phone booth. LVN 1 noticed a small amount of blood on the resident's forehead. She checked the resident's carotid artery (the artery that supply blood to the head and neck) and felt a weak pulse. She tried to palpate the radial pulse also, but was unable to feel the pulse because the resident's hand was cold. While performing the assessment, LVN 1 was on the telephone reporting to the night shift supervisor, RN 1, the resident's condition. At 4:15 a.m., RN 1 arrived at the location, assessed the resident as unresponsive and having a weak pulse. RN 1 called 911 emergency services. The paramedics arrived at approximately 4:25 a.m. and pronounced the resident asystole (having no cardiac/heart electrical activity) at approximately 4:30 a.m. The facility's investigation report, further indicated a police officer informed LVN 1 that the store's surveillance camera showed the resident was sitting in his wheelchair outside the convenient store at approximately 1:30 a.m. Later, the resident was pushing his wheelchair towards the direction of the phone booth and fell forward (no time stated in the investigation report), hitting his forehead on the ground. The police officer informed LVN 1 the cashier from the convenient store helped the resident back to his wheelchair and left him outside (no time stated). On 11/8/11, at 3 p.m., during an interview, the director of nursing stated the facility had an alarm system and a one-way door lock system on the front lobby door to ensure the safety of the residents at night. The DON explained once the front door was locked, people from the outside could not go inside the facility, but people from the inside of the facility could still exit. If a resident or staff attempted to exit the facility, the alarm would be activated. The DON explained a key was needed to activate and de-activate the alarm. The DON also stated staff members did not hear the alarm sounding off when the resident left the facility. The DON further indicated he tested the alarm at 5 a.m. and the alarm was working. The DON could not explain why the alarm was not heard by the staff working the 11 p.m. to 7 a.m. shift on 11/7/11. The facility did not have policy and procedure for the use of the alarm system. On 11/9/11, at 2:05 p.m., during another interview, the DON confirmed on 11/7/11, he spoke with Family Member 1 and explained to her the resident was not safe to go out of the facility because of his aggressive behavior. On 11/9/11, at 2:45 p.m., the DON stated the licensed nurses and the CNAs had to make rounds to check the residents every two hours. The DON could not explain why the resident was not checked for 3.5 hours (from 11:30 p.m. to 3 a.m.). The DON could not provide documentation of rounds made by nursing staff to the resident. On 11/10/11, at 4:10 p.m., during a telephone interview, RN 1 stated the alarm on the front door was to be activated at about 12 midnight after all the evening shift staff members leave the building. RN 1 stated once the front door was secured, RN 1 explained the people from the outside could not enter the facility. However, the people from the inside of the facility could still exit, but the alarm would be activated. RN 1 stated LVN 1 was to turn on the alarm and secure the front door on 11/7/11. RN 1 further stated she did not hear the alarm during the shift. RN 1 explained the only way to stop the alarm from activating was for a staff member to physically go to the front lobby door and de-activate the alarm by using a key. Six attempts were made to contact LVN 1 but there was no answer and messages were not returned. LVN 1 was no longer working in the facility since 11/9/11, after giving a verbal resignation. A review of the facility's policy and procedure titled "Rounds, Licensed Staff," revised on 12/24/08, indicated the residents will be checked by the nursing staff a minimum of every two hours and to observe the resident for privacy, dignity, and safety. According to an in-service training record dated 10/8/11, nursing staff were instructed in making sure rounds are conducted every two hours and knowing where the assigned residents are at all times. On 1/31/12, at 10: 45 a.m., during an interview, the DON stated the facility staff had been told to perform rounds every two hours or sometimes every one and a half hours if the resident had special needs. However, there was no documentation a specific frequency for the staff to check the resident had been determined. On 1/31/12, at 12 p.m., during an interview, the director of staff development (DSD) stated the CNAs were instructed to check all their assigned residents every one hour and a half (1.5) to a maximum of two hours. However, nursing staff did not document making rounds.According to the Autopsy Report signed by a deputy medical examiner dated 12/22/11, the cause of death was community acquired pneumonia and the manner of death was natural. The facility failed to ensure Resident 1, who was assessed at risk for elopement, received adequate supervision by failing to: 1. Monitor the resident?s whereabouts and observing his activities when out of bed according to the plan of care. 2. Check the resident every two hours and observing him for safety according to the facility's policy and procedure. 3. Ensure the alarm system, that alerted staff when someone exited the front door, was on.On 11/8/11, Resident 1 eloped from the facility using his wheelchair for locomotion and was found outside a convenient store which was 0.37 miles away from the facility. The resident was found sitting in his wheelchair with a trauma to his forehead and unresponsive. The resident was pronounced dead on 11/8/11.The above violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 940000001 |
MIRADA HILLS REHABILITATION AND CONVALESCENT HOSP |
940009244 |
B |
27-Apr-12 |
P6UD11 |
11114 |
72313 Nursing Service ?Administration of Medications and Treatments.(a)(2) Medications and treatments shall be administered as prescribe. 72311 Nursing Service-General(G) The facility?s inability to obtain or administer, on a prompt and timely basis,drugs, or services as prescribed under conditions which present a risk to the health, safety or security of the patient. On January 26, 2012, at 2:30 p.m., an unannounced complaint visit was made to the facility. Based on observations, interviews, and record reviews the facility failed to: 1. Carry out a physician?s order for a psychiatric consultation after Patient 7 choked and threaten to kill Patients 4, 5, and 6. 2. Administer an increase in Risperdal 0.5mg (an anti-psychotic) on January 20 and 21, 2012, as ordered by the psychiatrist.These failures resulted in Patient 7 becoming agitated and physically assaultive to Patients 4, 5, and 6from December 1, 2011 through January 22, 2012. On January 26, 2012, at 2:30 p.m., a tour of the facility was made with the assistance of the director of nurses (DON). Patient 4 was in her room sitting on her bed. The patient did not speak, but placed her hands around her neck, gesturing that she had been choked. Looking sad, Patient 4 repeated this action several more times during the investigation. The DON explained that Patient 4 did not speak English, so the facility called the immediate family and used pictures to communicate with her. On January 26, 2012, at 2:45 p.m., review of Patient 4?s clinical record (face sheet) indicated she was a 94 year-old female admitted to the facility on February 6, 2008. Patient 4?s diagnoses included chronic airway obstruction (difficulty breathing), pneumonia (excessive fluid in lungs), dysphagia (difficulty in swallowing), difficulty in walking, and hypertension (high blood pressure). The annual Minimum Data Set (MDS), a standardized assessment and care screening tool, dated December 28, 2011, indicated Patient 4 was able to be understood and understands others. The MDS indicated Patient 4 required supervision with activities of daily living (ADL).A Report of Suspected Dependent Adult/Elder Abuse (SOC 341)?dated January 23, 2012, documented that an incident happened on January 22, 2012 at 4:15 a.m. The nurse documented, ?heard resident (Patient 4) yell out and the Certified Nursing Aide (C.N.A.) went into the room and found Patient 4 crying and pointing her finger at her roommate (Patient 7) and placed her hands around her own neck, indicating she had been choked?. The patients were separated and Patient 4 denied any injuries. Both patient?s physicians and families were notified of the incident. Patient 4?s Nurse?s Notes dated January 23, 2012 at 4:20 a.m., documented the certified nurse?s aide (C.N.A.) notified the licensed nurse that Patient 4 was crying, trembling, and yelling ?sister, sister?, because her roommate (Patient 7) lifted the privacy curtain, walked over to Patient 4, grabbed her hand and tried to bite it. When Patient 4 pulled her hand away, Patient 7 grabbed her by the throat and began choking her. Patient 4 speaks another language, but was able to describe the incident using hand gestures. Patient 4 complained of tenderness around her neck and given medication for the pain. The patients were separated, the families, and physicians were notified.A telephone interview was conducted with Patient 4?s family member on January 27, 2012, at 2:15 p.m. The family member stated Patient 4 called him and told him she was choked by Patient 7. The family member stated Patient 7 first choked Patient 4 on the evening of January 21, 2012, and then again, in the early morning of January 22, 2012. The family member stated he called the facility and was told everything was okay and the staff would watch the patients. Patient 4?s family member stated Patient 4 told him she felt afraid, nervous, and unsafe around Patient 7. Another Report of Suspected Dependent Adult/Elder Abuse (SOC 341)? dated December 1, 2011, at 5:10 p.m.; indicated Patient 7 grabbed another patient (Patient 5) around the neck stating she was going to kill him. The patients were separated. Patient 5 was assessed but did not show any signs of physical injuries. Both patient?s families and physicians were notified of the incident. On January 27, 2012, a review of Patient 5?s clinical (Face sheet) indicated the patient was a 32 year-old male initially admitted to the facility on October 8, 2007, and readmitted on December 9, 2011. Patient 5?s diagnoses included hypertension (high blood press), hip fracture, heart failure, and deep venous thrombosis (DVT-blood clot) of the right fracture leg. The annual Minimum Data Set (MDS), a standardized assessment and care screening tool, dated December 15, 2011, indicated Patient 5 was able to be understood and understand others. According to the MDS, the patient was totally dependent with transferring, ambulating, and dressing. Patient 5?s medical record revealed an entry in the Nurse?s Notes dated December 1, 2011, at 5:10 p.m., that Licensed Vocational Nurse (LVN) 1 witnessed Patient 7 grabbing Patient 5 by his neck, and telling him she was going to kill him. LVN 1 notified the social service director (SSD), who was still in the facility at the time of the incident.Patient 5 stated in a declaration, dated January 27, 2012, at 10:15 a.m., ?I feel unsafe around Patient 7, because Patient 7 will attack you when she gets mad.? Patient 5 stated that Patient 7 would always follow him around the facility, either looking for him or Patient 6. Patient 5 stated, ?When Patient 7 gets confused I do not like being around her, because she might attack me.? On January 26, 2012, at 3 p.m., a review of Patient 7?s clinical record (face sheet) indicated the patient was an 85 year-old female readmitted to the facility on December 20, 2011, originally admitted on May 5, 2011. Patient 7?s diagnoses included angina pectoris (chest pain) and diabetes mellitus (excessive sugar in blood). An annual Minimum Data Set (MDS), a standardized assessment and care screening tool, dated November 8, 2011, indicated Patient 7?s diagnoses also included anxiety disorder (overwhelm with stress), psychotic disorder (mental disorder), and schizophrenia (disorder in thinking). The MDS indicated Patient 7 needed supervision with activities of daily living (ADL), such as ambulating and transferring.A care plan initiated on December 1, 2011 addressed Patient 7?s aggressive behavior. The nursing interventions included giving medications as ordered and obtaining psychiatric evaluation with treatment and follow-up.A Nurse?s Note dated December 17, 2011, at 4:00 p.m., indicated Patient 7 went into another patient?s room (Patient 6) and threatened to kill him. At 4:40 p.m., the police were called to the facility to help control Patient 7?s behavior. The police officer asked Patient 7 why she wanted to kill Patient 6. Patient 7 stated, ?Because he (Patient 6) has been cheating on me.? Patient 7 was remove from the facility and sent to the general acute care hospital for further evaluation. On December 20, 2011, Patient 7 returned to the facility with new medication orders. On January 20, 2012, Patient 7 saw the psychiatrist. The psychiatrist diagnosed Patient 7 with vascular dementia with depression and increased the Risperdal from 0.25 milligrams to 0.5 milligrams every night at bedtime. The patient?s Depakote (a mood stabilizer) was also increased to 125 mg every day. Review of the Medication Administration Record (MAR) for the month of January 2012, revealed the licensed nurse did not initial giving Patient 7?s Risperdal 0.5 milligrams on January 20 and 21, 2012. There was no documentation Patient 7 refused the medication on the back of the medication record.On January 21, 2012, at 4:35 p.m., another Nurse?s Note revealed Patient 7 suddenly wandered into Patient 6?s room and in an angry outburst declared Patient 6 was her husband, and was cheating on her. Patient 7 started screaming and tried to hit Patient 6, but the licensed nurses intervened. Patient 7 was sedated with Haldol (mental instability) 1mg (milligram) IM (intramuscular), and assisted back to her room.On January 23, 2012 at 4:30 a.m., Patient 7?s Nurse?s Notes documented the patient tried to bite Patient 4?s hand and when the patient pulled away, she grabbed Patient 4 by the throat and began choking her. The Interdisciplinary Team (IDT) discussed Patient 7?s aggressive behaviors with the physician and discharged the patient to an acute care hospital.On January 26, 2012, at 3 p.m., the social service director (SSD) was asked why there was a delay in Patient 7?s psychiatric evaluation. The SSD stated, ?I was made aware that Patient 7 choked Patient 5, on December 1, 2011, but the psychiatric consultation was not done until January 20, 2012, because I forgot to follow up on the consultation.?On January 27, 2012, at 11 a.m., an interview with LVN 1 revealed that she noted and transcribed the new Risperdal and Depakote orders, written by the psychiatrist, onto the MAR. LVN 1 stated and wrote in a declaration, ?I do not remember what happened on January 20 and 21, 2012, why the Risperdal was not given to Patient 7.? LVN 1 also stated she would always attempt to give Patient 7?s her medication even if she had to wait until the patient calmed down. After reviewing the medication record, LVN 1 stated she had not initialed giving Patient 7 the Risperdal on January 20 and 21, 2012. LVN 1 stated, ?As nurses, we are taught if it is not written, it is not done.?On January 27, 2012, at 12 p.m., an interview with the DON revealed she was unaware the recommendation for a psychiatric consultation was not follow-up by the SSD until January 20, 2012. The DON could not explain why LVN 1 did not give the Risperdal 0.5 mg on January 20 and 21, 2012, as ordered. The DON stated, ?The physician?s orders should have been followed.? A review of the facility?s policy revised on October 2004, for medication administrationindicated, ?All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms and help in diagnosis.?A review of the facility?s undated policy titled, ?Social Services,? indicated the facility and its individuals will provide treatments and services which are necessary to maintain resident/patient health and safety which prevent noticeable deterioration of physical, mental, or emotional conditions of the resident/patient.The facility failed to: 1. Carry out a physician?s order for a psychiatric consultation after Patient 7 choked and threaten to kill Patients 4, 5, and 6. 2. Administer an increase in Risperdal 0.5mg (an anti-psychotic) on January 20 and 21, 2012, as ordered by the psychiatrist.These violations, jointly, separately, or in combination, had a direct relationship to the health, safety, and security for Patients 4, 5, 6, and other patients in the facility. |
| 940000001 |
MIRADA HILLS REHABILITATION AND CONVALESCENT HOSP |
940009245 |
B |
27-Apr-12 |
P6UD11 |
5372 |
California Health and Safety Code ? 1418.91: California Code - Section 1418.91 a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a Patient of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. (c) For purposes of this section, "abuse" shall mean any of the conduct described in subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code. (d) This section shall not change any reporting requirements under Section 15630 of the Welfare and Institutions Code, or as otherwise specified in the Elder Abuse and Dependent Adult Civil Protection Act, Chapter 11 (commencing with Section 15600) of Part 3 of Division 9 of the Welfare and Institutions Code. Based on observation, interview, and record review the facility failed to report two incidences of alleged abuse of two patients in the facility to the Department within 24 hours. Patient 7 choked Patient 4 on January 21, 2012 and threatened to kill Patient 6, on December 17, 2011.Findings:On January 26, 2012, at 2:30 p.m., a tour of the facility was made with the assistance of the director of nurses (DON). Patient 4 was in her room sitting on her bed. The patient did not speak, but placed her hands around her neck, gesturing that she had been choked. Patient 4 repeated this action several more times during the investigation. The DON explained that Patient 4 did not speak English, so the facility called the immediate family and used pictures to communicate with her. On January 26, 2012, at 2:45 p.m., review of Patient 4's clinical record (face sheet) indicated she was a 94 year-old female admitted to the facility on February 6, 2008. Patient 4's diagnoses included chronic airway obstruction (difficulty breathing), pneumonia (excessive fluid in lungs), dysphagia (difficulty in swallowing), difficulty in walking, and hypertension (high blood pressure). The annual Minimum Data Set (MDS), a standardized assessment and care screening tool, dated December 28, 2011, indicated Patient 4 was able to be understood and understands others. The MDS indicated Patient 4 required supervision with activities of daily living (ADL).Patient 4's Nurse's Notes dated January 23, 2012 at 4:20 a.m., documented the certified nurse's aide (C.N.A.) notified the licensed nurse that Patient 4 was crying, because her roommate (Patient 7) tried to bite her hand. When Patient 4 pulled her hand away, Patient 7 grabbed her by the throat and began choking her. Patient 4 complained of tenderness around her neck and received medication for the pain.A telephone interview was conducted with Patient 4's family member on January 27, 2012, at 2:15 p.m. The family member stated Patient 4 called him and told him she was choked by Patient 7. The family member stated Patient 7 first choked Patient 4 on the evening of January 21, 2012, and then again, in the early morning of January 22, 2012. A Report of Suspected Dependent Adult/Elder Abuse (SOC 341) about the January 22, 2012 incident was reported to the Department. However, there was no Report of Suspected Dependent Adult/Elder Abuse (SOC 341) or any documentation about the choking incident on the evening of January 21, 2012 in Patient 4 or 7's medical record, or documentation that the incident being reported to the Department.On January 26, 2012, at 3 p.m., a review of Patient 7's clinical record (face sheet) indicated the patient was an 85 year-old female readmitted to the facility on December 20, 2011, originally admitted on May 5, 2011. Patient 7's diagnoses included angina pectoris (chest pain) and diabetes mellitus (excessive sugar in blood). An annual Minimum Data Set (MDS), a standardized assessment and care screening tool, dated November 8, 2011, indicated Patient 7's diagnoses also included anxiety disorder (overwhelm with stress), psychotic disorder (mental disorder), and schizophrenia (disorder in thinking). The MDS indicated Patient 7 needed supervision with activities of daily living (ADL), such as ambulating and transferring.A Nurse's Note dated December 17, 2011, at 4:00 p.m., indicated Patient 7 went into another patient's room (Patient 6) and threatened to kill him. At 4:40 p.m., the police were called to the facility to help control Patient 7's behavior. The police officer asked Patient 7 why she wanted to kill Patient 6. Patient 7 stated, "Because he (Patient 6) has been cheating on me." Patient 7 was remove from the facility and sent to the general acute care hospital for further evaluation. There was no Report of Suspected Dependent Adult/Elder Abuse (SOC 341) or documentation in Patient 6's or 7's clinical record regarding the incident on the evening of December 17, 2011, or documentation that the incident being reported to the Department.On January 27, 2012, at approximately 12 noon, an interview with the Director of Nurses (DON) revealed that the two incidences of Patient 7 choking Patient 4 on January 21, 2012 and threatening Patient 6 on December 17, 2011 were not reported to the Department within 24 hours.These violations, jointly, separately, or in combination, had a direct relationship to the health, safety, and security of Patients 4 and 6 and other patients in the facility. |
| 940000001 |
MIRADA HILLS REHABILITATION AND CONVALESCENT HOSP |
940009384 |
B |
02-Jul-12 |
XEER11 |
6497 |
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. Based on observation, interview and record review, the facility failed to ensure Resident 1 received adequate supervision to prevent accidents by failing to: 1. Supervise Resident 1 during smoking 2. Provide Resident 1 with a protective apron during smoking. 3. Ensure smoking materials will be only given to Resident 1 by staff. 4. Assess Resident 1 for safe smoking. Resident 1 sustained a 1.2 centimeters (cm) in length by 1.2 cm in width superficial burn on the mid-chest area while smoking unsupervised and without wearing a smoking apron for safety as stated in the resident?s care plan and the facility's policy and procedure. On 3/9/12, at 1:20 p.m., an unannounced visit was made to the facility to investigate an entity self-reported incident regarding Resident 1's burn. A review of the clinical record revealed the resident was a 56 years old female readmitted to the facility on 1/28/09, with diagnoses that included late effects of cerebrovascular disease (stroke) and right hemiplegia (paralysis of the right side of the body). According to the annual Minimum Data Set (MDS - standardized assessment and care planning tool) dated 1/18/12, the resident was able to make her needs known, was able to understand others, did not walk, required supervision during locomotion on and off the unit and used a wheelchair as a mobility device. A plan of care dated 8/24/09, was developed for the resident's risk for injury from smoking related to non-compliance with smoking rules as evidenced by receiving cigarettes from other residents, unsafe during smoking and requiring supervision. The approaches included completing a smoking assessment to determine abilities, requiring actual assistance with smoking, requiring continual observation while smoking, being supervised during smoking by staff, requiring the use of a smoking apron and reminding the resident to let the staff know if she is going to smoke in order to ensure supervision was provided. Further record review revealed there was no documented smoking assessment to determine resident's abilities and safe smoking practices. A nursing note dated 2/27/12, timed at 1:30 p.m., indicated a certified nursing assistant (CNA) reported to the charge nurse the resident had a burn on the mid-chest area. The resident told the charge nurse she sustained the burn from a cigarette. The burn was measured to be 1.2 cm in length by 1.2 cm in width, with no depth. The nursing note also noted the physician was notified and a topical treatment order was obtained. According to the facility's investigation report, upon noticing the burn, the resident stated it happened after lunch a couple of days prior and she probably dropped cigarette ashes on her. The resident also stated she obtained the cigarette from another resident but could not remember who. According to the facility's policy and procedure titled, "Smoking", undated, a resident's ability to handle smoking material will be evaluated by the interdisciplinary team on a periodic basis. Each resident will be classified in one of the following categories: resident allowed smoking unsupervised, resident allowed to smoke only with supervision, and resident not allowed to smoke. The policy also indicated residents' smoking materials will always be kept at the nurses' station on the unit and only given to residents by staff. The policy did not address if residents who were allowed to smoke unsupervised could keep their own smoking materials. On 3/9/12 at 1:45 p.m., during an observation, the resident was sitting in a wheelchair at the bedside and eating ice cream in a bowl. The resident was able to feed herself by using her left hand, which was noted with tremors (unintentional trembling or shaking movement). At 1:47 p.m., during an interview, the resident explained she was smoking on a Saturday afternoon (2/25/12) with other residents. The resident indicated she knew the security code to de-activate the alarm on the door leading to the smoking area and proceeded to use the security code. The resident further stated she was not offered an apron and was not supervised by staff when she was smoking. The resident also reported she obtained her cigarette from another resident who lit the cigarette for her. At 2 p.m., an observation of the resident's burn was conducted with Treatment Nurse 1. A dry circular discoloration was noted in between the resident's breasts. At 2:30 p.m., during an interview, the Director of Staff Development (DSD) stated the facility had no smoking schedule and had only three aprons. She explained the alert residents, who were determined safe to smoke, were given a locked box by the facility for safe keeping of their own lighter and cigarettes. The residents who needed supervision with smoking had their lighters and cigarettes locked in the medication cart. They had to ask the medication nurse for a cigarette and a staff member would bring them out to the designated smoking area to light their cigarette.According to the DSD, the door leading to the smoking area is not locked but had an alarm to alert staff when a resident was going out to the smoking area and to go check on the resident. The alarm would be activated when the door is opened and a code should be pressed to de-activate the alarm. The DSD stated the residents were not supposed to know the code to de-activate the alarm and were not to share cigarettes. In addition, after reviewing the resident?s clinical record, the DSD could not explain why an smoking assessment was not completed for the resident.The facility failed to ensure Resident 1 received adequate supervision to prevent accidents by failing to: 1. Supervise Resident 1 during smoking 2. Provide Resident 1 with a protective apron during smoking. 3. Ensure smoking materials will be only given to Resident 1 by staff. 4. Assess Resident 1 for safe smoking. Resident 1 sustained a 1.2 centimeters (cm) in length by 1.2 cm in width superficial burn on the mid-chest area while smoking unsupervised and without wearing a smoking apron for safety as stated in the care plan and the facility's policy and procedure. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1. |
| 940000001 |
MIRADA HILLS REHABILITATION AND CONVALESCENT HOSP |
940009471 |
A |
11-Sep-12 |
CMIK11 |
9936 |
? 72315. Nursing Service - Patient Care. (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. On 4/15/11, at 10:25 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1?s quality of care and treatment. Based on interview and record review, the facility failed to ensure Patient 1 was provided with necessary fluids for hydration by failing to:1. Develop a plan of care addressing the patient?s dehydration risk and interventions for the staff to implement to prevent dehydration 2. Monitor the patient?s fluid intake to ensure adequate hydration status. 3. Administer the IV fluids as ordered by the physician. 4. Notify the physician, the nurses were unable to initiate the IV hydration.Patient 1 developed a low blood pressure of 70/40 millimeters of mercury (mmHg ? normal value below 120/80), the physician ordered IV fluids for hydration, but the IV hydration was not started until five hours after it was ordered. The patient was transferred to an acute care hospital where she was found to have severe dehydration and acute kidney failure. A review of the closed clinical record indicated Patient 1 was a 76-year-old female who was admitted to the facility on 12/29/10, and re-admitted on 2/12/11, with diagnoses including hypertension (high blood pressure), dysphagia (difficulty swallowing), diabetes mellitus type II with peripheral vascular disease and bilateral above the knee amputation. The patient had a history of nausea and vomiting that led to a transfer to an acute care hospital on 2/7/11 for evaluation. The patient returned to the facility on 2/12/11. The admission Minimum Data Set (MDS - standardized assessment and care planning tool) dated 1/4/11, indicated the patient was able to make her needs known, was able to understand others, did not walk, needed supervision while eating and required extensive assistance for bed mobility, transfers and personal hygiene. The Care Area Assessment (CAA - a process to identify care areas of concern that may warrant interventions) indicated the patient was at risk for dehydration due to weight loss and diuretic use (Lasix ? a water pill) and the Care Area Trigger (CAT) Worksheet indicated dehydration was triggered. The plan was to monitor the patient for dehydration (poor skin turgor, dry mucosa, sunken eyeballs, etc.), provide assistance as need with consuming, and proceed with care planning. However, there was no plan of care developed for the patient?s dehydration risk.A Nutritional Data Collection/Assessment form dated 2/14/11, indicated the fluid needs of the patient were 1320-1520 milliliter per day (ml/day). The physician?s order indicated the patient received Amikacin IV antibiotic from 2/21/11 through 2/28/11 and Nitrofurantoin oral antibiotic was started on 3/7/11, for extended-spectrum beta-lactamase (ESBL) Klebsiella infection of the urine. A nursing note dated 3/1/11, timed at 5 p.m., indicated the patient had one episode of vomiting. A nursing note dated 3/6/11, timed at 8:18 p.m., documented the patient had two episodes of loose stool; the physician was notified and ordered a test for a bacterial infection, Clostridium Difficile (C-diff), in the stool. Nursing notes dated 3/7/11, timed at 4:51 a.m. and 3/8/11, timed at 5:07 a.m., documented the patient continued to have episodes of loose stools. A nursing note dated 3/8/11, timed at 12 noon, documented a positive C-diff test result and the physician ordered oral Flagyl antibiotic. The note also indicated the patient had another episode of loose stools. According to the recorded vital signs from readmission, the patient?s blood pressure remained above 100/60 mmHg. On 3/9/11 at 12 noon, Licensed Vocational Nurse 1 (LVN 1) documented the patient refused to eat lunch, looked weak and the blood pressure was 70/40 mmHg. The physician was informed and ordered IV fluid for a 48 hour-period with Dextrose 5% in « Normal Saline (D51/2 NS) solution at a rate of 60 cubic centimeter (cc) per hour. The physician also ordered a basic metabolic panel (BMP) blood test, stat (urgent). According to the Infusion Medication Administration Record form dated 3/9/11, timed at 12 noon, and at 1 p.m., attempts to place an IV catheter in the patient?s right arm were unsuccessful.The nursing note dated 3/9/11, timed at 3 p.m., by LVN 1 documented the patient?s blood pressure was checked again and it was 70/40 mmHg. LVN 1 informed the physician and received an order to, ?just monitor?, the patient.LVN 1 did not document the physician was made aware the ordered IV fluids were not given.The Infusion Medication Administration Record documented on 3/9/11 at 5:20 p.m., five hours after the initial order, an IV catheter was placed in the patient?s right hand. On 3/9/11 at 6 p.m., LVN 2 documented Family Member 1 requested the patient to be transferred to the hospital because she looked very weak. The physician was informed and at 8:10 p.m., the patient was transported to the hospital. According to the CMP test result dated 3/9/11, collected at 2:20 p.m., and obtained at 10:15 p.m. (after the patient?s transfer); the patient?s blood urea nitrogen (BUN) was 74 milligrams per deciliter (mg/dL) above the reference range of 8-26 mg/dL and the creatinine level was 4.3 mg/dL, above the reference range of 0.4 ? 1 mg/dL.The patient?s prior BUN and creatinine levels on 2/4/11, and 2/17/11, indicated they were within normal ranges. According to the clinical record from the acute care hospital emergency room, the patient had severe dehydration, required IV fluids and had acute renal failure with a creatinine level of 4.8 mg/dL and a BUN level of 78 mg/dL. The patient remained in the acute hospital until 3/18/11, when she was discharged home with the BUN and creatinine levels within normal ranges. According to the facility?s Hydration and Nutrition policy and procedure on Fluid Encouragement, revised 10/2008, the purpose of the policy was to increase the fluid intake as necessary and to prevent dehydration. The procedures included to document amount of fluid taken and amount of encouragement. The procedures also included care plan guidelines such as including in the approaches listing fluids to be encouraged and monitor for adequate hydration.According to a Medical Record policy and procedure on Recording Intake, undated, the policy was to record the total amount of liquids consumed by the patient. The procedures included to record the fluids as soon as the patient consumed the fluids, total up the amount of liquid consumed at the end of the shift and on the third shift to record the 24-hour total.On 4/21/11 at 2:10 p.m., during an interview, Registered Nurse 1 (RN 1) stated with the assistant director of nursing (ADON), they tried to insert a peripheral IV catheter in the patient but the attempts were unsuccessful. They then called an IV nurse from a pharmaceutical company who was able to insert the IV line at 5:20 p.m. RN 1 stated the patient was encouraged to take fluids during the time she did not have a peripheral IV catheter inserted but she was unable to provide evidence the patient?s fluid intake was measured to ensure adequate hydration status. On 4/21/11, at 2:25 p.m., during an interview, the ADON and the MDS Coordinator confirmed there was no care plan developed addressing the patient?s dehydration risk. The MDS coordinator also stated there should have been a plan of care addressing the patient?s risk of dehydration and the approaches to be implemented. On 4/21/11, at 3:45 p.m., during a telephone interview, the physician stated he did not remember if the nurse informed him the patient did not receive the IV fluids three hours after he had ordered them. The physician further indicated if he was made aware the patient did not receive the ordered IV fluids when she had a blood pressure of 70/40, he would have sent the patient to the acute hospital. On 4/21/11, at 4:30 p.m., during a telephone interview, LVN 1 stated she did not remember when she contacted the physician on 3/9/11, at 3 p.m., if she informed him the patient was not receiving the IV fluids as ordered. LVN 1 further indicated she encouraged the patient to drink fluids. According to the Sixth Edition of Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, page 792, ?extremely low blood pressure may be a sign of a serious condition, such as shock, massive hemorrhage (bleeding), hypovolemia (decreased circulating volume), or severe dehydration from nausea and vomiting. Elevated BUN levels occur in renal disease, reduced renal blood flow (such as with dehydration), urinary tract obstruction, and increased protein catabolism (such as occurs in burns). (Lippincott Williams & Wilkins 2009 Diagnostic Tests Made Incredibly Easy! ? 2nd ed. page 42). The facility failed to ensure Patient 1 was provided with necessary fluids for hydration by failing to:1. Develop a plan of care addressing the patient?s dehydration risk and interventions for the staff to implement to prevent dehydration 2. Monitor the patient?s fluid intake to ensure adequate hydration status. 3. Administer the IV fluids as ordered by the physician. 4. Notify the physician, the nurses were unable to initiate the IV hydration.Patient 1 developed a low blood pressure of 70/40 millimeters of mercury (mmHg ? normal value below 120/80), the physician ordered IV fluids for hydration, but the IV hydration was not started until five hours after it was ordered. The patient was transferred to an acute care hospital where she was found to have severe dehydration and acute kidney failure. The above violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Patient 1. |
| 940000072 |
MARLORA POST ACUTE REHABILITATION HOSPITAL |
940009485 |
B |
12-Sep-12 |
CV2311 |
11091 |
The Department received a SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) on March 23, 2012, alleging a resident (Resident 1) was neglected by a skilled nursing facility (SNF) due to withholding pain medications. On April 6, 2012, at 9:11 a.m., an unannounced complaint investigation was conducted.Based on interviews and record review, the facility failed to follow physician's orders for pain control for 1 of 1 resident (Resident 1). Resident 1 was transferred to the SNF three days post-op laminectomy (L4) surgery (surgery performed to primarily alleviate leg pain caused by lumbar spinal stenosis- a narrowing of one or more areas in the spine). The physician ordered muscle relaxants and pain medications that the facility failed to order timely to be administered to Resident 1. These failures resulted in Resident 1 complaining of severe uncontrolled back pain with spasm, and being readmitted to a general acute care hospital (GACH) for uncontrolled back pain. Findings: On April 6, 2012, a review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on March 9, 2012, at 5 p.m., from a GACH with diagnoses that included degenerative (gradually worsening: causing or showing a gradual deterioration in the structure of a body part) thoracic/thoracolumbar (pertaining to the middle segment of the vertebral column, between the cervical vertebrae and the lumbar vertebrae; intervertebral disc (pillow-like cushions in between the vertebrae) with spinal stenosis and underwent surgery on March 6, 2012 for a Lumbar Fusion (surgery to join, or fuse, two or more vertebrae).A review of a SNF Nursing Admission and Assessment form, dated March 9, 2012, indicated Resident 1 was alert and oriented requiring assistance with bed mobility, ambulation, and transferring. The pain assessment indicated the resident's primary pain site was the lower back and the goal was to control the resident's back pain.On April 6, 2012, a review of the GACH physician's transfer medication order, dated March 9, 2012, and timed at 2:36 p.m., indicated the physician ordered, Flexeril 10 milligrams (mg), three times a day for spasm (0900, 1300 and 1700), Acetaminophen 325 mg, two tablets twice a day as needed for temperature greater than 101F, Norco 7.5/325 mg, two tablets every three hours prn for severe pain. In addition, a hand written order by the physician, dated March 9, 2012, without a time included, Morphine elixir 30 milligrams every four hours as needed for severe pain (prn) and Soma 350 mg, four times a day for muscle relaxant. The physician's order at the SNF dated March 9, 2012, had a print timed of 10:22 p.m., which was over five hours after the resident was admitted. During an interview, April 6, 2012, at 11:03 a.m., the registered nursing (RN) supervisor stated she had three admissions on March 9, 2012. The RN Supervisor stated on March 9, 2012 at 8 p.m., she entered Resident 1's medication orders into the computer by the point and click system to be printed and faxed later to the pharmacy. According to a written declaration and interview, the RN supervisor stated that RN 2 called and placed the pharmacy order. However, during a telephone interview with RN 2 on May 30, 2012, at 9:37 a.m., RN 2 stated, "No, I did not call in the medication order to the pharmacy for Resident 1, but it was faxed to the pharmacy around 10:30 p.m.?The RN Supervisor stated on March 9, 2012, at 9 p.m., she gave the resident two Norco 7.5/325 mg tablets, but stated Resident 1 was asking for Flexeril and Soma for spasm. The RN Supervisor stated those medications were not in the facility's emergency kit (E-Kit) and the pharmacy was told the medication was needed, but not as a STAT (immediate) order, just a PRN (whenever necessary) order. The RN Supervisor stated she observed Resident 1 on March 9, 2012 at 11 p.m. in bed crying, wanting Flexeril and Soma. She stated Resident 1 was transferred back to the GACH on March 9, 2012 after the resident called 911 at 11:30 p.m., due to uncontrolled back pain.During a telephone interview, on April 6, 2012, at 11:38 a.m., Resident 1 stated she had back surgery on March 6, 2012, in which bone marrow (spongy fatty tissue inside large bones) and four screws were placed into her spine. Resident 1 stated while at the GACH at 4 p.m., on March 9, 2012, prior to transferring to the (SNF) she received two tablets of Norco 7.5/325 mg (hydrocodone/acetaminophen). The resident stated once transferred to the SNF she did not receive Norco 7.5/325 mg until 9 p.m., and the RN Supervisor came back and told her there were no Flexeril or Soma to give her. The resident stated, the RN Supervisor informed her she would see if any other residents were receiving Flexeril so she could give it to her. Resident 1 stated, "That's when I realized this is so wrong and I called 911 and RN 3 came back and told her no other resident was receiving Flexeril to give to her." The resident stated she told both the RN Supervisor and RN 2, she had already called 911.On April 6, 2012, at 1:42 p.m., during a subsequent interview, the RN Supervisor stated the pharmacy could have brought the medication, because it was open for twenty-four hours. We thought we could have managed, but Resident 1 was in so much pain and could not wait for the medications. The RN Supervisor stated, "I would have been frustrated too." During a telephone interview, on April 6, 2012, at 2:56 p.m., Pharmacist 1, from the facility's distributing pharmacy, stated the resident was admitted to the SNF on March 9, 2012, but the SNF did not fax the resident's medication order over until 10:33 p.m. (over five hours after the resident's admission). Pharmacist 1 stated new admission medications are filled within four hours. On May 15, 2012, at 8:24 a.m., during a telephone interview, Pharmacist 2 (pharmacy manager) stated there are two ways for the facility to order medications, by fax or called in by nurses or physician. Pharmacist 2 stated, "We didn't receive any verbal call in for Resident 1 on March 9, 2012.?Pharmacist 2 faxed a copy of Resident 1's medication order form sent to the pharmacy from the SNF on March 9, 2012. A review of the faxed medication order indicated the SNF faxed it to the pharmacy on March 9, 2012 at 10:33 p.m., which was over five hours after Resident 1 was admitted. On May 15, 2012, a review of the GACH's Emergency Room (ER) records indicated Resident 1 arrived in the ER at 12 a.m., on March 10, 2012, with a chief complaint of back pain. Resident 1 was brought in by paramedics from a skilled nursing facility with severe back pain. According to the ER note, Resident 1 complained that the pain radiated down her left leg with numbness to the left leg. The resident's blood pressure upon arrival was elevated at 139/103, (the resident had no prior history of high blood pressure) normal blood pressure is 120/80 blood pressure. According to an article titled, "Acute Pain and Blood Pressure" acute pain leads to generalized arousal and increased sympathetic nerve activity. This produces a dramatic increase in muscle sympathetic nerve activity (MSNA), which is paralleled by a marked increase of blood pressure, www.medscape.com.viewarticle/465355_2 . Resident 1's pulse rate was also elevated to 143 (pulse rate is the rate at which the heart beats/normal rate is 100 bpm) when the body is under stress, it responds by increasing the heartbeat to meet energy demands. While in the ER, the resident received Dilaudid 2 mg intramuscularly (narcotic pain reliever for moderate to severe pain) and Phenergan 25 mg intramuscularly (treat pain in combination with other medicines) were given to help take the edge off the resident's pain. However, during the night the resident required Morphine 30 mg by mouth to further control the pain.During an interview, on May 18, 2012 at 8:28 a.m., the director of nursing (DON) at the SNF stated they had three admissions on March 9, 2012 and when there was more than one admission all the medication orders are called in together to the physician to verify and then to the pharmacy. The DON stated then they enter the medication orders into a point and click computer system to be printed out at a later time and faxed to the pharmacy. The DON stated the turn-around time is usually four hours from the time the call was placed to the pharmacy until the medication is received.During an interview, on May 18, 2012 at 11:28 a.m., the medication nurse, (licensed vocational nurse-[LVN 1]) stated between 10:45 p.m. and 11 p.m., on March 9, 2012 she heard Resident 1 in the room crying and went to see why the resident was crying. LVN 1 stated the resident stated, "I don't want to be here anymore, I want to go back to the hospital. I am in so much pain."On May 30, 2012, at 11:20 a.m., during a telephone interview, Resident 1's family member stated the resident called and informed him the nurses just left her and had not checked on her. The family member also stated Resident 1 informed him the facility did not fill the physician's prescription for her pain medication. The family member stated he had called the facility three times, speaking to three different nurses. He stated he felt so helpless, because Resident 1 was crying stating the pain was so severe. He stated the nurses informed him the pharmacy was closed and that was why the medication was not in the facility. However, according to a subsequent interview with Pharmacist 1, on May 30, 2012, at 11:42 a.m., she stated the pharmacy hours of operation was twenty-four hours, Monday through Friday, and Saturday and Sundays with a pharmacist on call. She stated the day of the incident, March 9, 2012, which was a Friday; the pharmacy was open for business until 2 am Saturday morning. A review of the facility's policy, titled, "Medication Ordering and Receiving from Pharmacy" dated August 1, 2010, indicated, new medications, except for emergency or "stat" medications, are ordered as follows: a) if needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery and request delivery within two hours. b) Timely delivery of new orders is requires so that medication administration is not delayed. The emergency kit is used when the resident needs a medication prior to pharmacy delivery. A review of facility's undated policy, titled, " Department: Patient Care, Subject: Pain management, Policy Number: P " included unrelieved pain has negative physical and psychological consequences including the potential for threatening functional ability and pain medications prescribed for a resident must be assessed on admission or at the time first prescribed and on an ongoing basis. The facility failed by not ensuring: Resident 1?s pain was controlled by providing medication, prescribed by the physician, in a timely manner.The above violation had a direct relationship to the health, safety, and security of Resident 1. |
| 940000001 |
MIRADA HILLS REHABILITATION AND CONVALESCENT HOSP |
940010371 |
B |
10-Jan-14 |
B9QR11 |
11950 |
72547. 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: (C) Name, dosage and time of administration of drugs, the route of administration or site of injection, of other than oral. If the scheduled time is indicated on the record, the initial of the person administering the dose shall be recorded, provided that the drug is given within one hour of the scheduled time. If the scheduled time is not recorded, the person administering the dose shall record both initials and the time of administration. Medication and treatment records shall contain the name and professional title of staff signing by initials.(F) Medications and treatments administered and recorded as prescribed. The Department received an anonymous faxed complaint on December 5, 2013, alleging resident?s medications were not being given timely. It also indicated the residents had to wait at least two-three hours and some days more than three hours. Based on observations, interviews, and record review, the facility failed to: 1. Ensure the Medication Administration Records (MARs) for the 9 a.m. morning medications correctly reflected the time the medications were administered for 31 residents (Residents 7-38) on two different days (December 6 and 9, 2013). 2. Ensure two licensed vocational nurses (LVN 1 and 4) signed that 31 residents medications were administered late and their physician were notified as stipulated in the facility?s policy and procedure. These deficient practices resulted in 31 residents not receiving their medications at the prescribed time and had the potential to result in harm due to some of the medications being ordered three times a day ([TID] 9 a.m., 1 p.m., and 5 p.m.), which could result in the medications being given too soon. On December 6, 2013, at 10:55 a.m., LVN 1 was observed still passing 9 a.m. medications for his assigned residents, which included 22 residents (Residents 9-30). During another observation and interview on December 6, 2013 at 10:55 a.m., LVN 4 was observed in the hallway still passing resident?s 9 a.m. medications. During the interview, LVN 4 stated Resident 8 was his last resident to administer medications. On December 6, 2013, at 3:15 p.m., during a subsequent interview, LVN 4 stated he was nervous and had new resident admissions which made him late with his medication pass. He also stated, ?I am sorry and I will work on it.? At 3:55 p.m., on December 6, 2013, LVN 1, who was a newly hired nurse, stated after the medication pass observation at 10:55 a.m., he had nine more resident?s rooms to pass medications (22 residents). On December 9, 2013, at 8:40 a.m., during an interview, Resident 6, who was alert and oriented, stated her night medications were sometimes given as late as 11 p.m., according to the resident?s MAR, she receives Ativan 1 mg every night for anxiety at 9 p.m. The resident also stated there were times her morning medications were not given until 11 a.m. The MAR indicated the resident received levothyroxine 75 microgram (mcg) for hypothyroidism (thyroid doesn?t produce enough hormone) at 6:30 a.m., Fosamax 70 milligram (mg) weekly at 6:30 a.m. (used to treat or prevent osteoporosis [bones become fragile and more likely to fracture]), and Prilosec/omeprazole 20 mg (treat symptoms of GERD [gastroesophageal reflux disease, a digestive disorder that affects the lower esophageal sphincter], and other conditions caused by excess stomach acid) for esophageal reflux daily before breakfast at 6:30 a.m., and Paxil 10 mg at 9 a.m., for depression, and Norco 5/325 mg at 8 a.m. for pain management, calcium 500 mg with vitamin D, and Qvar 40 mcg inhaler two puffs for asthma. On December 9, 2013, at 10:55 a.m., during an interview, the director of nurses (DON) stated she was aware of the staff passing medications late, and admitted it was an ongoing problem of the facility.At 11:15 a.m., On December 9, 2013, LVN 4 was again observed in the hallway passing 9 a.m. medications. During an interview, the same day, at 11:35 a.m., LVN 4 stated he completed his medication pass at 11:15 a.m. He indicated that eight residents (Residents 31-38) received their 9 a.m. medications late. On December 9, 2013, at 3 p.m., during a telephone interview, LVN 1 clarified that he was late passing medications to 22 residents (nine rooms, Residents 9-30). LVN 1 stated he did not document that the medications were given late, but he signed the late medications as given on the MARs at 9 a.m. LVN 1 stated he did not notify the physician the medications were late. LVN 1 further indicated he made sure the resident?s next medications were given at the scheduled time at 12 p.m.A review of the MARs for the 31 residents (Residents 7-38), all were initialed by LVN 1 and LVN 4 as given at the prescribed time, 9 a.m. Seven residents (Residents 9, 13, 19, 24, 34, 37, and 38) had medications that were ordered for more than once a day and had the potential of harm due to the next scheduled dose given too soon. All seven residents received their 9 a.m. medications late on December 6, 2013 at approximately 11:30 a.m. A review of Lexicomp (https//online.lexi.com) an online site that provides clear, concise, point of care drug information, including dosing, administration, warnings and precautions, as well as clinical content indicated the following drug information for Sinemet, Novolog, lopressor, benztropine, Hydralizine, Midodrine, and clonidine. a. Resident 9 had a physician order for Sinemet 25/100 mg TID (combination drug of levodopa and carbidopa used to treat the symptoms of Parkinson's disease or Parkinson-like symptoms (e.g., shakiness, stiffness, difficulty moving). Parkinson's disease is thought to be caused by too little of a naturally occurring substance (dopamine) in the brain. According to Lexicomp, if it is close to the time for the next dose, skip the missed dose and go back to your normal time. Do not take two doses at the same time or extra doses. However, according to the MAR for December 6, 2013, Resident 9 received Sinemet at approximately 11:30 a.m., and again at 1 p.m.b. Resident 13 had a physician order for Novolog 8 units TID (man-made insulin that is used to control high blood sugar in adults and children). According to Lexicomp, the onset of action is 0.2-0.3 hours, the peak effect is one to three hours, and the duration is three to five hours. If a dose is missed, take a missed dose as soon as you think about it, but if it is close to the time for your next dose, skip the missed dose and go back to your normal time. Do not take two doses at the same time or extra doses. According to Resident 13?s MAR for December 6, 2013 indicated Novolog subcutaneous was given at approximately 11:30 a.m., and again at 1 p.m. c. Resident 19 had a physician order for Lopressor 25 mg TID (also known as metoprolol and is used to treat high blood pressure). According to the Lexicomp, the onset for peak effect is one to two hours. Limited information is available on acute metoprolol toxicity; several cases of over dosage with metoprolol tartrate or metoprolol succinate have been reported, some resulting in death. If a dose is missed, take a missed dose as soon as you think about it, but if it is close to the time for your next dose, skip the missed dose and go back to your normal time. Do not take two doses at the same time or extra doses. A review of Resident 19?s MAR for December 6, 2013, indicated the Lopressor was given at approximately 11:30 a.m., and again at 1 p.m. d. Resident 24 had a physician order for Benztropine 1 mg TID (helps decrease muscle stiffness, sweating, and the production of saliva, and helps improve walking ability in people with Parkinson's disease). According to Lexicomp, the medication peaks in seven hours and if a dose is missed, take a missed dose as soon as you think about it, but if it is close to the time for your next dose, skip the missed dose and go back to your normal time. However, according to Resident 24?s MAR for December 6, 2013, the resident was given a dose of Benztropine at approximately 11:30 a.m., and again at 1 p.m. e. Resident 34 had a physician order for Hydralizine 25 mg TID (used to treat high blood pressure). According to Lexicomp, over dosage of hydralazine may produce hypotension, tachycardia, headache, and generalized skin flushing. Myocardial ischemia and cardiac arrhythmias may develop; profound shock can occur in severe over dosage. After oral administration of a single dose of hydralazine, the antihypertensive effect begins in 20?30 minutes and lasts two to four hours. If a dose is missed, take a missed dose as soon as you think about it, but if it is close to the time for your next dose, skip the missed dose and go back to your normal time. Do not take two doses at the same time or extra doses. However, according to Resident 34?s MAR for December 6, 2013, the resident received a dose of hydralazine at approximately 11:30 a.m., and again at 1 p.m. f. Resident 37 had a physician order for Midodrine 10 mg TID (used to treat low blood pressure). According to Lexicomp, the medication peaks in 30 minutes. If a dose is missed, take a missed dose as soon as you think about it, but if it is close to the time for your next dose, skip the missed dose and go back to your normal time. Do not take two doses at the same time or extra doses. According to the resident?s MAR for December 6, 2013, the resident received the Midodrine at approximately 11:30 a.m. and again at 1 p.m. g. Resident 38 had a physician?s order for Clonidine 0.2 mg TID (used to treat high blood pressure). According to Lexicomp, the onset of action for an immediate release is half an hour to one hour. If a dose is missed, take the missed dose as soon as you think about it, but if it is close to the time for your next dose, skip the missed dose and go back to your normal time. According to the resident?s MAR for December 6, 2013, Resident 38 received another dose of Clonidine 0.2 mg at approximately 11:30 a.m., and again at 1 p.m.On December 9, 2013, at 1 p.m., during a teleconference interview with the DON and the facility?s pharmacy consultant, he stated medications are late if given one hour after the scheduled time and it is considered a medication error. The pharmacist stated the nurses? initials should be circled indicating that it was not given at 9 a.m., the correct time given should be documented, and the physician needed to be notified. The DON agreed with the pharmacy consultant?s statement. A review of the facility?s in-service record titled, ?Staff Development In Service Attendance Record,? dated November 11, 2013, was conducted by the DON and the material presented included a review of medication follow-up. LVN 1 and LVN 4 were present for this in service. A review of the facility?s policy and procedure titled, ?Policies for Medication Administration,? last revised on April 2, 2013, indicated if medications were not administered as ordered, initials needed to be circled with a recorded reason why. It also indicated if medications were given at a different time from the scheduled time, the correct time given should be written in the box with the nurse?s initials. The policy also stipulated, under ?Times of Medication Administration,? medications are administered according to a standard schedule unless specified by the physician otherwise.LVN 1 and LVN 4 failed to notify the resident?s physician of the late administration of medications, which had a potential to cause harm, and did not sign that it was given late as stipulated in the facility?s policy. The above violation had a direct or immediate relationship to the health, safety, or security of 31 residents (Residents 7-38). |
| 970000141 |
MAPLE HEALTHCARE CENTER |
940010523 |
B |
06-Mar-14 |
K1BV11 |
4217 |
T-22 72520 (b): Upon transfer of the patient of a skilled nursing facility to a general acute care hospital, the skilled nursing facility shall inform the patient, or the patient?s representative, in writing of the right to exercise this bed hold provision. No later than June 1, 1985, every skilled nursing facility shall inform each current patient or patient?s representative in writing of the right to exercise the bed hold provision. Each notice shall include information that a non-Medi-Cal eligible patient will be liable for the cost of the bed hold days, and that insurance may or may not cover such costs. On 10/25/13, an unannounced complaint investigation was conducted. Based on interview and record review, the facility failed to: 1. Provide written information to the patient and legal representative that specifies the duration of the bed hold during which the patient is permitted to return and resume residence at the facility. As result, Patient 1 who was Medi-Cal eligible, was not able to return to the skilled nursing facility after a brief hospital stay and neither was the Patient provided with a bed hold. The review of Patient 1?s medical record on 10/25/13 at 12:15 p.m. indicated that Patient 1 was a 52 year old male, who was admitted to the facility on 9/4/13. His admitting diagnosis included paranoid schizophrenia, anxiety state, and other convulsions. The history and physical (H&P) indicated that Patient 1 was evicted from a board and care facility after he had assaulted another resident. Patient 1 was evicted from the facility and taken to jail for two days after which he became homeless and was admitted to an acute care facility for suicidal ideation. He claimed that voices told him to kill himself. Further review of the H&P Revealed that Patient 1 had a history of poly-substance abuse that included cocaine, marijuana and alcohol.A review of the notice of proposed discharge/transfer dated 10/16/13 indicated that the reason for the proposed discharge was for the safety of individuals in the facility that were being endangered by Patient 1. According to the documentation in patient 1?s medical record, he was transferred to an acute care hospital on 10/16/13 for a psychiatric evaluation and treatment. The effective date of the proposed transfer/discharge was 10/16/13. The notice was not signed by Patient 1 or a representative of the patient. Also, the notice was incomplete in that it lacked the address of the Department of Public Health and the Ombudsman?s office. The director of nursing and the social service designee stated during an interview on 10/25/13, at 12:30 pm, that Patient 1 was threatening staff and other patients.According to the documentation in Patient 1?s medical record, the interdisciplinary team met on 10/16/13 and reviewed the facility?s inability to accommodate the patient at the facility and a decision was made to inform the acute care facility not to send Patient 1 back to the skilled nursing facility. The administrator and the director of nursing stated during an interview on 10/25/13, at 1:00 p.m., that Patient 1 was returned to the facility by ambulance from the acute care, however the facility refused to readmit the patient and refused to offer him the next available bed. The ambulance took the patient back to the acute care hospital. A review of the facility?s policy on 10/25/13, at 12:45 pm, regarding ?transfer or discharge, preparing a resident for,? stipulated that the facility shall prepare a resident for a transfer or discharge. The policy also referenced discharge summary and plan, transfer or discharge orientation, resident rights and dignity, discharge instructions for care and discharge summary; none of which were provided to Patient 1. There was also no documentation in Patient 1?s medical record that the facility implemented the above policy for Patient 1. The facility failed to: 1. Provide written information to the patient and/or legal representative that specifies the duration of the bed hold, during which the patient is permitted to return and resume residence at the facility. The above violation had a direct relationship to Patient 1?s health, safety and security. |
| 940000109 |
MONTEBELLO CARE CENTER |
940010945 |
B |
21-Aug-14 |
OQ6311 |
5155 |
The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. This requirement is not met as evidenced by: The following violation was noted during the facility's annual recertification survey on 8/8/14.The facility failed to provide adequate assistance devices to prevent accidents. Resident 8 fell on 7/11/14, and sustained a right femur fracture (broken upper leg bone) as a result of the facility's failure to implement safe transfer techniques and interventions to prevent falls based on Resident 8's identified risk factors and assessed needs.Resident 8 was readmitted to the facility on 2/28/08, with diagnoses including dementia (a brain disease that causes long term loss of ability to think and reason clearly, that is severe enough to affect a person's daily functioning), cerebrovascular accident (stroke) with left side weakness, degenerative joint disease (also known as osteoarthritis, caused by inflammation, breakdown, and eventual loss of cartilage of the joints), and was legally blind. On 8/5/14 at 11:00 a.m., during concurrent clinical record and administrative document review and interview with the Director of Nurses (DON), the DON stated Resident 8 fell on 7/11/14, when Certified Nursing Assistant 3 (CNA 3) attempted to transfer the resident by herself from wheelchair to the bed. The DON stated Resident 8 became weak and slid down onto the floor, assisted by CNA 3. The DON stated CNA 3 did not use a gait belt (belt used to stabilize a resident during transfer) to transfer the resident as required by the facility's written standard protocol for safe transfers. When the DON was asked what the interdisciplinary team (IDT) had identified as the root cause of the fall, she stated, "CNA 3 did not follow safe transfer techniques. Resident 8 was weak and dead-weight, and CNA 3 attempted a one-person transfer without using a gait belt." When requested to interview CNA 3, the DON stated CNA 3 was no longer employed at the facility.The "Post Fall SBAR" (Situation, Background, Assessment, Request) report dated 7/11/14, reflected, "On 7/11/14, Resident had assisted fall. Nurse aide attempted to lift the resident from wheelchair to bed. Resident's body became flaccid and began to slowly slip down. Resident's body ended in kneeling position with upper body on CNA and lower body touching floor..."The quarterly Minimum Data Set (MDS) assessment dated 1/13/14, the annual MDS assessment dated 4/2/14, and the quarterly MDS assessment dated 7/10/14, reflected Resident 8 was totally dependent on staff for activities of daily living (ADL). Resident 8 required total assistance with "two + (plus) persons" physical assistance for bed mobility and transfer in and out of bed, and had impairment or limitations in range of motion (ROM) on both upper and lower extremities.The annual "Falls Risk Review (FRR)" dated 4/2/14 and the quarterly FRR dated 7/8/14, reflected Resident 8 was a "high risk for falls" due to an unsteady gait or balance, antipsychotic medication use (medications primarily used to manage psychosis, delusions, hallucinations, or disordered thought, and other non-psychotic disorders), vision deficit, and poor safety awareness.Resident 8's care plan for falls initiated on 1/14/14, and the care plan with review dates of "4/14 and 7/14." These care plans did not include the number of staff assistance required to safely transfer the resident as identified in the MDS assessments dated 1/13/14, 4/2/14, and 7/10/14.The incident report dated 7/11/14, indicated, "Resident became weak during transfer and slid down..." Resident 8's x-ray report dated 7/16/14, reflected Resident 8 sustained an acute distal right femoral shaft fracture (a break in the upper bone of the leg) with slight medial displacement. Resident 8's treatment included no weight bearing (NWB), use of right leg immobilizer splint (a device used to prevent, restrict, or reduce normal movement in a limb), and pain medications as needed for pain.The facility's policy titled, "Lifting and Transferring of Residents" dated 7/14, indicated, "Residents are lifted and transferred safely in all instances. Residents who require assistance in transferring are transferred using a gait/transfer belt... The designated method of transferring of a resident is indicated in the plan of care and MDS."On 8/8/14, a review of "The Physician Guidelines" at www.mdguidelines.com/fracture published that "Elderly individuals who have weakened bones as a result of osteoporosis or other bone disease may experience a femur fracture from a simple fall..." The facility failed to ensure that Resident 8, who had identified risk factors including but is not limited to degenerative joint disease and left side weakness, was transferred with 2 + persons assist per the MDS assessments, and with a gait belt per facility's policy and practice. As a result, Resident 8 fell and sustained a fractured femur.This violation had a direct relationship to the health, safety, or security of Resident 8 and constitutes a Class B Citation. |
| 940000092 |
MAYWOOD SKILLED NURSING & WELLNESS CENTRE |
940012009 |
A |
12-Feb-16 |
NTFO11 |
16621 |
F329 ?483.25(I) (1)(i-vi) Unnecessary Drugs Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. The Department received a complaint allegation on 5/22/15, regarding a resident (Resident 1) developing a pressure sore on the buttocks that was becoming larger with drainage. The complainant alleged the facility was not providing wound treatment, which resulted in Resident 1 having a lot of pain and not receiving pain medication for the pain. An unannounced complaint investigation was initiated on 5/27/15. The facility failed to ensure Resident 1?s drug regimen was free from unnecessary drugs, including but not limited to: 1. Failure to ensure medications administered to Resident 1 had adequate monitoring. 2. Failure to ensure medications were not given in an excessive dose and duration and in the presence of adverse consequences to Resident 1, which indicated the dose should be reduced or discontinued. 3. Failure to follow the physician?s orders for monitoring Resident 1?s oxygen saturation every shift.These failures resulted in Resident 1 exhibiting shortness of breath (SOB) and wheezing requiring an increase in respiratory treatments, and later resulted in Resident 1 requiring a steroid inhaler for the increased episodes in shortness of breath (SOB), wheezing, and a decrease in O2 saturation down to 75 percent ([% ]normal reference range [NRR] is 95%-100%). Resident 1 was receiving large amounts of MS, without an adequate indication for its use and had the potential to result in addiction, respiratory depression, and the potential of the black boxed warning for a fatal (death) respiratory depression.A review of Resident 1?s discharge summary from a general acute care hospital (GACH), for the resident?s admission from 3/18/15-3/26/15, prior to his admission to this skilled nursing facility (SNF), indicated Resident 1 was not treated, during the GACH stay, for chronic pain with morphine sulfate (MS). A review of a "Combined Home Medication and Inpatient Medication Reconciliation Order Form," indicated the nurse would list and clarify, as well as possible, the following medications reported as taken by the resident prior to admission. It stipulated the physician would indicate whether to continue the drug, note any changes, and sign the bottom. The form indicated, ?If no indication was made, the drug will not be continued without further orders.? MS Contin Extended Release (ER) tablet 100 milligram (mg) at 6 a.m. and 6 p.m., and MS Intermediate Release (IR) 15 mg orally whenever necessary (PRN) were listed, but was not checked to indicate to be continued. A review of Resident 1?s GACH?s discharge medication list did not include for Resident 1 to receive MS after discharge.A review of Resident 1?s SNF Admission Face Sheet indicated the resident was a 54 year-old male, who was admitted to the facility on 4/17/15. Resident 1?s diagnoses included chronic obstruction pulmonary disease ([COPD]chronic lung disease), congestive heart failure ([CHF] heart muscle does not pump blood as well as it should), diabetes mellitus (high blood sugar), leg cellulitis (common skin infection that happens when bacteria spread through the skin to the deeper tissues), and morbid obesity (elevated body mass index [BMI] that exceeds 30 kilogram/meter [kg/m], a measurement obtained by dividing a person's weight by the square of the person's height). A review of Resident 1?s Minimum Data Set (MDS), an assessment and care screening tool, with a reference date of 5/25/15, indicated the resident had the ability to understand and be understood with good memory recall. Under Sectional G/Functional Status, it indicated that the resident required extensive assistance in bed mobility, transferring, walking in the room, and all other activities of daily living (ADLs), except for eating, which the resident only required supervision. According to the MDS, the resident utilized a wheelchair for locomotion. A review of a type-written consult note, by a pain control physician, MD2, dated 4/7/15, indicated Resident 1 was complaining of severe pain in legs with tightness, but refused to take the Lasix medication (a diuretic use to remove excess body fluid). MD2 documented the pain from Resident 1?s legs was the result of edema (an accumulation of excess fluid in body tissues) and MD2 also indicated there was a concern about Resident 1 receiving large doses of MS. MD2 documented under the Plan; discuss opiate tolerance (MS), dependence abuse, diversion and possibilities of addiction, although Resident 1 wished to continue the high doses of MS. MD2 changed the MS to Neurontin (an anti-seizure medication used to treat neuropathic pain [a result of damage to peripheral nerves, often causes weakness, numbness and pain]) 100 milligram (mg) three times a day.A review of Resident 1?s physician?s orders (MD1), dated 4/17/15, indicated to administer morphine sulfate (MS) ER ([extended release]effective within an hour and half and lasted up to 15 hours) 100 milligram (mg) every 12 hours around the clock (ATC) at 6 a.m. and 6 p.m., by mouth for pain management (for an unspecified pain). There was also an order, dated 4/17/15, for Resident 1 to receive MS 15 mg IR ([immediate release] effective within 30 minutes and last up 2-4 hours) by mouth every day, whenever necessary (PRN) for break through pain (also unspecified). The physician?s order also indicated to monitor the residents? oxygen (O2) saturation every shift (O2 saturation is an estimate of blood oxygen levels, [NRR from 95-100 percent (%)]).According to the physician's orders, dated 5/6/15, Resident 1?s MS PRN order changed to 15 mg IR by mouth increased to every (Q) six hours PRN for breakthrough pain. On 5/19/15, the MS PRN order was increased again to MS IR 30 mg Q6 hours for breakthrough pain, in addition to the Q12 ATC 100mg of MS. A review of Resident 1?s Medication Administration Record (MAR) for the month of July 2015, indicated on 7/1/15, a licensed vocational nurse (LVN 1) administered MS 30 mg by mouth every four hours instead of six hours as prescribed by the physician for Resident 1?s break through pain. MS IR 30 mg was given at 10 a.m., at 2 p.m. (within 4 hours), and at 9 p.m., without an adequate indication for its use, in addition, Resident 1 received the routine 100 mg of MS at 6 a.m. and 6 p.m., (for a total dose of 290 mg of MS within 15 hours on 7/1/15, from 6 a.m. to 9 p.m.). According to the physician?s orders, dated 4/17/15, Albuterol 0.083%/2.5 MG (milligram)/3ML (milliter) 1 unit dose with Atrovent 0.02%/0.5MG/2.5ML 1 unit dose (a broncho-dilator used to prevent wheezing (a whistling sound that can be made while breathing, can be a symptom of a respiratory illness or other causes or conditions) , difficulty breathing, chest tightness, and coughing) via HHN (a hand held nebulizer) every four hours whenever necessary (PRN) for wheezing. Resident 1 received the respiratory treatment the following times: For May 2015, 7 PRN treatments were given for SOB For June 2015, 34 PRN treatments were given for SOB. For July 2015 (7/1-8, 2015), 2 PRN treatments were given for SOB/wheezing. A review of the physician's orders, indicated MD1 ordered Advair (a steroid that prevents the release of substances in the body that cause inflammation) on 6/13/15, of 250/50 one puff every 12 hours for the resident?s diagnosis of COPD with SOB and wheezing.On 7/6/15 at 8:55 a.m., upon entering Resident 1?s room, an O2 tank was observed by the resident?s bed. During an interview, Resident 1 stated that he used the oxygen when he had ?problems with breathing.? Resident 1 stated he had breathing problems because of his medical conditions of ?CHF and COPD.? When Resident 1 was asked how staff monitored his oxygen levels, he stated, ?The last time they checked my oxygen saturation was over a month ago.? A review of Resident 1's physician's orders, dated 4/17/15, indicated an order for O2 at 2 liter per minute (LPM) via nasal cannula (N/C) PRN to keep O2 saturation92% and to monitor O2 saturation every shift (QS). A review of Resident 1?s Medication Administration Records (MAR) indicated the resident?s oxygen saturation levels were documented as checked every day, on each shift, for the months of May, June, and July 2015. On 7/6/15 at 9:55 a.m., while in Resident 1?s room, a licensed vocational nurse (LVN 1) was observed checking Resident 1?s blood pressure (B/P) and O2 saturation measurements, prior to his medication administration. LVN 1 stated checking the resident?s B/P and O2 saturation was necessary before the resident received his medications. During the observation, Resident 1 questioned LVN 1 why she was checking his oxygen saturation, because it had not been checked the day prior or in a long time.At approximately 10:05 a.m., on 7/6/15, once LVN 1 administered Resident 1?s medication, she was interviewed outside the resident?s room. LVN 1 stated she was Resident 1?s nurse the day prior on 7/5/15. LVN 1 was asked if she checked Resident 1?s O2 saturation on 7/5/15 and she stated, ?No, I did not check the resident?s oxygen saturation, I?m sorry.? However, a review of the MAR for 7/5/15 indicated LVN 1 documented a saturation percentage on the MAR to indicate it was checked. LVN 1 stated, ?I?m sorry,? while starting to cry. LVN 1 was shown the MAR for the month of 7/2015, which indicated she had signed several times indicating Resident 1?s O2 saturation was 98%, although she did not check it. A review of a declaration written by LVN 1, dated 7/6/15, and a concurrent interview, indicated LVN 1 would sign Resident 1?s MAR to indicate she checked the resident?s O2 saturation, but would not. LVN 1 stated she would write an oxygen percentage, although she did not check Resident 1?s saturation. LVN 1 stated and wrote on the declaration that she understood the importance of checking Resident 1?s O2 saturation as it related to the resident?s diagnoses of CHF and COPD and excessive use of morphine sulfate. LVN 1 concluded she was aware that MS can depress the resident?s respiratory system. A review of Resident 1?s MARs for the following months, indicated Resident 1 received the following amounts of MS, which included ATC and PRN:For May 2015: Resident 1 received 7,115 mg of MS. For June 2015: Resident 1 received 7,230 mg of MS. For July 2015 ([8 days] 7/1-7/8/15): Resident 1 received 1,960 mg of MS. Resident 1 received a total of 16, 305 mg of MS for 69 days.On 7/6/15 at 10:15 a.m., during an interview, LVN 2 stated, ?In the last three weeks the resident (Resident 1) had asked for the breathing treatments more, which the resident stated the Advair had been helping him a lot.? LVN 2 stated Resident 1 refused Lasix because it makes him have to urinate every 30 minutes and it was hard for the resident to get back from the patio, where he smokes all day, to his room. LVN 2 was asked about necessary documentation for Resident 1?s PRN MS dosages and he stated he was never told he had to document the need for the PRN administration of the MS. LVN2 stated he would not write on the back of the MAR the reason for giving the PRN pain medication (morphine), the location or description of the pain or the effectiveness of the medication for Resident 1. LVN 2 stated he would only document on the back of the MAR of the effectiveness of the PRN albuterol respiratory treatment that he would administer to Resident 1. During a concurrent review of Resident 1?s physician medication orders, LVN 2 stated, ?I do not see parameters for the PRN morphine on the physician?s order. The physician order should have parameters of when to administer the morphine and for what type of pain. LVN 2 stated, "When the resident (Resident 1) had pain in his arm I would give him the morphine for any general pain. We should notify the physician if we see PRN medication (morphine) given at the same time each day, because the physician may need to change the MS order.? LVN 2 stated he was trained by (LVN 1) and that the entire facility's licensed nurses were trained to only document the PRN morphine medication administration on the Pain Assessment Flow Sheet and not on the back of the MAR as indicated in the facility?s policy and procedure. A review of the facility?s policy, dated 8/4/07 and titled, ?Policy and Procedure Medication Administration Record (MAR), indicated all licensed personnel shall initial all administered medications and document on the back of the MAR the following: 1. All refused medications. 2. PRN medications, including results thereof (i.e. reason for giving PRN medication, effectiveness or ineffectiveness, etc.). 3. Initials written in error. 4. Others as deemed appropriate. The policy also stipulated the facility?s director of nurses and/or pharmacy consultant shall conduct a review of the MARs on a monthly, and as needed basis, to determine adherence to documentation requirements of medication administration. A review of the facility?s undated policy and procedure titled, Medication Ordering and Receipt, indicated, ?Upon receipt of a Physician?s Order, the nurse will verify that the order is complete. Any medication order or dose that appears to be inappropriate considering the resident?s age, condition or diagnosis, or identified allergies will be verified with the attending physician or facility nurse. Medication orders specify the following :?(8) Diagnosis or indication for administration; (9) PRN orders will include the reason or condition for administration in the order.At 11:35 a.m., on 7/6/15, during an interview, LVN 1 was questioned about the MS 30 mg she gave twice on 7/1/15, before the physician?s prescribed time. LVN 1 stated she did give the MS 30 mg at 10 a.m. and 2 p.m., instead of the prescribed PRN Q 6 hours. LVN 1 stated she did realize the physician ordered it to be given Q 6 hours and there was no new order to give it sooner than six hours prescribed time. LVN1 stated she should have called the physician to receive an order to give the MS 30 mg prior to the six hours. LVN 1 also stated since the order did not specify the type and/or location of pain, she gave Resident 1 MS 30 mg for any and all pain (i.e., complaint of arm pain). LVN 1 denied observing Resident 1 exhibiting any physical signs and symptoms of pain, such as grimacing, fidgeting, rubbing and/or massaging any painful area. On 7/7/15, at 10:24 a.m., a telephone interview was conducted with Resident 1?s physician (MD1). MD 1 stated oxygen saturation monitoring was needed for the resident due to his known episodes of SOB. MD1 stated that Resident 1 recently had an episode of SOB with a drop in his O2 saturation to 75%, MD1 stated that was why it was important for him to know what Resident 1?s O2 saturation levels were. A review of a Monthly Prescribing Reference (MPR), dated October 2015, indicated a major contraindication for MS use was respiratory depression, having a diagnosis of an acute or severe bronchial asthma, which Resident 1 had. According to the MPR, under Warnings/Precautions for MS use, indicated an increased risk of fatal respiratory depression, abuse potential, especially when administering it routinely and an accidental exposure may result in a fatal overdose. It also indicated if the resident had a pulmonary disease, e.g. COPD, to monitor closely for respiratory depression, which LVN 1 was falsely documenting Resident 1?s O2 saturation as prescribed by the physician. The facility failed to ensure Resident 1?s drug regimen was free from unnecessary drugs, including but not limited to: 1. Failure to ensure medications administered to Resident 1 had adequate monitoring. 2. Failure to ensure medications were not given in an excessive dose and duration and in the presence of adverse consequences to Resident 1, which indicated the dose should be reduced or discontinued. 3. Failure to follow the physician?s orders for monitoring Resident 1?s oxygen saturation every shift.The above violations presented either imminent danger that death or serious harm would result or a substantial that death or serious physical or mental harm would result. |
| 940000092 |
MAYWOOD SKILLED NURSING & WELLNESS CENTRE |
940012353 |
A |
28-Jun-16 |
SONT11 |
15778 |
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. The Department received a complaint on 4/29/14, alleging a resident (Resident 1) had been to a hospital twice in the last two weeks for choking on food that had to be removed by the hospital. 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, including but not limited to: 1. Failure to ensure Resident 1's anxious behavior with deep breathing while eating was addressed on the plan of care. 2. Failure to ensure Resident 1 received the prescribed diet. 3. Failure to ensure Resident 1, who had difficulty in swallowing and had a high risk for aspiration (the entry of material (such as pharyngeal secretions, food or drink, or stomach contents), was supervised when non-prescribed food was in her reach. 4. Failure to ensure Resident 1 was served a puree diet, as prescribed by the physician, since 3/9/14, and reordered on 4/5/14. These failures resulted in Resident 1 receiving food not prescribed by the physician, choking on food twice, within five days of the two incidents, receiving the Heimlich maneuver (first-aid procedure for dislodging an obstruction from a person's windpipe) twice with suctioning to remove food particles and requiring two transfers to a general acute care hospital (GACH) via the paramedics. These failures had the potential for Resident 1, who had difficulty in breathing after the incidents, to aspirate food particles, develop respiratory complications and stop breathing. A review of Resident 1's admission Face sheet indicated Resident 1 was a XXXXXXX year-old female who was admitted to the facility on XXXXXXX, and last readmitted on XXXXXXX. Resident 1's diagnoses included congestive heart failure ([CHF] heart is unable to pump sufficiently to maintain blood flow to meet the needs of the body), atrial fibrillation (abnormal rate or rhythm of the heart), diabetes mellitus (a life-long disease that affects the way your body handles glucose, a kind of sugar, in your blood), hypertension (high blood pressure), and esophageal reflux disease (reflux means the back flow or return of food). A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool,) dated 2/28/14, Under Section G/ Functional Status, indicated Resident 1 was non-ambulatory (cannot walk) and required extensive staff assistance with all activities of daily living (ADLs), which included eating. A review of Resident 1's dysphagia evaluation (to evaluate the resident's ability to swallow), dated 6/2/11, indicated Resident 1 had exhibited episodes of choking while receiving a mechanical soft diet (a diet that consists of foods that are mechanically altered so that they are soft and easy to chew and swallow) and that Resident 1 was at risk for aspiration, choking, and aspiration pneumonia (an inflammation (usually due to an infection) of the lungs and bronchial tubes that occurs after you inhale foreign matter). A review of Resident 1's dietary progress note, dated 10/18/13, indicated Resident 1 was confused and very anxious requiring extensive staff assistance during meals. There was no documentation regarding the resident?s behavior of deep breathing while eating. A review of Resident 1's care plan, dated 1/18/13, and last updated on 1/18/14, titled, "Nutritional Status; At Risk for Significant Weight Changes," indicated that impaired ADL/Limitations, mood and behavioral problems and cognitive impairment were listed as other contributory factors. The nutritional approaches included to provide Resident 1 with a mechanically altered /therapeutic diet (foods that do not require much chewing and are soft on the mouth; controls the intake of certain foods or nutrients). Resident 1?s goal was to have no signs and symptoms of aspiration and/or choking. The plan of care indicated the staff would provide Resident 1 with the diet as ordered and assist and/or feed Resident 1. Resident 1's nutritional status care plan, dated 3/5/14, indicated there were concerns that the resident's appetite may be affected due to the resident's mood and behavior problems and cognitive impairment (thinking abilities impaired). According to the plan of care, the staff was to monitor Resident 1's food intake. A review of a nurse's note, dated 4/4/14, and timed at 8 p.m., indicated the staff responded to a call for help after Resident 1 was found choking and coughing. According to the nurse's note, the staff had to repeatedly perform the Heimlich procedure on Resident 1. The note indicated Resident 1 coughed out small particles of bread after the Heimlich and a finger sweep, in an attempt to remove the food particles from the resident's throat and mouth. The nurse's note indicated Resident 1's vital signs were assessed with an oxygenation saturation of 82 percent [%] (normal reference= 95-100 %, if the level is below 90 %, it is considered low), a heart rate of 98 beats per minute ([bpm] normal reference range= 60-100 bpm), respirations rate of 23 breaths per minute (normal reference range= 12-16) and a blood pressure of 154/78 ([B/P] normal reference range=120/80). The nurses' note indicated Resident 1 continued to cough and have shortness of breath ([SOB] breathlessness). A nurse's note, dated 4/4/14, and timed at 8:10 p.m., indicated the paramedics were able to remove brown colored particles from Resident 1's airway. Resident 1 was then transported to a GACH for emergency service. On 4/30/14 at 5:55 p.m., when interviewed a certified nurse assistant (CNA 6), translated by CNA 5 (from Spanish to English), CNA 6 stated that on 4/4/14, she was sitting with Resident 1 in the corridor when the snacks of peanut butter and ham and cheese sandwiches were sent from the kitchen. CNA 6 stated she placed a stack of regular textured sandwiches on a table in the corridor near Resident 1. CNA 6 stated she left Resident 1 sitting in the hallway unsupervised, with the sandwiches in reach, while she went from room to room passing sandwiches to other residents. CNA 6 stated approximately two to three minutes later, she observed Resident 1 choking on one of the sandwiches. CNA 6 stated Resident 1 was not breathing and she (CNA 6) screamed for help. CNA 6 stated the charge nurse came and pressed on Resident 1's stomach, but nothing came out and Resident 1 was still choking. CNA 6 stated that was when 911 emergency services were called. A review of Resident 1's paramedic's sheet, dated 4/4/14 indicated the paramedics were called at 8:37 p.m., on 4/4/14, and the documented arrival time on the scene was 8:38 p.m. Upon the paramedics arrival to the facility, they documented Resident 1's respirations were ?Brady? (refers to an abnormally slow breathing rate) and required the paramedics to use Magill's forceps (used to remove a foreign body from the airway obstructions quickly) to remove the meat from Resident 1's airway. Resident 1's blood pressure was 192/84, heart rate was 120, and the respiratory rate was 20. A review of Resident 1's GACH's emergency department (ED) record, dated 4/4/14, indicated Resident 1 was transferred to the hospital via paramedics due to a choking episode while eating. The ED note indicated Resident 1 presented with an altered level of consciousness (ALOC) after a ?big ?piece of meat was removed by the paramedics from the resident's throat. Resident 1's diagnoses included foreign body-choking resolved and rule-out aspiration. Resident 1's chest x-ray was clear and the resident was discharged to the facility. A review of a physician's progress note, for Resident 1, dated 4/4/14, indicated, " Choking at times with swallowing food." The physician documented, "If choking recurs refer to hospital ASAP (as soon as possible).? A review of a nurse's note, dated XXXXXXX, and timed at 1 a.m., indicated Resident 1 was readmitted to facility from the GACH. A plan of care, dated 4/5/14, and titled, ?Risk for Choking, ?indicated Resident 1 was at risk for choking secondary to difficulty swallowing (after Resident grabbed a sandwich). The staff approaches included to provide the diet as ordered to Resident 1; monitor for coughing and choking when eating; keep foods away from the resident, change the texture of diet as ordered, and supervise Resident 1 when she was eating. A review of Resident 1's physician's re-capped orders for the month of 4/2014 indicated Resident 1 had a diet order for pureed texture (foods that have a pudding-like texture, smooth, blended or pureed), no added salt, and control/consistent carbohydrate (sugars and starches that provide energy ), low cholesterol and low fat diet since 3/9/14. Resident 1's physician telephone orders, dated 4/7/14, and timed at 5 p.m., indicated there were new orders to discontinue Resident 1's previous diet orders and change to a pureed texture with nectar fluids (liquids that can help prevent choking and stop fluid from entering the lungs), no added salt, and control/consistent carbohydrate low cholesterol, and low fat diet. Another care plan, dated 4/7/14, and titled, "Dysphagia; Risk for Choking," indicated Resident 1 was at risk for aspiration and/or pneumonia due to Resident 1's decreased safety awareness. The staff approaches and interventions included to give diet as ordered, puree nectar, monitor the resident for signs and symptoms of shortness of breath, and/or respiratory distress. A review of a speech therapy functional limitation addendum, dated 4/7/14, indicated Resident 1 had previously been hospitalized for possible aspiration, due to decreased cognition. The speech therapist ([ST] a person who assesses, diagnoses, treats, and helps to prevent communication and swallowing disorders in residents) documented Resident 1's current status for swallowing as, " No safety, and at aspiration risk, ? indicating Resident 1's swallowing ability was severe. The ST documented Resident 1's projected status for swallowing as, ?Requiring assistance with all oral intake due to poor safety awareness." A review of a nurse's note, dated 4/9/14, and timed at 7:25 a.m., indicated the staff observed Resident 1 choking and coughing. The nurse's note indicated the facility called a " Full code (all possible measures are taken to revive a person and sustain life)," and Resident 1's vital signs were assessed with an oxygen saturation of 75 %, a heart rate of 81 beats per minute, respirations rate at 22 breaths per minute, and a blood pressure of 170/80. A nurse's note, dated 4/9/14, and timed at 7:40 a.m., indicated the staff, using a suction device, was able to remove some small food particles from Resident 1's mouth and throat. An entry on the nurse's note, timed at 7:45 a.m., indicated the paramedics was called. At 8:30 a.m., on 4/9/14, Resident 1 was transported via paramedics to the GACH by the paramedics to the emergency room. A review of Resident 1's GACH record, a physician documented history and physical (H/P), dated 4/9/14, indicated Resident 1's chief complaint was listed as ?choked on a sausage." According to the facility's physician's orders, Resident 1 had an order for a pureed diet. The H/P indicated Resident 1's primary diagnosis included dysphagia. Resident 1's GACH's discharge summary, dated 4/9/14 indicated the resident was recently seen in the ED the prior week for dysphagia and choking. The note indicated Resident 1 was seen by a gastroenterologist (an internal medicine physician that specializes in the treatment of disorders of the gastrointestinal tract), who recommended and placed Resident 1 on a pureed diet with thick nectar, but was fed a sausage in the facility. Resident 1 complained of discomfort and a little shortness of breath (SOB), while in the ED. A chest x-ray (CXR) was done for SOB on 4/9/14 and compared to the CXR done on 4/4/14. The CXR was within normal limits and Resident 1 was transferred to the SNF on XXXXXXX. A review of Resident 1's paramedic sheet, dated 4/9/14, indicated the paramedics were called to the facility at 7:57 a.m., on 4/9/14, and arrived on the scene at 8:01 a.m., according to the paramedic's sheet, Resident 1's airway was partially obstructed with wheezing (breathe with a whistling or rattling sound in the chest, as a result of obstruction in the air passages) audible, " FB (foreign body in larynx [voice box]), " removed with forceps (an instrument resembling a pair of pincers or tongs, used for grasping, manipulating, or extracting). Resident 1's blood pressure was 190/90, pulse was 120, and the respiratory rate was 28. On 5/5/14 at 9 a.m., when interviewed, the director of nursing (DON) stated that Resident 1 was "Always restless," and when eating her food the resident would ?deep breath." which put the resident at risk for choking. The DON stated that Resident 1 demonstrated the restlessness and deep breathing while eating for more than a year and that the resident had choked twice while eating her food on 4/4/14 and 4/9/14. The DON stated while reviewing Resident 1?s record that there was no assessment and/or plan of care to address Resident 1's identified behavior of deep breathing while eating food. The DON stated, "It should have been addressed, but we missed it." At 3:35 p.m., on 5/5/14, when interviewed, CNA 7 stated on 4/9/14, she was feeding Resident 1 her breakfast meal when the resident started to hyperventilate (rapid or deep breathing that can occur with anxiety or panic) with very fast breaths while eating and the resident started choking on her food. CNA 7 stated Resident 1 had labored breathing initially, and then the resident would have fast breathing alternating with no breathing, while coughing, but the food did not dislodge. CNA 7 stated the charge nurse then grabbed Resident 1's stomach area and told her (Resident 1) to cough, but again the food did not come out. CNA 7 stated that prior to Resident 1's choking episode; she was told to be careful with feeding Resident 1, because the resident could choke on any small amount of food. CNA 7 stated she was not told that Resident 1 would hyperventilate and/or deep breathe while eating and what she should do when the resident hyperventilated while eating. 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, including but not limited to: 1. Failure to ensure Resident 1's anxious behavior with deep breathing while eating was addressed on the plan of care. 2. Failure to ensure Resident 1 received the prescribed diet. 3. Failure to ensure Resident 1, who had difficulty in swallowing and had a high risk for aspiration (the entry of material (such as pharyngeal secretions, food or drink, or stomach contents), was supervised when non-prescribed food was in her reach. 4. Failure to ensure Resident 1 was served a puree diet, as prescribed by the physician, since 3/9/14 and reordered on 4/5/14. 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. |
| 940000109 |
MONTEBELLO CARE CENTER |
940012523 |
B |
22-Aug-16 |
JCP311 |
5318 |
F225 ? 42 CFR 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 4/4/16, at 1:30 p.m., an unannounced visit was conducted at the facility to investigate a complaint. The Department received an anonymous call that the facility was not reporting to the Department an injury of unknown source. Based on interview and record review, the facility failed to implement its abuse prohibition policy and procedure by failing to: 1. Report to the Department (the Licensing and Certification Program) an injury of unknown source immediately (not to exceed 24 hours). Resident 10, who had dementia (loss of brain function), had a skin discoloration on the right ankle with swelling on 2/15/16. The x-ray report showed the resident had a right ankle fracture. The resident and the facility did not know how the resident sustained the injury. The facility did not report the injury of unknown source to the Department immediately. This deficient practice resulted in an injury of unknown source that was not thoroughly investigated to prevent further occurrences. A review of Resident 10's clinical record indicated that the resident was 96-year old female, who was admitted to the facility on 7/18/06 and re-admitted on 2/1/16, with diagnoses that included dementia dysphagia (difficulty or discomfort in swallowing), and hypertension (high blood pressure). A review of the Minimum Data Set (MDS, a comprehensive, systematic assessment tool), dated 1/19/16, indicated Resident 10 was impaired with her cognitive skills for daily decision making and required extensive assistance (resident involved in activity; staff provide weight-bearing support) with activities of daily living. On 4/5/16 at 4:15 p.m. during an interview, a facility staff (anonymous) stated Resident 10 had a fracture and at the time the fracture was discovered, the resident?s foot was so black and the resident was screaming in pain. The facility staff stated the facility did not report the incident to the Department. On 4/6/16 9:45 a.m., during an interview with director of nursing (DON), she stated that on 2/15/16, a facility staff noticed that Resident 10 had pain on the right foot, the physician was called, and the physician ordered an x-ray. The DON stated that in her investigation after the incident (February 2016), a facility staff saw the resident hitting the wander guard (a departure alert system) that was attached to the resident's right ankle against the wheelchair and bed and the behavior might have contributed to the fracture. On 4/7/16 at 11:20 a.m., during an interview with the administrator (ADM), he stated that the facility never reported Resident 10?s fracture of unknown source to the Department, but he should have. According to the facility?s summary report, completed on 4/8/16, Resident 10 was observed, on 2/15/16, at 5:20 a.m., by a certified nursing assistant (CNA 7) with a skin discoloration to the right ankle, while the CNA was removing the resident?s socks. The resident?s right ankle was swollen and painful to touch. An x-ray was taken and the x-ray report indicated that the resident had a displaced (a break in a bone in which the two pieces of bone become incorrectly aligned) lateral (side) and possible media (middle) right ankle fracture (break in the bone). The resident could not relay how she got the discoloration due to being confused as her baseline. The facility?s summary report indicated CNA 8 was interviewed during the investigation and the CNA stated that she noticed Resident 10 kick other residents? wheelchairs if the wheelchairs were in her way. On 4/11/16 at 9:45 a.m., during an interview with the ADM, he stated a second investigation, which was started on 4/7/16 and ended on 4/11/16, regarding Resident 10's right ankle fracture was conducted. The ADM stated the investigation revealed that the resident?s fracture was due to the resident?s behavior of kicking other residents? wheelchairs and not from the wander guard. The ADM stated the conclusion he found in his investigation was the final conclusion. A review of the facility's policy and procedure titled, "Abuse-Investigations," revised on 10/15/13, indicated anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin , or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The notified supervisor will report the suspected abuse immediately (not to exceed 24 hours) to the Administrator or designee and other officials in accordance with the state law. The facility failed to implement its abuse prohibition policy and procedure by failing to: 1. Report to the Department (the Licensing and Certification Program) an injury of unknown source immediately (not to exceed 24 hours). The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 970000141 |
MAPLE HEALTHCARE CENTER |
940012671 |
A |
28-Oct-16 |
E9IR11 |
18499 |
Naso-Gastric Tubes ?483.25(g)(2) A resident who is fed by a naso-gastric tube or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills. Medical Director ?483.75(i) (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. During a recertification survey on September16, 2016, the following violations were identified regarding Resident 5. Based on observation, interview, and record review, the facility failed to provide and co-ordinate appropriate medical care and services to prevent recurrent dislodgement of Resident 5?s gastrostomy tube (GT, a small stomach tube for medications, food, and fluids administration) and development of a pressure injury of the skin from the gastrostomy tube disc (a plastic device used to keep a GT in place) by failing to: 1. Promptly investigate circumstances surrounding Resident 5's recurrent GT dislodgement and take corrective action. 2. Identify the cause of Resident 5's GT dislodgement and develop a care plan to prevent future gastrostomy tube dislodgement as indicated in the facility's policy for Accidents and Incidents. 3. Update Resident 5's care plan with interventions that were targeted and meaningful when the desired outcome related to GT dislodgement was not met. 4. Identify Resident 5 as a resident who was at-risk for pressure injury due to the use of an abdominal binder, resulting in pressure of the GT disc against the resident's skin, and implement promptly interventions to prevent a pressure injury, as indicated in the facility's policy for Accidents and Incidents. 5. Collaborate and coordinate with the medical director to provide further clinical guidance to identify, evaluate, and address Resident 5?s continued GT dislodgement and transfer to the GACH. The above violations resulted in Resident 5 being transferred six times for GT replacement in the general acute care hospital (GACH) from 1/17/16 to 8/25/16, and subsequently developing an open area at the GT insertion site (abdominal area) from the pressure of the GT disc against the resident's skin. a1. A review of Resident 5's Admission Record (face sheet) indicated that the resident was admitted to the facility on 9/18/2015 with diagnoses that included cerebrovascular disease (stroke) with hemiplegia (paralysis of one side of the body), and hemiparesis (weakness of one side of the body), gastro-esophageal reflux disease (a chronic condition that occurs when stomach acid or stomach contents flows back and irritates the lining of the esophagus [food pipe that delivers food from mouth to stomach]), ulcerative colitis (an inflammatory bowel disease that causes long-lasting inflammation and ulcers [sores] in the digestive tract), and had a GT. A review of Resident 5's quarterly Minimum Data Set (MDS, a resident assessment and care screening tool), dated 6/24/16, indicated that the resident had short and long-term memory problems with cognition (ability to think and reason) that was severely impaired, and required extensive assistance to totally dependent on the staff with all activities of daily living. The MDS indicated Resident 5 did not exhibit a behavior of rejecting care and/or pulling her GT. 1. A review of Resident 5's nurses Progress Notes on 1/17/16, at 8:20 a.m. indicated that a certified nurse assistant (CNA) reported that Resident 5?s GT was dislodged. The note indicated the physician was made aware and the resident was transferred to a GACH for GT replacement on the same day and returned to the facility with the GT patent (unobstructed) and intact and without leakage to the site. Resident 5's care plan, initiated on 1/18/16, indicated Resident 5 attempted to pull out the gastrostomy tube, related to encephalopathy (a general term that means brain disease, damage, or malfunction) with poor safety awareness and the resident was at risk for injuries. The goal indicated to minimize pulling out of gastrostomy tube/injuries daily for three months. The interventions included: I. To apply abdominal binder at all times ii. Discuss risks and complications with family that may result from continuous gastrostomy tube removal and replacement iii. Involve resident with diversional activities to keep occupied iv. Provide music to engage resident with auditory stimulation v. Provide pillow/towel as needed to minimize site of gastrostomy tube vi. Provide activities that require resident to use hands vii. Reevaluate continued need for abdominal binder quarterly and as needed to ensure least restrictive form of restraint without compromising safety viii. Transfer the resident to GACH when gastrostomy tube is pulled out for re-insertion as ordered by the attending physician and ix. Use two nursing staff members when providing care to reduce risk of injury when abdominal binder was removed. 2. A review of the ?Change of Condition (also known as SBAR: Situation, Background, Assessment, and Recommendation, provides a framework for communication between members of the health care team)," dated 2/12/16, indicated Resident 5 had a dislodged gastrostomy tube. The section of the resident's assessment that indicated "Things that make the problem/symptoms worse; things that make the problem/symptoms better, and other contributing factors that have occurred with the problem/symptoms," indicated that the facility staff was unable to determine any problem/symptoms associated with the cause of the gastrostomy dislodgement. The note indicated a physician's order to transfer Resident 5 to a GACH for gastrostomy tube replacement. A review of Resident 5's nurses' Progress Note, dated 2/12/16, at 11:27 p.m., indicated Resident 5 was transferred back to the facility and the resident was calm and cooperative. Another plan of care dated 3/4/16, indicated Resident 5 tends to pull out the gastrostomy tube and needs an abdominal binder to minimize pulling out of the gastrostomy tube. The care plan indicated that the resident will minimize pulling out of his gastrostomy tube daily for three months and will minimize injuries from pulling out of gastrostomy tube within the next three months. The care plan indicated the following facility interventions: I. Apply abdominal binder at all times; ii. Monitor any behavioral problems related to use of abdominal binder; iii. Provide restrictive clothing to minimize sight of gastrostomy tube; iv. Reevaluate need for continued use of abdominal binder quarterly and as needed; v. Take the resident to the activity room and involve in diversional activities to keep occupied; and vi. Provide visual checks every 2 hours to visually inspect that abdominal binder remained in place and applied appropriately. 3. A review of Resident 5's Change of Condition (SBAR), dated 7/16/16, at 10:06 a.m., indicated that Resident 5 had gastrostomy tube dislodgement. The notes indicated a physician order was received to send the resident to the GACH for gastrostomy tube re-insertion. A review of Resident 5?s nurses? Progress Notes, dated 7/16/16, at 7:27 p.m., indicated that Resident 5 returned to the facility from the GACH with reinserted gastrostomy tube intact. A review of Resident 5's Nursing Admission/ Readmission Data, dated 7/29/16, indicated the resident was readmitted to the facility from a GACH. The Nursing Admission/ Readmission Data indicated Resident 5 had weakness/paralysis, and the gastrostomy tube site had skin redness and drainage. 4. A review of Resident 5's Change of Condition (SBAR), dated 7/30/16, at 3:57 p.m., indicated the resident's GT was out (dislodged). The section of the resident's assessment that "Things that make the problem/symptoms worse; things that make the problem/symptoms better, and other contributing factors that have occurred with this problem/symptoms," indicated "unable to determine." (i.e. unable to determine the cause of the gastrostomy dislodgement.) The SBAR indicated a new physician order to transfer Resident 5 to the GACH for gastrostomy tube replacement. A review of Resident 5's nurses' Progress Notes, dated 7/31/16, at 3:55 p.m., indicated the resident returned from the GACH. The documentation indicated the gastrostomy tube site was clean, dry and intact. 5. A review of Resident 5's Change of Condition (SBAR), dated 8/24/16, at 4:32 p.m., indicated the resident's gastrostomy tube was dislodged. The review of the SBAR for the resident's gastrostomy dislodgement which indicated "Things that make the problem/symptoms worse; things that make the problem/symptoms better, and other contributing factors that have occurred with the problem/symptoms," revealed that the facility staff was unable to determine the cause of the gastrostomy dislodgement. The SBAR indicated a new physician?s order to transfer Resident 5 to the GACH for gastrostomy tube replacement. A review of Resident 5's nurses' Progress Notes dated 8/24/16, at 10:19 p.m., indicated the resident returned from the GACH, and the gastrostomy tube was intact and patent. The progress note indicated an abdominal binder was in place to prevent dislodgement and will continue to monitor. 6. A review of Resident 5's Change of Condition (SBAR), dated 8/25/16, at 4:18 p.m., indicated the resident was noted to have a dislodged gastrostomy tube. The note indicated there was leakage noted around the gastrostomy site and as well on the resident's shirt. . The SBAR indicated Resident 5 had an abdominal binder in place. The SBAR indicated a new physician?s order to transfer Resident 5 to the GACH for gastrostomy tube replacement. On 9/13/16, at 6:50 a.m., during an initial tour observation accompanied by licensed vocational nurse (LVN 4), Resident 5 was observed in his bed with gastrostomy tube feeding. The resident was observed calm and did not exhibit behaviors of attempting to pull out the gastrostomy tube. During a concurrent interview with LVN 4, she stated that Resident 5 did not have a behavior of attempting to pull out his gastrostomy tube. On 9/13/16, at 11 a.m., during an interview and review of Resident 5's clinical record, LVN 2 stated Resident 5 had an abdominal binder in place to prevent gastrostomy tube dislodgement; however she was not aware of the cause of frequent gastrostomy tube dislodgments. LVN 2 stated Resident 5 was not known to exhibit behavioral symptoms of attempting to pull out the gastrostomy tube. On 9/15/16, at 3:50 p.m., during an interview, the director of nurses (DON) stated the facility did not do an investigation or incident report on gastrostomy tube dislodgement. DON stated an IDT meeting could have been done for each incident of Resident 5's gastrostomy tube dislodgment to discuss and identify the appropriate interventions and to prevent further gastrostomy tube dislodgement. The DON stated that Resident 5 was compliant and did not exhibit behavior of pulling out gastrostomy tube. The DON stated the resident's care plan did not reflect the actual status of the resident that addressed the resident's minimization of pulling out the gastrostomy tube. On 10/14/16 at 10:30 a.m., during an interview, the DON stated Resident 5?s primary care physician (PCP) was also the medical director of the facility. The DON stated the PCP was notified and made aware of each of Resident 5?s GT dislodgment. The DON stated that a gastroenterologist ([GI], a physician who specializes in diagnosis and treatment of conditions that affect the gastrointestinal tract) consult could have been recommended for Resident 5. According to the 4/2008, facility?s policy and procedures titled, ?Medical Director,? the Medical Director was responsible for: i. Ensuring adequate and appropriate physician services. ii. Participating in efforts to improve quality of care and services. iii. Serving as a source of education, training, and information. iv. Acting as a consultant to the director of nursing services in matters relating to resident care services. v. Helping assure that residents receive adequate services appropriate to meet their needs. vi. Helping assure that the resident care plan accurately reflects the medical regimen. According to the 12/2011, facility's policy and procedures, titled "Accidents and Incidents: Investigating and Reporting," all accidents or incidents involving residents shall be investigated and reported to the Administrator. The policy indicated the facility shall promptly initiate and document investigation of the accident or incident. The policy indicated the Report of Incident/Accident form should include: i. Circumstances surrounding the accident or incident. ii. The name of witnesses and their accounts of the accident or incident. iii. The injured person's account of the accident or incident and iv. Any corrective action taken; and follow up information. A review of the 10/2010, facility's policy and procedures titled "Care Plans: Comprehensive," indicated that the facility's Care Planning/Interdisciplinary Team were responsible for developing and maintaining a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The policy indicated the comprehensive care plan was based on a thorough assessment and was designed to: - Incorporate identified problem areas to aid in preventing or reducing declines in the resident's functional status and/or functional levels; and reflecting currently recognized standards of practice for problem areas and conditions. - Care plan interventions were designed after careful consideration of the relationship between the resident's problem areas and their causes, and addressed the underlying source of the problem area. - Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. - Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change, - The Interdisciplinary Team was responsible for the review and updating of care plans: When there has been a significant change in the resident's condition; when the desired outcome was not met; when the resident have been readmitted to the facility from a hospital stay; and at least quarterly. a2. A review of Resident 5's Change of Condition (SBAR), dated 8/29/16, at 10:40 a.m., indicated the resident was noted to have a device related pressure injury from the disc of the gastrostomy tube. The note indicated the resident had an open (skin breakdown) at the gastrostomy tube site, located at the left side of the abdomen, downward area (3 p.m., to 6 p.m., location) with the deepest injury at the 6 p.m., location. The review of the SBAR for the "Things that make the problem/symptoms worse; things that make the problem/symptoms better, and other contributing factors that have occurred with the problem/symptoms," was left blank. During the evaluator's observation and interview while LVN 2 was providing treatment to Resident 5's gastrostomy tube site on 9/13/16, at 11 a.m., LVN 2 stated that the surrounding skin of the gastrostomy tube site was red, and the abdominal binder caused pressure to the gastrostomy tube disc onto the resident's abdominal skin that caused a skin breakdown. During a record review of Resident 5's care plans and concurrent interview on 9/16/16, at 9:15 a.m., LVN 2 stated that there was nothing in the care plan that addressed and anticipated the complication of the abdominal binder that contributed to pressure exerted on the gastrostomy tube disc that led to the resident?s skin break down. A review of the 7/2016, facility's policy and procedures titled "Pressure Injury Risk Assessment," indicated pressure injuries were often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e. wound discharge). The policy indicated that nurses would conduct skin assessments at least weekly to identify changes and the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure injuries. The policy indicated that once risk factors have been identified, proceed to the Care Area Assessment, care planning and interventions individualized for the resident and their particular risk factors. The facility failed to provide and co-ordinate appropriate medical care and services to prevent recurrent dislodgement of Resident 5?s gastrostomy tube and development of a pressure injury of the skin from the gastrostomy tube disc by failing to: 1. Promptly investigate circumstances surrounding Resident 5's recurrent GT dislodgement and take corrective action. 2. Identify the cause of Resident 5's GT dislodgement and develop a care plan to prevent future gastrostomy tube dislodgement as indicated in the facility's policy for Accidents and Incidents. 3. Update Resident 5's care plan with interventions that were targeted and meaningful when the desired outcome related to GT dislodgement was not met. 4. Identify Resident 5 as a resident who was at-risk for pressure injury due to the use of an abdominal binder, resulting in pressure of the GT disc against the resident's skin, and implement promptly interventions to prevent a pressure injury, as indicated in the facility's policy for Accidents and Incidents. 5. Collaborate and coordinate with the medical director to provide further clinical guidance to identify, evaluate, and address Resident 5?s continued GT dislodgement and transfer to the GACH. Resident 5 was transferred six times for GT replacement in the GACH from 1/17/16 to 8/25/16, and subsequently developing an open area at the GT insertion site from the pressure of the GT disc against the resident's skin. 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. |
| 970000109 |
Montecito Heights Healthcare & Wellness Centre, LP. |
940012768 |
B |
22-Nov-16 |
OILJ11 |
6221 |
F164 - ?483.10(e) Privacy and Confidentiality
The resident has the right to personal privacy and confidentiality of his or her personal and clinical records.
Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.
Except as provided in paragraph (e)(3) of this section, the resident may approve or refuse the release of personal and clinical records to any individual outside the facility.
The resident's right to refuse release of personal and clinical records does not apply when the resident is transferred to another health care institution; or record release is required by law.
The facility must keep confidential all information contained in the resident's records, regardless of the form or storage methods, except when release is required by transfer to another healthcare institution; law; third party payment contract; or the resident.
On 8/30/16 at 10:25 a.m., an unannounced complaint investigation was conducted at the facility regarding an allegation of employee to resident abuse.
Based on observation, interview, and record review, the facility failed to implement its policy and procedure regarding the prohibition of unauthorized and inappropriate photographing and audio/visual recording of Resident 2 and two other residents by failing to:
1. Prevent a certified nursing assistant (CNA 1) from using her cellular (cell) phone to take a recorded video and a picture of Resident 2, and to take pictures of two other residents, without the residents? consent.
2. Prevent CNA 1 from sending the recorded video and pictures to a former resident of the facility (Resident 1) via text messaging.
This deficient practice resulted in the violation of the residents' privacy.
A review of Resident 1's face sheet (admission record) indicated the resident was admitted to the facility on XXXXXXX16 with the admitting diagnoses of muscle weakness and difficulty walking. The resident was discharged from the facility against medical advice (AMA) on 4/20/16 and was readmitted back to the facility on XXXXXXX16 for treatment of the stabbed wounds in the left axilla (space below the shoulder) and left rib.
A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 8/22/16 indicated the resident had clear speech, was able to make his needs known, and his cognition (ability to think and reason) was intact.
During an interview, on 9/6/16 at 2:20 p.m., Resident 1 stated he started a relationship with a former employee of the facility (CNA 1) in March 2016. Resident 1 stated he left the facility in April 2016 and went to live with CNA 1 at her place of residence. Resident 1 stated when he was staying at CNA 1's residence, CNA 1 would send him video and pictures of residents at the facility without the residents' knowledge that they were being recorded and their pictures were taken. Resident 1 stated he had the video and pictures on his cell phone and he would show them to the surveyor.
During an observation, on 9/8/16 at 7:30 a.m., Resident 1 showed the surveyor a recorded video on his cell phone of Resident 2, who was wearing a white shirt and walking around in the hallway, and a woman's voice was being heard in the background telling the resident to go back to bed. In addition to the recorded video, the surveyor saw four pictures of residents in Resident 1's cell phone - one picture of Resident 2 in the bedroom, two pictures of a resident walking in the hallway, and one picture of another resident in the nursing station.
During an interview, on 9/8/16 at 10:40 a.m., the administrator (ADM) stated she saw the video of a man walking in the hallway (Resident 2), a picture of a resident in a bedroom (Resident 2) and a resident standing at the nursing station. The ADM stated they (the facility staff) were able to identify one resident (Resident 2) in the pictures, but the other pictures were too blurry to identify the two other residents. The ADM stated that for one resident (Resident 2) whom the facility staffs were able to identify in the video and picture (in the bedroom), the facility would notify the responsible party of the breech of privacy.
In a Declaration Statement submitted by Resident 1, dated 9/8/16, Resident 1 wrote that the video and pictures in his cell phone were sent to him via text messaging by CNA 1 in May of 2016, when he was no longer in the facility.
During an interview, on 9/9/16 at 8:30 a.m., Resident 1 stated he deleted the recorded video and pictures from his cell phone last night (9/8/16) while he was talking to the administrator, director of nursing (DON), and facility's consultant inside his room.
A review of the face sheet of Resident 2 indicated the resident was admitted to the facility on XXXXXXX16 and was discharged on XXXXXXX 16.
According to the facility's policy and procedure titled, "Privacy Abuse and Unauthorized Photographs," revised on 8/2016, it is the policy of this facility to prohibit unauthorized and inappropriate photographing, audio/visual recordings of residents in compromising or demeaning poses or positions or otherwise take and/or distribute suck photographs, audio/visual records for purposes with than a genuine medical need and for which such action may be considered mentally abuse.
The facility failed to implement its policy and procedure regarding the prohibition of unauthorized and inappropriate photographing and audio/visual recording of Resident 2 and two other residents by failing to:
1. Prevent a certified nursing assistant (CNA 1) from using her cellular (cell) phone to take a recorded video and a picture of Resident 2, and to take pictures of two other residents, without the residents? consent.
2. Prevent CNA 1 from sending the recorded video and pictures to a former resident of the facility (Resident 1) via text messaging.
The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 940000109 |
MONTEBELLO CARE CENTER |
940013088 |
A |
29-Mar-17 |
Z5R411 |
11606 |
483.25(d) (1) (2) (n) (1-3)
FREE OF ACCIDENT HAZARDS/SUPERVISON/DEVICES
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.
On 1/10/17 an unannounced visit was made to the facility to investigate a complaint regarding a fall.
The facility failed to ensure Resident 1 was provided adequate supervision to prevent accidents by failing to:
1. Ensure Resident 1 was not left in her room unattended while she was in her wheelchair in accordance with the facility's "Action Plan." (The Facility's plan to prevent Resident 1 from falling in response to Resident 1's Family's grievance.)
2. Provide a properly functioning alarm device (alarm pad - a pad placed on the resident's bed or wheelchair connected to a battery operated alarm which is activated when the resident attempts to get up, alerting the staff that the patient requires assistance) in accordance with the facility's "Action Plan."
These deficient practices resulted in Resident 1 falling and sustaining a head injury and a neck fracture.
A review of the Admission Record indicated Resident 1 was admitted to the facility on XXXXXXX 15 and readmitted on XXXXXXX 15. Resident 1's diagnoses included: Dementia (memory loss), kyphosis (abnormal "C - like" curvature of the spine, also known as hunchback), and difficulty walking.
A review of Resident 1's Minimum Data Set ([MDS] medical, mental, and psychosocial assessment of the resident), dated 10/6/16, indicated Resident 1 had severe cognitive deficits(significant memory loss that affects daily functions and decision making), decreased hearing, decreased vision, and decreased comprehension of others. Resident 1 required extensive assistance with one person physical assist with bed mobility, transferring, walking, toilet use, and bathing. The MDS also indicated Resident 1 was not steady and only able to stabilize self with staff assistance when moving from a seated to standing position, on and off the toilet, and surface to surface transfer (moving between bed and chair or wheelchair). Resident 1 required a wheelchair to get around the facility.
A review of Resident 1's fall care plan interventions, last re-evaluated on June 2015 included: Increased visual checks by staff. Have call light within reach. Keep bed in lowest position and side rails used as an enabler.
A review of Resident 1's annual Falls Risk Review dated 4/5/16, indicated Resident 1's conditions which placed the resident at risk for falls included: Poor safety awareness/judgement and memory deficits, sensory deficits in vision and hearing, unsteady gait/balance, medications (high blood pressure medications and laxatives).
A review of Resident 1's family member (FM) 1?s grievance letter, dated 4/11/16, indicated the following: On two occasions FM 1 observed Resident 1 left unsupervised on 4/2/16 and 4/6/16. FM 1 expressed her concern for Resident 1's quality of care and safety as Resident 1 was physically weak, had poor judgement regarding personal safety and stressed by "any attempts from her part to get up can result in fatal consequences." FM 1 requested a plan of action.
A review of Resident 1's physician's order dated 4/13/16 indicated: May apply alarm device in bed and wheelchair to alert staff when Resident 1 attempts to get out bed or the wheelchair unassisted due to lack of safety awareness every shift.
A review of an email the facility sent to FM 1 included the facility's "Action Plan" for Resident 1 dated 4/14/16 to prevent the resident from falling in response to FM 1's grievance. The "Action Plan" included the following:
1. Ensure communication between nursing staff assigned to Resident 1 to maintain observation supervision while Resident 1 was in a wheelchair outside of her room and not to leave Resident 1 in her room unattended while she's in her wheelchair.
2. Provide Resident 1 an alarm pad for her wheelchair.
3. Continue to monitor Resident 1 per care plan.
A review of Resident 1's Progress Notes, dated 1/3/17 at 6:19 p.m., indicated Resident 1 had an unwitnessed fall resulting in a laceration(open wound)to her forehead at 5:45 p.m., 9-1-1 was called, and Resident 1 was sent out to the hospital at 6:05 p.m.
A review of the facility Event Summary Report, dated 1/5/17 at 6:20 p.m., indicated the staff heard someone calling for help from Resident 1's room. Resident 1 was found lying on the floor by licensed vocational nurse (LVN) 1 with blood coming from her front head and complaining of pain in the head and neck. The Event Summary Report indicated Resident 1 had an alarm but the alarm did not sound, was not set up properly, did not have a battery in working order, and was not turned on.
An interview was conducted on 1/19/17 at 3:55 p. m with LVN 1 who was Resident 1's nurse on the day Resident 1 fell. She said she was aware that Resident 1's alarm device was not working properly one hour into her shift. LVN 1 stated at 4:30 p.m., the registered nurse (RN) supervisor handed her a new alarm device for Resident 1. LVN 1 stated she wheeled Resident 1 into her room to place a new alarm device but then heard another resident asking for help and left Resident 1 in her room. LVN 1 returned when Resident 1's roommate was calling for someone to help her. LVN 1 verified Resident 1's fall occurred two hours after she was first aware of Resident 1's alarm not working properly. LVN 1 stated she was aware of the facility's action plan regarding the nursing interventions that were to be implemented to prevent Resident 1 from falling. LVN 1 stated a copy of the "Action Plan" was posted over Resident 1's bed head board, Resident 1 was not to be left alone in her room while in her wheelchair and that Resident 1's alarm device was not working.
During an interview with the RN Nursing Educator on 1/24/17 at 10:33 a.m. she stated that the alarm device was supposed to be checked every shift by the licensed nurses and documented on the treatment administration record. If the alarm device was not working, the licensed nurses were to find out what the problem was to ensure the resident's alarm was working properly, such as replacing batteries, pressure pads, or the entire device.
During an interview with the RN supervisor on 1/24/17 at 3:45 p.m., the RN supervisor stated on the day Resident 1 fell, as she made her rounds she noticed Resident 1's alarm device was not working properly. The RN supervisor got a new alarm from central supply at the beginning of the shift and gave it to LVN 1.
During an interview with the Director of Nursing (DON), on 1/26/17 at 3:45 p.m., she stated the evening licensed nurses are supposed to start their shift at 3:00 p.m. and are supposed to make their rounds, and check on their assigned residents alarm devices. The maintenance of alarm devices are the licensed nurse's responsibility.
A review of Resident 1's Fire Department EMS (Emergency Medical Services) Report, dated 1/3/17, indicated emergency medical services responded to a 9-1-1 call and found Resident 1 complaining of neck pain. Resident 1 had a "Z" shaped laceration to her forehead, and was transported to the general acute care hospital (GACH) emergency department.
Resident 1's GACH Emergency Department Physician notes, dated 1/3/17, indicated the Fire Department EMS paramedics brought Resident 1 to the emergency department with c-spine precautions (cervical-spine precautions, where the neck is immobilized using a neck brace)complaining of neck pain. The Emergency Department Physician found Resident 1 to have a seven centimeter(cm)forehead laceration, pain to her neck and ordered Resident 1 have a CT scan (computerized tomography scan, combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images of the area). Resident 1 was found to have a cervical-spine fracture located at cervical 2 (C-2), which is the second top neck bone of the cervical spinal column and displacement (shifting) of the C-2 bone. The Emergency Department Physician identified Resident 1's condition as "serious" and ordered Resident 1 admitted to the GACH.
Record review of the GACH Neurosurgeon (doctor who performs surgery on the brain and spinal column) consultation, dated 1/8/17, indicated Resident 1 had an acute C2 fracture (C-2 bone help to control the rotation of the head.) with a 2-3 mm (millimeter) displacement indicating she would be placed in an aspen collar (hard, stiff neck brace that restricts neck movement and decreases pain).
During a concurrent interview and observation with Resident 1 on 1/11/17 at 3:35 p.m. at the GACH. She was observed to have a large, four inch "Z - shaped" scab from her hairline to the side of her eyebrow and a large bruise from the right side of her forehead along the side of right hair line and extending down her right neck. Resident 1 was wearing her aspen collar and looked visibly uncomfortable. Resident 1 was observed with facial grimacing, frowning, and pointing to her neck and stated she was in pain.
A review of the GACH Discharge Summary, dated 1/16/17, indicated Resident 1 was admitted on XXXXXXX 17 and discharged on XXXXXXX17.
A review of Resident 1's GACH medication administration from 1/3/17 to 1/16/17 indicated Resident 1 received Morphine Sulfate (narcotic medication for severe pain) two milligrams (mg) intravenously (IV, in the vein) eight times for complaints of pain and Codeine/APAP #2 (combination medication using a narcotic and an analgesic to treat moderate to severe pain) twelve times for complaints of pain.
According to the facility's "Falls Management" policy, revised 3/15/16, "those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury and develop individualized plan of care and review and revise care plan regularly."
The facility failed to ensure Resident 1 was provided adequate supervision to prevent accidents by failing to:
1. Ensure Resident 1 was not left in her room unattended while she was in her wheelchair in accordance with the facility's "Action Plan." (Facility's plan to prevent Resident 1 from falling in response to Resident 1's Family's grievance.)
2. Provide a properly functioning alarm device (alarm pad - a pad placed on the resident's bed or wheelchair connected to a battery operated alarm which is activated when the resident attempts to get up, alerting the staff that the patient requires assistance) in accordance with the facility's "Action Plan."
The facility?s failure to provide adequate supervision resulted in Resident 1 falling and sustaining a head injury and a neck fracture.
This violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 950000032 |
MESA GLEN CARE CENTER |
950012598 |
A |
26-Sep-16 |
TFYZ11 |
10578 |
483.13 (c) 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 interventions strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. On December 29, 2015, an unannounced visit was made to the facility, to investigate an entity reported incident regarding Resident 2 who sustained multiple skin tears on her face, jaw, right eyebrow, and right cheekbone with swelling and bleeding noted after staff found Resident 1 hitting Resident 2. The facility failed to ensure that Resident 1 did not inflict injuries to Resident 2 by failing to: a. Provide frequent visual checks as indicated in the plan of care for Resident 1?s poor impulse control manifested by hitting others. b. Implement the facility's policy regarding abuse prevention. c. Coordinate interventions between the Social Worker and nursing staff to address Resident 1's escalating aggressive behavior to prevent aggression to Resident 2. Resident 1 was found hitting Resident 2 with her right hand that had three large rings, causing severe injuries and bleeding to Resident 2's face, chest, and arms. Interdisciplinary (IDT) Progress Notes in Resident 2's clinical record dated December 29, 2015 at 8:45 a.m. and 9:00a.m indicated certified nursing assistant (CNA) 2 while making rounds, entered Resident 1 and 2's room and observed Resident 1 making, ? physical contact? with Resident 2. CNA 2 separated the residents. Resident 1 continued to "strike out and attempted to hit and kick staff". The licensed nurse from the 11 p.m. to 7 a.m. shift notified the registered nurse (RN 1), regarding the physical altercation between the two residents. RN 1 assessed Resident 2 and found "multiple skin tears, 2 centimeters (cm) in length on the: right cheekbone, right lower jaw, and right eyebrow, scratches on the scalp and multiple discolorations along the right side of the face, bleeding and moderate swelling. ". Resident 1 was noted to have three large rings on the right hand with moderate amount of blood noted on them. The IDT progress note indicated the physician and family were notified of the incident. A review of an undated written statement by LVN 1 about the altercation that took place on December 25, 2015, indicated CNA 2 entered the Residents' room at 4:33 a.m. after hearing shouts for help. Residents 1 and 2 were lying side by side on the floor mattresses. Resident 2 was covering her face with her hands, while Resident 1 was hitting her with her right hand. Resident 2's hands had blood on them as she covered her face. Resident 1's right hand had three rings, which were covered with blood. Resident 2 complained of throbbing pain to the right side of her face. During a telephone interview on May 6, 2016 at 1:40 p.m., CNA 2 stated she had gone on her break on the night of the incident and upon returning at about 4 am from her break time, she heard Resident 2 calling for help. She went to the residents' room and found both Resident 1 and 2 on the floor. She stated upon entering, Resident 1 was hitting Resident 2. Resident 1 had rings on her hand and she was hitting Resident 2 with that hand and the rings were covered with blood. CNA 2 stated she called another CNA and the licensed staff to help her separate the residents. Resident 1 continued to strike out and attempted to hit staff. On December 29, 2015 at 2:17 p.m., Resident 2 was observed sitting in a wheelchair, with bruises (injuries appearing as areas of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) on the left cheek. The entire right side of her face was bruised dark brown/black. On her right upper arm she had a dark red and black bruise. Her left arm had a black and red bruise towards the top of the elbow. The upper chest area under the neck had mild bruising. The left lower leg had a dry scab and some light bruising, the right lower leg had a dry scab, thin skin and no bruising. During an interview at the time of the observation, Resident 2 was asked about the incident, she was not able to narrate. When asked how she felt, she stated, "It hurts" referring to her face. During an interview on December 29, 2015 at 2:29 p.m., certified nursing assistant (CNA 1) stated she was assigned to care for Resident 2 often and that since the incident on December 25, 2015, Resident 2 "Flinches like she's in pain whenever her face is being cleaned." CNA 1 narrated Residents 1 and Resident 2 were roommates. They both have low beds, and each had a mattress next to each other on the floor between their beds. She stated Resident 1 was able to pull herself to the floor, and Resident 2 sometimes "flop" from the bed over to the mattress on the floor. On December 29, 2015 at 2:57 p.m., Resident 1 was observed in a room by herself. She did not have a roommate. In an interview on December 29, 2015 at 3:10 p.m., Resident 1 communicated with an erasable board. Resident 1 wrote that Resident 2 called her a bad name but denied hitting Resident 2. Record review indicated Resident 2 was 107-yrs old admitted to the facility on October 30, 2010. The resident's diagnoses included anxiety disorder (feeling of worry, nervousness, and unease). Resident 2?s MDS, dated December 7, 2015, indicated Resident 2 was understood and able to understand others. The resident required extensive assistance with one person physical assist for activities of daily living. A review of an untitled care plan dated June 10, 2015, indicated Resident 2 had a potential for bleeding/bruising/skin tears secondary to aspirin and Coumadin (anticoagulant used to treat/prevent blood clots) use. Resident 1 was 34 years old admitted to the facility on February 3, 2008, and readmitted on October 22, 2010. The Resident's diagnoses included mood disorder (a psychological disorder characterized by the elevation or lowering of a person's mood, such as depression or bipolar disorder. True clinical depression is a mood disorder, which can interfere with everyday life for an extended time); impulse disorder (resident manifested behaviors including hitting, scratching, and pulling hair). A Minimum Data Set (MDS) (a standardized assessment and care screening tool) dated November 2, 2015 indicated Resident 1 was usually understood and usually able to understand others. Resident 1 required one person physical assist for activities of daily living including dressing, eating, toileting, and hygiene. An untitled care plan dated September 24, 2013, and reviewed on November 5, 2014 indicated Resident 1 had impaired cognition with manifested behaviors of scratching, hitting, pulling hair, and banging on the rails. Nursing interventions included: encouraging the Resident 1 to communicate using the letter board and always having two staff present during care. An untitled care plan dated April 19, 2013, indicated Resident 1 had poor impulse control manifested by hitting others. Nursing interventions included to provide frequent visual checks. A review of a Nurse's Note dated December 17, 2015 at 3 p.m., indicated Resident 1 refused to remain in bed. According to the Nurse's Note Resident 1's bed was in the lowest position. Resident 1 used the stronger arm (the right arm) to log roll herself off of the bed and maneuver her body onto mattress located on the floor next to her bed. A review of the Social Services Progress Notes dated 12/2/15 indicated that nursing informed Social Services that Resident 1 was throwing things such as cups all over the place. Another Social Services Progress Notes dated 12/14/15 indicated an increased behavior of throwing things all over the place. The note indicated that Social Services talked to Resident 1 regarding the possibility of the roommate being hit by the things that Resident 1 was throwing all over the place. On December 29, 2015, at 3:40 p.m., during a review of Resident 1's clinical record with RN 1, there was no documentation of how frequently the visual checks were to be done. During an interview at the same time, RN 1 was not able to describe how frequently visual checks are done. RN 1 was not able to show documentation of frequent visual checks in Resident 1's clinical record. During an interview on 6/10/16, at 10:30 a.m., when asked about how frequent checks should be done, the Director of Nurses (DON) stated all staff was doing rounds every 2 hours but they do not document this activity. When asked to show the nursing progress notes from December 18 thru 25, 2016, the DON reviewed Resident 1's record and stated there were no nursing notes for Resident 1 from December 18-25, 2015. There was no evidence staff implemented the plan of care for Resident 1's abusive behavior. There was no documented evidence the facility made every effort to identify events that may lead to abuse situation, in accordance with their policy. There was no documented evidence the Social Worker coordinated with nursing staff about Resident 1's escalating aggressive behavior to prevent aggression to Resident 2. A review of the facility "Abuse Policy", revised December 2011, indicated the facility will make every effort to identify events that may lead up to abuse situation including: staff will monitor residents with behaviors that may lead to abusive situations. The facility failed to ensure that Resident 1 did not inflict injuries to Resident 2 by failing to: a. Provide frequent visual checks as indicated in the plan of care for Resident 1?s poor impulse control manifested by hitting others. b. Implement the facility's policy regarding abuse prevention. c. Coordinate interventions between the Social Worker and nursing staff to address Resident 1's escalating aggressive behavior to prevent aggression to Resident 2. Resident 1 was found hitting Resident 2 with her right hand that had three large rings, causing severe injuries and bleeding to Resident 2's face, chest, and arms. 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. |
| 950000078 |
MOUNT SAN ANTONIO GARDENS |
950012615 |
A |
4-Oct-16 |
SM2111 |
5686 |
483.13(b) 483(c) (1) (i) FREE FROM ABUSE/INVOLONTARY 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. On 7/28/16, an unannounced visit was made to the facility to investigate an entity reported incident regarding Certified Nursing Assistant (CNA) 1 abusing Resident 1. Based on interviews and record review, the facility failed to protect Resident 1 from physical and mental abuse during the evening (3 p.m. to 11 p.m.) shift. CNA 1, while providing care to Resident 1, placed a wash cloth inside the resident's mouth and a pillow over her face. A review of the face sheet indicated Resident 1 was admitted to the facility on 04/01/2011 and readmitted on 10/30/2013 with diagnoses that included: pain, major depressive disorder, Alzheimer's disease, (a slowly progressive disease of the brain that is characterized by symptoms like impairment of memory and eventually by disturbances in reasoning, planning, language, and perception), blindness, hypertension (elevated blood pressure), localized edema (swelling), delirium (confused thinking and reduced awareness of the environment), and osteoarthritis (a type of arthritis that occurs when flexible tissue at the end of bones wears down). A review of the Minimum Data Set (MDS, standardized assessment and care screening tool) dated 07/24/2016, indicated Resident 1 was rarely/never able to understand and was rarely/never understood by others. Resident 1's daily decision making was severely impaired. Resident 1 was totally dependent on staff with transfers, moving between locations, dressing, eating, personal hygiene, and bathing. Resident 1 had episodes of agitation, scratching, biting and screaming. On 07/28/2016 at 2:50 p.m., an interview was conducted with the administrator who stated that on 7/27/16, CNA 2 told her that she witnessed CNA 1 place a washcloth inside Resident 1's mouth and put a pillow over her face. The administrator stated she was not aware that CNA 1 was abusing Resident 1 until CNA 2 brought this allegation to her attention. The administrator stated that she started an investigation and interviewed additional staff who worked closely with CNA 1, and found that there were more witnesses to the alleged abuse. She stated the investigation led her to believe the abuse allegations against CNA 1 was true and that CNA 1's main purpose of placing a washcloth in Resident 1's mouth and a pillow over her face was to muffle Resident 1's screams. The administrator stated that when CNA 1 was scheduled at the Villa she was the only CNA to provide care for Resident 1. The administrator stated she found CNA 1's actions toward Resident 1 to be a form of physical abuse, and that upon CNA 1's termination, CNA 1 stated "it wasn't just me." On 07/28/2016 at 4:38 p.m., an interview was conducted with CNA 3. She stated Resident 1 would become very agitated, bite, and twist hands. CNA 3 stated that on 07/14/2016, during the evening shift, she and CNA 1 were changing Resident 1's diaper and the resident started screaming and fighting. CNA 3 witnessed CNA 1 put a wash cloth inside Resident 1's mouth and a pillow over her face. CNA 3 stated she believed CNA 1 acted in such a way to reduce the screaming and the germs/splashing from Resident 1's mouth. CNA 3 stated that CNA 1 was not gentle when handling residents and that the residents would cry when they were cared for by CNA 1. On 08/04/2016 at 3:55 p.m., an interview was conducted with CNA 2. She stated that on July 16 and 17, 2016 she worked with CNA 1. CNA 2 stated that on July 17, 2016 during patient care, Resident 1 was screaming and combative. CNA 2 stated she was holding Resident 1 while CNA 1 was cleaning the resident. CNA 2 stated she witnessed CNA 1 put a wash cloth inside Resident 1's mouth and a pillow over her face. CNA 1 told CNA 2 the action was done "because of her germs." CNA 2 stated she removed the pillow from Resident 1's face and CNA 1 placed it over the resident's face again. CNA 1 stated that the wash cloth inside Resident 1's mouth and pillow over her face remained until completion of the care, approximately 3 to 5 minutes. Once the care was completed, CNA 2 removed the pillow and washcloth from Resident 1's mouth. CNA 2 stated she reported the incident to the administrator on 7/27/16. A review of the facility's investigation of possible abuse dated 07/27/2016 indicated that the Registered Nurse (RN 1) remembered a time and upon administration of a suppository, Resident 1 yelled. RN 1 stated that CNA 1 put a towel over Resident 1's face. A follow-up investigation report dated July 29, 2016 indicated that, while there were only two employees who witnessed the abuse incidents, the practice may have been ongoing. A review of the Elder Abuse Prevention policy and procedure dated 05/10/2016 indicated, "It is the policy of the facility to prohibit abuse, mistreatment...All employees must ensure residents' well-being and comply with Federal and State regulations. Any employee who engages in or physical, verbal, sexual or mental abuse...will be subject to disciplinary action." The facility failed to protect Resident 1 from physical and mental abuse from CNA 1, who placed a wash cloth inside the resident's mouth and a pillow over her face while providing care. The violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 950000078 |
MOUNT SAN ANTONIO GARDENS |
950012621 |
B |
4-Oct-16 |
SM2111 |
7587 |
483.13(c) (1) (ii)-(iii) (c) (2) ? (4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On 7/28/16, an unannounced visit was made to the facility to investigate an entity reported incident regarding Certified Nursing Assistant (CNA) 1 abusing Resident 1. Based on interviews and review of records, the facility failed to ensure that the alleged violation involving CNA1?s abusive behavior to Residents 1 and 2 were reported immediately to the administrator of the facility and to other officials. Four staff members of the facility failed to report the abusive behavior of CNA1 immediately when they witnessed or made aware of the abusive behavior. Resident 1 was admitted to the facility on 4/1/2011 and readmitted on 10/30/2013 with diagnoses that included: pain, major depressive disorder, Alzheimer's disease, blindness, hyper tension, localized edema (swelling), delirium (confused thinking and reduced awareness of the environment), and osteoarthritis (a type of arthritis that occurs when flexible tissue at the end of bones wears down). A review of the Minimum Data Set (MDS, standardized assessment and care screening tool) dated 07/24/2016, indicated Resident 1 was rarely/never able to understand and was rarely/never understood by others. Resident 1's daily decision making was severely impaired. Resident 1 was totally dependent on staff with transfers, moving between locations, dressing, eating, personal hygiene, and bathing. On 07/28/2016 at 2:50 p.m., an interview was conducted with the Administrator. She stated that on 7/27/16, CNA 2 brought to her attention an allegation that CNA 1 abused Resident 1. CNA 2 told the Administrator that she witnessed CNA 1 place a washcloth inside Resident 1's mouth and put a pillow over her face. The Administrator stated she was not aware that CNA 1 was abusing Residents 1 and 2. The Administrator stated that she started an investigation and interviewed additional staff who worked closely with CNA 1. She stated that she found that there were witnesses to the alleged abuse. On 07/28/2016 at 4:38 p.m., during an interview, CNA 3 stated that on 07/14/2016 she witnessed CNA 1 physically abuse Resident 1. She stated she and CNA 1 were providing care to Resident 1 when the resident began to scream. CNA 1 put a wash cloth inside of the resident's mouth and a pillow over her face. CNA 3 told CNA 1 "not to do that". CNA 3 stated she was aware that CNA 1's actions were physical abuse but failed to report the incident to anyone. On 08/04/2016 at 2:58 p.m., an interview was conducted with CNA 4. She stated that around 2 weeks ago, possibly July 18, 19, or 20th, Resident 2 told her that she was scared of an employee taking care of her. CNA 4 stated that Resident 2 provided a physical description that fit CNA 1. CNA 4 stated that she was aware that she was a mandated reporter and should have reported immediately, but did not. A review of Resident 2's face sheet indicated an admission date of 11/04/2013 with diagnoses that included dysphagia (difficulty or discomfort in swallowing), polyneuropathy (general degeneration of nerves that connect the brain and spinal cord), insomnia, pain, hypothyroidism (thyroid gland does not produce enough hormones), dorsopathy (condition impairing the backbone), tendinitis (swollen tissue connecting to muscle), and osteoporosis (bones become weak and brittle). A review of the Minimum Data Set (MDS, standardized assessment and care screening tool) dated 05/10/2016 indicated Resident 2 was able to understand and was usually understood by others; required extensive assistance from staff with toilet use and bathing. On 08/04/2016 at 3:24 p.m., an interview was conducted with CNA 2. CNA 2 stated that on the following dates, she witnessed CNA 1 physically abuse Resident 1, Resident 2, and other residents (did not recall which other residents): 1. On 07/16/2016 and 07/17/2016, while providing care for Resident 1, CNA 1 placed a wash cloth inside the resident's mouth and a pillow over her face to muffle the screams. 2. On 07/26/2016, when CNA 1 was showering Resident 1, CNA 2 could hear the resident screaming. After CNA 1 left, Resident 2 told CNA 2 that CNA 1 had slapped her with a wash cloth on the face. 3. Since February 2016, when residents tried to get up from their seat/wheelchair, CNA 1 would push them hard enough to make the residents sit back down. CNA 2 stated the pushing incidents happened approximately 10 times with different residents. CNA 2 stated that putting a wash cloth inside a resident's mouth, putting a pillow over the face, slapping with a wash cloth, and pushing, was physical abuse. CNA 2 stated she is a mandated reporter and she failed to report the abusive behavior immediately. On 08/04/2016 at 4:45 p.m., an interview was conducted with CNA 5. She stated that on 07/19/2016, during a telephone conversation with CNA 2, CNA 2 made her aware of the physical abuse that CNA 2 witnessed. CNA 5 stated she advised CNA 2 to report the incidents and reminded CNA 2 that abuse has to be reported. A review of the facility's investigation of the abuse allegation dated 07/29/2016, indicated that the abusive behavior was not reported to the Administrative staff (Director of Staff Development, Director of Human Resources, Director of Nursing, and the Administrator) until 7/27/16. The Administrator stated the staff did not report because they were fearful of CNA 1. According to the "Your Legal Duty Abuse Prevention" power point used to in-service employees on abuse, dated April 2014 indicated that "A mandated reporter is one who is required by law to report if they are told of abuse, observe abuse or have reasonable suspicions of abuse. In California all employees of Long Term Care Facilities are mandated reporters. "Abuse should be reported immediately, or as soon as possible." The facility's staff failure to report the abusive behavior of CNA1 resulted in continued physical and mental abuse for Residents 1 and 2, and other residents in the facility. The above violation had a direct relationship to the health, safety, or security of the residents. |
| 950000073 |
Monrovia Post Acute |
950012829 |
A |
21-Dec-16 |
2SUI11 |
7560 |
F323 ?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 9/13/2016 at 1:00 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding an accident and supervision. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls for Resident 1 who was assessed with high risk for falls, by failing to: 1. Implement its policy and procedures regarding the use of shower chairs. 2. Implement the plan of care that Resident 1 was at risk for falls and injury, therefore needing to be assisted with bathing, showering, and shampoo with at least one staff. The facility?s failure resulted in Resident 1 falling while unattended in the shower, and sustained a left hip fracture. Resident 1 was admitted to a general acute hospital (GACH) and had to undergo surgery, an open reduction and internal fixation of the left hip (surgical incision is made to expose the bone which is then realigned and held in position with metal rods and screws). Resident 1 remained in the GACH for five days. A review of Resident 1?s clinical record revealed admission to the facility on xxxxxxx with diagnoses including acute bronchitis (swelling of the lining of bronchial tubes where air passes to the lungs) muscle weakness, primary osteoarthritis (when the protective cartilage on the end of your bone wears down overtime), age related osteoporosis (thinning of the bone). Resident 1 was transferred to the acute hospital via ambulance on 8/31/2016 due to a change in condition and re-admitted to the facility on 9/04/2016. A review of Resident 1's "Fall Risk Assessment," dated 8/04/2016 indicated Resident 1 had a fall risk total score of 10. A total score of 10 represents a high risk for falls. Resident 1's care plans included the following: a. At risk for falls and injury, dated 8/4/2016, approaches included: Anticipate resident needs and monitor resident for pattern of risk factors or tendency to fall. b. Requires assistance with activities of daily living, dated 8/4/2016, approaches included: Assist in bathing, showering and shampoo with at least one staff. A review of Resident 1's annual Minimum Data Set (MDS-an assessment and care planning tool) dated 8/05/2016, indicated Resident 1 had a total Brief Interview for Mental Status (BIMS) score of 12 indicating Resident 1 is cognitively intact. Resident 1 required one-person physical assist for bathing and transferring. Resident 1's balance for moving from a seated to standing position, walking, and surface-to-surface transfer was indicated to be not steady, only able to stabilize with staff assistance. A review of Resident 1's Licensed Personnel Progress Notes dated 8/31/2016 at 9:45 a.m., indicated Resident 1 was found lying on the shower room floor in supine (lying face forward) position. Resident 1 complained of severe left hip pain and was unable to move both lower extremities. Resident 1 stated she slid off the shower chair onto the floor, while trying to turn the water off. On 9/13/2016 at 1:35 pm, during an interview with Certified Nurse Assistant 1 (CNA 1), she stated she gave Resident 1 a shower at 10:00 am on 8/31/2016. CNA 1 stated she put Resident 1 into a shower chair and wheeled Resident 1 to Shower Room 2 (SR 2). CNA 1 stated when she was about to finish Resident 1's shower, Resident 1 told CNA 1 that she still felt soap on her body. CNA 1 stated she realized she forgot to bring in a towel and extra sheets to dry and cover Resident 1. CNA 1 stated she told Resident 1 to stay put in the shower chair and handed the resident the movable shower head so that the resident could rinse herself while CNA 1 got the towel and the sheet in Station 2 linen closet. CNA 1 stated Resident 1 was alert and understood her completely because both of them spoke and understood Spanish. CNA 1 stated she left SR 2 and proceeded to get the towel and sheet leaving Resident 1 unsupervised for two (2) minutes. CNA 1 stated she heard somebody yelling for help and saw CNA 2 and Licensed Vocational Nurse 2 (LVN 2) standing in front of SR 2 door. CNA 1 stated she had a hard time opening SR 2 door because Resident 1 was lying down on the shower room floor with her legs and feet pointing towards the shower room door. The shower chair flipped forward and was next to Resident 1. CNA 1 stated she observed Resident 1 awake and verbally responsive stating, "I did not hit my head and only my left leg is painful." CNA 1 stated she forgot to use the call light and ask someone to bring towels and linen, and should not have left Resident 1 unattended while in the shower room. During an observation and concurrent interview on 9/13/2016 at 1:45 pm, CNA 1 demonstrated there were forty (40) steps from SR 2 to Station 2 linen closet. SR 2 call light was in good working condition at the time of visit. During an interview on 9/13/2016 at 2:40 pm, LVN 1 stated she was in charge of Resident 1 when the fall incident happened. LVN 1 stated Resident 1 required one (1) person assist. On 9/14/2016 at 11:50 am, an interview with CNA 3 was conducted. CNA 3 confirmed Resident 1 was in SR 2 unsupervised and was found lying down on the floor awake and verbally responsive. On 9/14/2016 at 12:30 pm, an interview with LVN 2 was conducted. LVN 2 stated she saw Resident 1 lying down on the SR 2 floor awake, both legs and feet pointing towards the shower door. LVN 2 also stated Resident 1 verbalized "pain on the left leg." LVN 2 stated that the shower chair flipped forward beside Resident 1. A review of Resident 1's general acute care hospital (GACH), Discharge Summary dated 9/4/2016, indicated Resident 1 discharge diagnoses included: Fracture of the left femur due to a fall. While in the GACH Resident 1 underwent a surgical procedure, an open reduction and internal fixation of the left hip (surgical incision is made to expose the bone which is then realigned and held in position with metal rods and screws). Resident 1 remained in the GACH for five days. A review of undated facility Policy and Procedure on use of Shower Chairs indicated: A resident using a shower chair should be supervised at all times and provided with appropriate assistance as determined by the nursing assessment. The facility failed to provide adequate supervision to prevent falls for one of four sample residents (Resident 1), who was assessed with high risk for falls, by failing to: 1. Implement its policy and procedures regarding the use of shower chairs. 2. Implement the plan of care that Resident 1 was at risk for falls and injury, therefore needing to be assisted with bathing, showering, and shampoo with at least one staff. The facility?s failure resulted in Resident 1 falling while unattended in the shower, and sustained a left hip fracture. Resident 1 was admitted to a general acute hospital (GACH) and had to undergo surgery, an open reduction and internal fixation of the left hip (surgical incision is made to expose the bone which is then realigned and held in position with metal rods and screws). Resident 1 remained in the GACH for five days. The violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 950000048 |
MONROVIA GARDENS HEALTHCARE CENTER |
950012992 |
A |
24-Feb-17 |
MCGE11 |
9720 |
F 309-Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care.
F-157-Notification of changes. (i) A facility must immediately inform the resident: consult with the resident?s physician;
(B) A significant change in the resident?s physical, mental, or psychological status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).
On 10/26/16, at 10:20 a.m., an unannounced visit was made to the facility to investigate a complaint regarding the facility refusal to call 911 for Resident 1 who was complaining of chest pains.
Based on interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for Resident 1. Resident 1 diagnoses included: Coronary artery disease (plaque (fatty accumulation) buildup in the walls of the arteries that decrease the supply blood to the heart), and a previous coronary artery bypass graft in 2014 (This surgical procedure diverts the flow of blood around a section of a blocked or partially blocked artery of the heart).
The facility staff failed to:
1. Adequately assess Resident 1's (who had a history of heart disease and an operation to remedy blocked blood vessels in the heart) complaint of chest pain as a potential symptom of a heart attack, which occurs when the blood flow to the heart suddenly becomes blocked and the heart can't get oxygen. This would lead to the heart muscle to die and the heart to stop beating.
2. Notify Resident 1's physician of Resident 1's change in condition and Resident 1?s new onset of complaints of chest pain.
Review of the complainant allegations indicated while in the general acute care hospital (GACH), Resident 1 informed GACH staff 1 that on 10/9/16 at 9:30 p.m., he started having chest pains and informed the charge nurse at the skilled nursing facility. Resident 1 stated "I begged them to call 911, begged them to call paramedics." Resident 1 stated the nurse told him "I'm sorry we don't have the authorization to make that call." Resident 1 stated he felt chest pains all night and kept asking the evening nurse to call. Resident 1 stated "I think the evening nurse got upset with me and stopped coming."
A review of Resident 1's Admission Record indicated he was admitted to the facility on XXXXXXX2016 with diagnoses including but not limited to hypercholesterolemia (high level of cholesterol in the blood), and end stage renal disease (loss of kidney function).
A review of Resident 1's History and Physical dated 10/06/2016 included diagnoses of coronary artery disease, a previous coronary artery bypass graft in 2014, chronic renal failure (loss of kidney function) on hemodialysis (dialysis machine and a special filter called an artificial kidney, or a dialyzer, used to clean your blood).
A review of Resident 1?s physician orders dated 10/3/16 included the following: Oxygen at two liters per minute via nasal cannula (oxygen supplied into the nostrils) as needed for shortness of breath and wheezing. Aspirin chewable tablets 81 milligrams (mg) one tablet daily to prevent blood clots, and Isosorbide mononitrate extended release tablets (prevents chest pain) 30 mg one tablet daily.
An interview was conducted with Resident 1 on 10/26/2016 at 11:10 a.m. Resident 1 did not want to talk about the incident of having chest pain which resulted in him going to the hospital. Resident 1 stated he was fearful the facility might retaliate against him.
An interview was conducted with Certified Nurse Assistant (CNA 1) on 10/26/16, at 3:00 p.m. CNA 1 stated on 10/9/16, Resident 1 told her around dinner time, that "he has chest pain and does not feel good.? CNA 1 stated she reported Resident 1's complaint right away to registered nurse (RN) 1. CNA 1 stated she did not check Resident 1's vital signs.
A review of Resident 1's "Daily Skilled Documentation" dated 10/9/2016 at 9:36 p.m. indicated the following: Blood pressure 112/64, Temperature 97.6 degrees, pulse 72 beats per minute regular rate, and respiration 22 breaths per minute. Denies pain or discomfort. Lung sounds clear, no congestion and no wheezing and no cough. Respiration even and unlabored, with shortness of breath and no acute distress noted. RN 1 did not document that CNA 1 had informed him of Resident 1's complaint of chest pain. RN 1 did not document that Resident 1 had any complaints of chest pain during that shift.
A telephone interview was conducted with RN 1 at 9:40 a.m. on 10/27/2016. RN 1 stated he was at the facility to document Resident 1's episode of chest pain on 10/09/2016. RN 1 stated he assessed Resident 1 at 8 p.m. on 10/09/2016 and forgot to document his assessment. RN 1 also stated he did not inform the doctor because Resident 1 "looks normal, vital signs was normal and pulse oximetry (a test to measure the amount of oxygen in the blood) was 98%."
A review of RN 1's late entry note for 10/9/2016 at 9:30 p.m., dated 10/27/2016 indicated the following: Resident 1's family member visited around 8 p.m. After 15 minutes the family member told him Resident 1 wanted to go to the hospital because of discomfort. Resident 1 told him, "breathing not well and need oxygen." RN 1 took Resident 1's vital signs and performed a "top to toe body assessment with good condition." The family member told him to "give him oxygen let him feel well." RN 1 set up oxygen for Resident 1 as ordered and Resident 1 and the family member were satisfied. Resident 1 had no further complaints of pain or discomfort. RN 1 failed to document that CNA 1 had informed him of Resident 1's complaint of chest pain. There was no documentation that RN 1 attempted to inform Resident 1?s physician of Resident 1?s change in condition that Resident 1 was complaining of chest pains.
A review of Resident 1's "Health Status Note" dated 10/10/2016 at 8:27 a.m. indicated the dialysis center staff informed the facility that Resident 1 came into the dialysis center complaining of body aches and pains, not feeling "good" at all. Resident 1 requested to go to the hospital instead of going back to the nursing home.
A review of Resident 1's GACH Internal Medicine Hospital History and Physical record dated 10/10/2016 indicated Resident 1 was sent from the dialysis center because of cough and chest pain. Resident 1 was admitted due to elevation of Troponin (laboratory test which measures a protein released due to damaged heart muscle) level. Resident 1's GACH Troponin level was 0.490 nanograms (ng) (unit of weight) /milliliter (ml) (unit of measurement) (normal range was 0.000-0.05 ng/ml per GACH standard) which indicated very abnormally high.
A review of Resident 1's cardiac angiogram (a procedure performed to diagnose coronary artery disease) report dated 10/12/2016, indicated Resident 1 had a lesion (a region in an organ or tissue that had suffered damage) due to a Non-ST Elevation Myocardial Infarction (NSTEMI - a type of heart attack caused by a partially block artery of the heart). Resident 1 sustained damage to his heart due to a decrease in blood flow to a portion of his heart.
A review of Resident 1's GACH Discharge Summary dated 10/16/2016 indicated Resident 1 was treated medically and was discharged back to facility. The GACH discharge diagnoses included but not limited to NSTEMI and status post cardiac angiogram.
National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI): What is a Heart Attack? (Updated January 27, 2015) included the following:
"Acting fast at the first sign of heart attack symptoms can save your life and limit damage to your heart. Treatment works best when it's given right after symptoms occur."
"Many people aren't sure what's wrong when they are having symptoms of a heart attack. Some of the most common warning symptoms of a heart attack for both men and women are:"
"-Chest pain or discomfort. Most heart attacks involve discomfort in the center or left side of the chest. The discomfort usually lasts more than a few minutes or goes away and comes back. It can feel like pressure, squeezing, fullness, or pain. It also can feel like heartburn or indigestion."
"-Upper body discomfort. You may feel pain or discomfort in one or both arms, the back, shoulders, neck, jaw, or upper part of the stomach (above the belly button)."
"-Shortness of breath. This may be your only symptom, or it may occur before or along with chest pain or discomfort. It can occur when you are resting or doing a little bit of physical activity."
"If you think you or someone else may be having heart attack symptoms or a heart attack, don't ignore it or feel embarrassed to call for help. Call 9-1-1 for emergency medical care. Acting fast can save your life."
The facility staff failed to:
1. Adequately assess Resident 1's complaint of chest pain as a potential symptom of a heart attack, which occurs when the blood flow to the heart suddenly becomes blocked and the heart can't get oxygen. This would lead to the heart muscle to die and the heart to stop beating.
2. Notify Resident 1's physician of Resident 1's complaints of chest pain for further evaluation. These violations either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 950000048 |
MONROVIA GARDENS HEALTHCARE CENTER |
950013067 |
A |
21-Mar-17 |
9BZP11 |
10015 |
483.25(b) (1) Treatment /services 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.
Based on observation, interview and record review, the facility failed to provide the necessary care and services to prevent new pressure ulcer development (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and or/ friction) to Resident 1 by failing to:
1. Ensure the resident did not lie on her back directly on the pressure ulcer.
2. Implement the plan of care to turn and reposition the resident in bed every two hours.
3. Revise the plan of care to address the frequency in which the resident should be turned as well as positioned while in bed.
4. Follow the physician's treatment orders to apply Santyl (debriding ointment) to Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed) to her Sacrococcyx (sacral [a triangular shaped bone at the bottom of the spine] coccyx [tailbone]) and Duoderm patch (absorbs excretions from the wound) to the Stage II pressure ulcer to her left buttock.
5. Notify the physician of Resident 1's Stage III pressure ulcer to her right buttock.
6. Offload the resident's heels (take off pressure from the heels, to suspend) when in bed.
These failures resulted in Resident 1 developing an avoidable Stage III pressure ulcer to her right buttock and Stage II pressure ulcer to her left buttock.
A review of the Nursing Admission/Readmission Data Tool indicated Resident 1 was readmitted on XXXXXXX 17, with the following pressure ulcers:
a) Sacrococcyx stage III pressure ulcer measured 4 cm (L) x 2.5 cm (W).
b) Left heel stage I pressure ulcer (non-blanchable redness of intact skin) measured 4 cm (L) x 4 cm (W). The resident's right heel also had an arterial ulcer (inadequate blood supply to an area of the skin) which measured 3 cm (L) x 2.5 cm (W).
Resident 1's diagnoses included hypothyroidism (thyroid gland does not make enough thyroid hormone) and dementia (A progressive deterioration of intellectual functions including memory loss).
A review of the Minimum Data Set dated 1/31/17, indicated Resident 1 was assessed with short and long term memory recall problems, required extensive assistance in bed mobility (staff provide weight bearing support) with one person physical assist and was incontinent of bowel (lack of voluntary control over defecation ).
A review of the Braden Scale for Predicting Pressure Ulcer Risk-V 2 (V-2 [Braden scale version 2]) dated 1/25/17, indicated Resident 1 was at risk for developing pressure ulcer due to her very limited sensory perception, very moist skin, bedfast, very limited mobility, inadequate nutrition and maximum assistance in moving.
A review of Resident 1's Care Plan intervention for Sacrococcyx stage III pressure ulcer dated 1/24/17 indicated the resident was to be turned and repositioned to her right side and back every two hours while in bed. The Care Plan intervention for Resident 1's left heel Stage I pressure ulcer and right heel pressure ulcer dated 1/25/17, indicated to elevate both heels when in bed.
On 2/2/17 at 8:30 a.m., 9:10 a.m., 10:24 a.m., 1120 a.m., 11:50 a.m., 12:05 p.m., 1:37 p.m., 2 p.m.; 2/3/17 at 8:02 a.m., 9:07 a.m., 10:02 a.m., Resident 1 was observed lying in the same position on her back and was not turned and repositioned every two hours while in bed.
On 2/2/17 at 11:50 a.m., the resident's feet with heel protectors were observed resting on the foot elevator (blue colored foam cushion).
On 2/2/17 at 2:45 p.m., treatment observation was conducted in the presence of DON (Director of Nursing) and CNA 5.
TN 1 measured Resident 1's pressure ulcers. The resident was observed with 1.5 cm (L) x 0.5 cm (W) stage 2 pressure ulcer to her coccyx. The resident's right buttock had a stage III pressure ulcer which measured 2 cm (L) x 2 cm (W) with moderate amount of yellow slough in the wound bed. The resident's left buttock was observed with 1.6 cm (L) x 0.8 cm (W) Stage II pressure ulcer.
Resident 1's right heel pressure ulcer measured 1.6 cm (L) x 2.1 cm (W) 0.7 cm in depth with moderate amount of yellow slough in the wound bed. The resident's skin on the sacrum and left heel was clear and intact. TN 1 cleansed the coccyx pressure ulcer with Normal Saline and applied Duoderm patch. The right buttock pressure ulcer was cleansed with Normal Saline; Santyl ointment was applied and covered with a bordered wound dressing. The right heel arterial ulcer was cleansed with Normal Saline, Santyl ointment and Xerofoam petroleum dressing (non-adherent gauze dressing) were applied and the ulcer was covered with a dry dressing. TN 1 stated that the stage II pressure ulcer to the left buttock had no treatment order because it was not observed until 2/2/17, during treatment of the pressure ulcers.
During an interview on 2/8/17 at 2:35 p.m., CNA 4 (Certified Nursing Assistant) stated she turned and repositioned Resident 1 on her back, left side and right side while in bed. CNA 4 was aware Resident 1 had pressure ulcers to her buttocks and coccyx. CNA 4 stated she was not informed by any staff member not to turn and reposition Resident 1 on her back until 2/7/17. CNA 4 stated pressure ulcers will not heal when the resident is lying directly on the pressure ulcer. CNA 4 stated she got busy taking care of another resident and was unable to turn and reposition Resident 1 every two hours while the resident was in bed. CNA 4 stated she incorrectly applied the foot elevator to Resident 1 by not floating her heels.
During an interview on 2/8/17 at 3:01 p.m., LVN 2 (Licensed Vocational Nurse) stated she was aware Resident 1 had pressure ulcers to her buttocks and lying directly on the pressure ulcer will make the wound worse. LVN 2 stated she did not realize Resident 1 was lying on her back and the resident's heels were resting on the foot elevator when she went to the resident's room on 2/2/17.
On 2/8/17 at 3:26 p.m., the medical record of Resident 1 was reviewed with DON and TN 1. The physician treatment orders for the pressure ulcers indicated the following:
a. On 1/25/17, Sacrococcyx stage III pressure ulcer was to be cleansed with Normal Saline, apply Santyl ointment, and cover with bordered gauze dressing daily for 30 days.
b. On 2/1/17, left buttock stage II pressure ulcer was to be cleansed with Normal Saline, apply Duoderm patch change every Monday, Wednesday, and Friday for 14 days.
The Change of Condition SBAR dated 2/2/17, indicated Resident 1 developed a stage II pressure ulcer to her left buttock measuring 1.6 cm (L) x 0.8 cm (W). (Resident 1 was not assessed as having a pressure ulcer to her right buttock nor was the physician notified until 2/2/17, when the resident was observed with a stage III pressure ulcer to her right buttocks, during the treatment observation with the DON).
During a concurrent record review and interview, the TN 1 stated she was confused for not following the physician's pressure ulcer treatment orders to Resident 1's Sacrococcyx and left buttock. TN 1 stated she applied Santyl ointment to Resident 1's stage III right buttock pressure ulcer on 2/2/17, without notifying the physician for a treatment order. During a concurrent record review and interview, the DON stated the Care Plan intervention for Sacrococcyx stage III pressure ulcer dated 1/24/17 was incorrect because Resident 1 should not be repositioned on her back because the pressure ulcer will not heal and the resident will have further skin breakdown. The DON stated the Care Plan for pressure ulcers to Sacrococcyx and left buttock was not revised to specify Resident 1 should be turned to her right side and left side only while in bed to promote healing of the pressure ulcers. The DON and TN 1 both stated the facility had turning and repositioning schedules every two hours for bedfast residents (confined to bed due to illness) but no monitoring system was in place to make sure it was followed by the staff.
The facility failed to:
1. Ensure the resident did not lie on her back directly on the pressure ulcer.
2. Implement the plan of care to turn and reposition the resident in bed every two hours.
3. Revise the plan of care to address the frequency in which the resident should be turned as well as positioned while in bed.
4. Follow the physician's treatment orders to apply Santyl (debriding ointment) to Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed) to her Sacrococcyx (sacral [a triangular shaped bone at the bottom of the spine] coccyx [tailbone]) and Duoderm patch (absorbs excretions from the wound) to the Stage II pressure ulcer to her left buttock.
5. Notify the physician of Resident 1's Stage III pressure ulcer to her right buttock.
6. Offload the resident's heels (take off pressure from the heels, to suspend) when in bed.
The facility?s failure to provide the necessary care and services resulted in the development of Resident 1?s avoidable Stage III pressure ulcer to her right buttock and Stage II pressure ulcer to her left buttock.
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. |
| 950000048 |
MONROVIA GARDENS HEALTHCARE CENTER |
950013068 |
A |
21-Mar-17 |
9BZP11 |
8740 |
483.25(b) (1) Treatment /services to Prevent /heal Pressure Sores
(b) Skin Integrity -
(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual?s clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
On 2/01//2017, an unannounced visit was made to the facility to conduct a recertification survey; during the course of the survey the following was found:
Based on observation, interview and record review, the facility failed to provide the necessary care and services to prevent pressure ulcer development (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and or/ friction) to Resident 2 by failing to:
1. Implement the plan of care to turn and reposition the resident in bed every two hours.
2. Revise the plan of care to address the frequency in which the resident should be turned and positioned while in bed.
3. Accurately assess the condition of the skin on the resident's left hip.
4. Monitor the resident's skin on her right upper back.
These failures resulted in Resident 2 developing an avoidable unstageable pressure ulcer (full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough [yellow, tan, gray green or brown] and /or eschar [tan, brown or black] in the wound bed) to her left hip. Resident 2 also developed an avoidable Stage II pressure ulcer (shallow open crater without slough, may also present as an intact or open ruptured serum filled blister) to her right upper back.
A review of the Nursing Admission/Readmission Data Tool indicated Resident 2 was readmitted on XXXXXXX 15, without a pressure ulcer. Resident 2's diagnoses included cerebrovascular accident (CVA- an interruption of the blood supply to part of the brain) with left sided weakness and contractures (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching; this can lead to permanent disability) to her left shoulder, elbow, hand and knee.
A review of the quarterly Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 1/18/17, indicated Resident 2 was assessed with short and long term memory recall problems, required extensive assistance in bed mobility (staff provide weight bearing support) with two person physical assist and was incontinent of bowel and bladder (lack of voluntary control over defecation and urination).
A review of the Braden Scale for Predicting Pressure Ulcer Risk-V 1 (a nursing tool which uses a scoring system to evaluate resident's risk of developing a pressure ulcer) indicated Resident 2 scored 12 on 11/16/15 and 10 on 10/7/16. A total score of 10-12 indicated Resident 2 was high risk for developing pressure ulcer.
A review of the Change of Condition SBAR (SBAR-situation background assessment recommendation) indicated Resident 2 was assessed on 11/13/16, with 2 centimeter (cm) in length (L) x 0.5 cm in width (W) oval shape MASD (moisture associated skin damage) to her left hip. On 1/7/17, the left hip MASD had progressed to DTI pressure ulcer (deep tissue injury [intact or non-intact skin with localized area of persistent non-blanchable deep red maroon, purple discoloration) described as purplish red in color. The DTI measured 2.5 cm (L) x 1.5 cm (W). On 1/15/17, the left hip DTI had progressed to 2.6 cm (L) x 2 cm (W) unstageable pressure ulcer with brownish (90 %) and yellow (10 %) slough (dead tissue) in the wound bed. On 1/28/17, Resident 2 was assessed with an open semi moist blister (stage II pressure ulcer) to her right upper back. The pressure ulcer to the right upper back was not measured.
During multiple observations on 2/1/17 at 2:30 p.m., 3:45 p.m., 4:50 p.m.; 2/2/17 at 8:20 a.m., 9:15 a.m., 10:21 a.m., 11:30 a.m., 12:10 p.m., 1:35 p.m.; 2/3/17 at 8 a.m., 9:05 a.m., 10 a.m., 10:35 a.m., Resident 2 was observed lying on her back in bed.
During the treatment observation on 2/2/17 at 3:50 p.m., TN 1 (Treatment Nurse) measured the pressure ulcers. Resident 2 was observed with 2.6 cm (L) x 2.3 cm (W) and 1 cm in depth unstageable pressure ulcer to her left hip. The wound bed had large amount of yellow green slough and the periwound (tissue surrounding the wound itself) was brownish red in color. The resident's right upper back had 2.7 cm (L) x 0.8 cm (W) Stage II pressure ulcer described by TN 1 as an opened blister. TN 1 cleansed the left hip pressure ulcer with Normal Saline (sterile mixture of salt and water), applied Santyl ointment and covered the pressure ulcer with bordered gauze dressing. The right upper back Stage II pressure ulcer was cleansed with Normal Saline, applied triple antibiotic and covered with dry dressing. Resident 2 was observed unable to turn and reposition herself in bed due to left sided weakness and contractures to her left upper and lower extremities.
On 2/3/17 at 10:35 a.m., CNA 3 (Certified Nursing Assistant) was interviewed in the presence of the Director of Nursing (DON). The Occupational therapist staff acted as the interpreter for CNA 3 a Spanish speaking staff. CNA 3 stated she was aware Resident 2 had pressure ulcers to her left hip and right upper back. CNA 3 stated Resident 2 will have a skin breakdown and the wound will get worse when not turned and repositioned every two hours while in bed. CNA 3 was also aware Resident 2 should be turned and repositioned every two hours but failed to do so.
On 2/3/17 at 10:45 a.m., the medical record of Resident 2 was reviewed with DON (Director of Nursing) and TN 1. The initial Care Plan for pressure ulcer prevention dated 11/18/15 indicated Resident 2 had potential/actual impairment to skin integrity related to cardiovascular accident with generalized weakness. The Care Plan interventions included turning and repositioning Resident 2 every two hours and as needed while in bed. The Care Plan interventions for left MASD (11/13/16), left hip DTI pressure ulcer (1/7/17), left hip unstageable pressure ulcer (1/15/17) and right upper back open blister (1/28/17) were not revised to indicate which specific side the resident's body should be turned and repositioned every two hours while in bed to prevent further skin breakdown and to promote healing of the pressure ulcer. The DON was unable to provide documentation as to what caused the left hip to be assessed as MASD on 11/13/16, when the location of the hip was not over the incontinence area. Also, the Care Plan interventions did not indicate monitoring of Resident 2's skin condition to prevent blister formation to her right upper back. TN 1 stated the Care Plan for pressure ulcers were not revised because she "Over looked" them. DON and TN 1 both stated staff did not have a written or visual monitoring system to ensure residents who required assistance with bed mobility were appropriately turned and repositioned every two hours and/or not lying directly on the pressure ulcer.
According to Medical Surgical Nursing Ninth Edition pages 186-187, "Prevention remains the best treatment for pressure sores. Reposition the patients frequently to prevent pressure sore at least every two hours and every hour in chair. Never position the patient directly on the pressure sore."
The facility failed to:
1. Implement the plan of care to turn and reposition the resident in bed every two hours.
2. Revise the plan of care to address the frequency in which the resident should be turned and positioned while in bed.
3. Accurately assess the condition of the skin on the resident's left hip.
4. Monitor the resident's skin on her right upper back.
As a result Resident 2 developed an avoidable unstageable pressure ulcer to her left hip. Resident 2 also developed an avoidable Stage II pressure ulcer to her right upper back.
The facility?s failure to provide the necessary care and services resulted to the development of Resident 2?s avoidable unstageable pressure ulcer to her left hip. Resident 2 also developed an avoidable Stage II pressure ulcer to her right upper back.
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. |
| 950000050 |
MISSION CARE CENTER |
950013176 |
A |
4-May-17 |
XI2D11 |
12059 |
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.
483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.
On 2/22/17, at 7:30 a.m. an unannounced visit was made to the facility to investigate a complaint regarding a resident?s fall. During the investigation an emergency situation was observed involving another resident (Resident 1).
Based on observation, interview, and record review the facility?s staff failed to meet professional standards of quality in providing cardio pulmonary resuscitation (CPR) (manual application of chest compressions and ventilation to a person in cardiac arrest (heart stops beating) to Resident 1. The facility staff failed to:
1. Properly set up and apply a non-rebreather mask (NRB) (This is a device used to deliver high concentration 10 - 15 liters per minute [L/min] of oxygen.) to Resident 1.
2. Properly set up and apply an adult manual resuscitator, also known as a bag valve mask (BVM) also known as Ambu Bag (Consists of a mask, a self-inflating bag, which is compressed (squeezed) to supply oxygen to the resident, who is not breathing or having difficulty breathing, and an opening to connect to an oxygen supply and a reservoir bag.)
A review of Resident 1 Admission Record indicated Resident 1 was admitted to the facility on XXXXXXX17 after being discharged from the general acute care hospital (GACH). Resident 1's diagnoses included: Atherosclerotic heart disease (build-up of plaque that blocks blood flow directly in the heart) with angina pectoris (chest pain).
According to Resident 1's order summary report for emergency response, dated 2/21/17, Resident 1 indicated she wanted CPR and full treatment.
A review of Resident 1's Physicians Orders for Life Sustaining Treatment (POLST), a physician order for end of life care based on the person's, or responsible party's wishes, indicated CPR to be performed if needed.
On 2/22/17 at 2:20 p.m. CODE BLUE (facility's code that resident requires emergency assistance) was heard over the facility's overhead speakers. The Code Blue was observed to be for Resident 1.
At 2:20 p.m. Resident 1 was observed lying in bed, pale, mouth open, gasping for air. Resident 1's abdomen was observed retracting (sinking in) with every breath. Resident 1's neck veins were bulging. She was hard to arouse and unable to speak. Resident 1 was observed with a non-rebreather mask (NRB) (This is a device used to deliver high concentration 10 - 15 liters per minute [L/min] of oxygen. It includes a face mask which is attached to a plastic reservoir bag and they are connected to an oxygen supply source. The reservoir bag needs to be inflated with oxygen prior to use and the resident inhales (breathes in) the oxygen in the reservoir bag, which refills again from the oxygen source. When the resident exhales (breathes out), it exits the mask through a one-way valve to outside the mask unit. If the reservoir bag is not filled with oxygen prior to use the resident has no source of air/oxygen to breathe in and may inhale their exhaled carbon dioxide. The NRB requires an oxygen flow rate of 10-15 L/min to replace the oxygen inhaled and keep the bag inflated.). Resident 1's NRB reservoir bag was observed to be deflated. The NRB's oxygen tubing was connected to Resident 1's bedside oxygen concentrator (a portable device which produces oxygen, used for daily oxygen therapy to treat chronic respiratory diseases, not severe respiratory distress. Resident 1's vital sign monitor indicated: Oxygen saturation of 84% (percentage of oxygen in the body where 94% to 100% is normal range); Pulse rate of 128 (heart beats per minute where 60-100 is normal range per minute). Resident 1's appearance remained the same. Resident 1's physician, Registered Nurse (RN) 1 and 2, and Licensed Vocational Nurses 1 and 2, were observed at Resident 1's bedside.
At 2:25 p.m. LVN 1 was directly in front of Resident 1 and was handed an adult manual resuscitator, also known as a bag valve mask (BVM) also known as Ambu Bag (Consists of a mask, a self-inflating bag, which is compressed (squeezed) to supply oxygen to the resident, who is not breathing or having difficulty breathing, and an opening to connect to an oxygen supply and a reservoir bag.) LVN 1 was observed to apply the BVM to Resident 1's face, the self-inflating bag was observed to be collapsed. LVN 2 connected the oxygen tubing to the oxygen tank. LVN 1 was observed holding the BVM to Resident 1's face and trying to squeeze the main bag while the reservoir bag at the other end was deflated (not filled with oxygen). Resident 1 continued to be observed in respiratory distress, pale, open mouth breathing, gasping for air, abdomen retracting with every breath, neck veins bulging, and unable to speak.
On 2/22/17 at 2:30 p.m. Resident 1 was observed to be in continued respiratory distress, when the Fire Department arrived and provided care to Resident 1. A Fire Department Crew Member was observed opening the BVM bag and allowed the deflated reservoir bag to fill with air and then reapplied it to Resident 1. The Fire Department Crew Member stated the BVM was on wrong. After the BVM was reapplied Resident 1 became more alert and responsive. Resident 1's oxygen saturation increased from 84% to 91% and was transported out of the facility to the GACH emergency department.
From 2:20 p.m. to 2:30 p.m. Resident 1 was observed with the NRB mask and BVM being incorrectly applied and operated.
On 2/22/17 at 3:05 p.m. during an interview, LVN 1 stated Resident 1's NRB and BVM's reservoir bags would not inflate (fill with oxygen). LVN 1 stated the BVM bag was collapsed when she tried to squeeze it. LVN 1 did not know why Resident 1 continued in respiratory distress from 2:20 p.m. to 2:30 p.m.
During an interview on 2/22/17 at 3:50 p.m. RN 1 stated Resident 1 was found non-responsive and called a CODE BLUE for Resident 1. RN 1 stated Resident 1's doctor happened to be in the facility and came to her room and saw her non-responsive and the doctor began giving Resident 1 CPR. RN I stated multiple staff arrived to help. RN I stated she saw LVN 1 had applied the NRB and BVM incorrectly. RN 1 stated she realized it was wrong but was busy trying to coordinate things for the paramedics.
On 2/22/17 at 4:45 p.m. LVN 3 stated Resident 1 initially had low oxygen saturation levels while on the NRB because it was connected to the oxygen concentrator which was set at 15 L/min with a deflated bag reservoir. LVN 3 stated Resident 1 continued in respiratory distress while on the non-rebreather and was switched to a bag valve mask and continued in respiratory distress. LVN 3 stated the main bag was collapsed in and the reservoir bag would not inflate.
A review of the employee files of LVN 1, 2, 3, RN 1, and 2, indicated that they were certified in providing CPR.
During an interview with the facility Director of Nursing (DON), on 3/9/17 at 8: 45 a.m. DON indicated every nurse during a CODE BLUE plays an active role in patient care: charting, chest compression, providing oxygen, and charge nurse makes calls and assists the nurses at the bedside. The nurse charting should be observing if the patient is responding to treatment and charge nurse is assigning staff tasks. DON stated side effects of continued ineffective oxygen administration during a respiratory distress emergency response is detrimental (causes harm), increases the time of respiratory distress, can cause brain damage, and cause the heart to work harder.
An article in "Nursing Times." October 2007, titled "Respiratory Procedures: Use of a non-rebreathing oxygen mask (www.nursingtimes.net)," lists the proper way to use a NRB mask, which included the following:
1. Attach the oxygen tubing to the oxygen source.
2. Set the oxygen flow rate to 12-15 L/min.
3. Occlude (cover) the valve between the mask and the oxygen reservoir bag.
4. Check the reservoir bag is filling up.
5. Remove the finger.
6. Squeeze the oxygen reservoir bag to check the patency (open, unobstructed) of the valve between the mask and the reservoir bag.
7. Place the mask with a filled oxygen reservoir bag on the patient's face ensuring a tight fit.
8. Adjust the oxygen flow rate until it is sufficient.
9. Ensure the reservoir bag deflates by approximately one-third with each breath.
According to the MEDLINE Adult Manual Resuscitator (device used in CPR) manufacturer instructions it states the following: The Adult Manual Resuscitator is designed for the use in various clinical situations to provide respiratory support in the presence of reversible apnea (to restore breathing) commonly associated with respiratory arrest.
WARNINGS: This device should only be used by personnel trained in adult CPR procedures.
PREPARATIONS FOR USE:
1. Test the resuscitator for proper functioning: With patient port completely occluded (closed off), squeeze bag body to assure resistance is present.
2. Before using the mask, inspect for adequate inflation.
DIRECTIONS FOR USE:
1. Place the patient in a supine (lying on back) position. Establish an open airway.
2. Grasp bag body with one hand.
3. Ventilate the patient by compressing (squeezing) the bag body for inhalation and releasing the bag body for patient's passive exhalation and bag body re-expansion. Continue this cycle as directed by medical authority.
4. Using supplemental oxygen: Connect oxygen supply tubing to oxygen source at appropriate flow rate. Fixed carbon dioxide (the fixed amount of toxic gas with in a person's body) values may be compromised (lower than expected) if oxygen flow is not sufficient. Oxygen flows equal or greater than 15 liters per minute may be necessary.
A review of the facility policies provided indicated there was no present procedure for emergency medical response to respiratory distressed residents or policies on how to use a non-breather mask or BVM. This was confirmed by the DON during an interview on 3/9/17 at 8: 45 a.m.
The facility?s staff (LVN 1, 2, 3, RN 1, and 2) who were certified to provide CPR, and Resident 1?s physician, failed to meet professional standards correctly use two emergency respiratory equipment while providing CPR to Resident 1. The facility failed to:
1. Properly set up and apply a non-rebreather mask (NRB) to Resident 1
2. Properly set up and apply an adult manual resuscitator, also known as a bag valve mask/Ambu Bag to Resident 1.
The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 950000073 |
Monrovia Post Acute |
950013327 |
B |
5-Jul-17 |
CGXI11 |
26761 |
California Code of Regulations, Title 22, Section 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 manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529.
California Code of Regulations, Title 22, and Section 72529 ? Safeguards for Patients? Monies and Valuables.
(a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following:
(1) No licensee shall mingle patients? monies or valuables with that of the licensee or the facility. Patients? monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee?s or the facility funds. The provisions of this section shall not be interpreted or preclude prosecution for the fraudulent appropriation of patients? monies and valuable as theft, as defined by section 484 of the panel Code.
(2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf.
(A) Records of patients? monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits, and balances. All of these records shall be maintained at the facility for a minimum of three years from the date of transaction. At no time may the balance in a patient?s drawing account be less than zero.
(9) Within 30 days following the death of a patient, except in a coroner or medical examiner case, all money and valuables of that patient which have been entrusted to the licensee shall be surrendered to the person responsible for the patient or to the executor or the administrator of the estate in exchange for a signed receipt. Whenever a patient without known heirs dies, written notice within five working days, shall be given by the facility to the public administrator of the county as specified by Section 1145 of the California Probate Code and a copy of said notice shall be available in the facility for review by the Department.
(c) No licensee, owner, administrator, employee or their immediate relative or representatives of the aforementioned may act as an authorized representative of patients? monies or valuables, unless the patient is relative within the second degree of consanguinity.
From 5/15/17 to 5/17/17, the California Department of Public Health Licensing and Certification Program conducted a Change of Ownership Survey at the facility. During an investigation of management of patients? financial affairs, the following deficient practices were identified.
The facility failed to:
1. Develop and implement policies and procedures to protect patients? trust accounts (monies deposited by the patients into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) and prohibit misappropriation of patients? monies;
2. Provide evidence that showed the facility was assigned or authorized to handle Patients 1, 8, 9, 21, 30, 31, 33, 38, 43, 47, 49, 68, 69, 71 and 77s? monies;
3. Surrender to the person responsible for the patient or to the executor or the administrator of the patient?s estate in exchange for a signed receipt within 30 days following a death of a patient. Patient 77 died on XXXXXXX16. The facility/Administrator continued keeping Patient 77?s money in the trust account and continued receiving Patient 77?s money from the Social Security Administration after Patient 77?s death; and
4. Maintain a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. The facility failed to provide accurate and detailed records of Patients 1, 8, 9, 21, 30, 31, 33, 38, 43, 47, 49, 68, 69, 71 and 77s? monies and provided these patients with quarterly statements of their trust accounts.
These deficient practices resulted in the wrongful use of Patients 1, 8, 9, 21, 30, 31, 33, 38, 43, 47, 49, 68, 69, 71 and 77s? personal funds, intended for the immediate benefit of these patients only, including meeting Patients 1, 8, 9, 21, 30, 31, 33, 38, 43, 47, 49, 68, 69, 71 and 77s? wants and needs and improving the patients? quality of life.
On 5/15/17, the California Department of Public Health Licensing and Certification Program conducted a Change of Ownership Survey at the facility. A list of all patients whom the facility manages their monies/held money for was requested during the entrance conference with the Administrator on 5/15/17, at 10 a.m. A list (List 1) of 13 patients (Patients 1, 8, 21, 30, 31, 43, 47, 49, 68, 69, 71, 73 and 78), whom the facility manages their monies/held money for, was provided by the Administrator at that time.
On 5/15/17, at 2:45 p.m., the quarterly statements of the patients? trust accounts were requested. The Business Office Manager Designee (BOMD) and the Administrator stated they were supposed to provide the patients or their responsible parties with a quarterly patient trust account statements; however, they were unable to provide any quarterly trust account statements for the patients (Patients 1, 8, 21, 30, 31, 43, 47, 49, 68, 69, 71, 73 and 78) on the list (List 1) provided by the Administrator on 5/15/17, at 10 a.m.
On 5/16/17, at 11 a.m., the BOMD provided another list (List 2) of patients, whom the facility manages their monies/held money for, to the surveyors. A review of List 2 indicated 14 patients (Patients 1, 8, 9, 21, 30, 31, 33, 38, 43, 47, 49, 68, 69, and 71), whom the facility manages their monies/ held money for. List 2 was different from List 1, which was provided by the Administrator on 5/15/17. When reviewing List 1 and List 2, it was noted that Patients 73 and 78 were not listed on List 2; whereas Patients 9, 33 and 38 were not listed on List 1.
On 5/16/17, at 2:45 p.m., the Social Worker provided her ?Probate Conservatorship? binder for review. Patients 29 and 77 were included in the binder for probate conservatorship. During an interview and a concurrent record review with the Social Worker on 5/15/17, at 3 p.m., the Social Worker stated the facility was the responsible party for Patients 8, 21, 29, 31, 38, 47, 68 and 77 because they had no family involved in their medical and financial needs. When reviewing Lists 1 and 2, it was noted that Patients 29 and 77 were not listed on both Lists 1 and 2. During an interview and a concurrent record review with the BOMD and the Administrator on 5/15/17, at 4:15 p.m., the BOMD stated Patient 29 had no money and Patient 77 was no longer in the facility, which was the reason they were not included on the lists. The BOMD stated Patient 77 had passed away.
During an interview and a concurrent review of the ?Probate Conservatorship? binder with the Social Worker on 5/16/17, at 2:45 p.m., it was noted that Patients 8, 21, 29, 31, 38, 47, 68 and 77 were not conserved. A review of the face sheets for Patients 8, 21, 29, 31, 38, 47, 68 and 77, indicated the facility was the ?Responsible Party? of these patients. The Social Worker stated the facility had received authorizations from Patients 8, 21, 29, 31, 38, 47, 68 and 77 to be their responsible party; however, there was no documented evidence found in these patients? records indicating these patients or their representatives had assigned or authorized the facility to manage these patients? monies. The Social Worker stated the signed authorization was supposed to be in the patients? medical records. The Social Worker reviewed the patients? records and confirmed there was no documentation that the patients or responsible party had assigned or authorized the facility to manage these patients? monies.
During an interview with the BOMD on 5/17/17, at 5:40 p.m., the BOMD stated a copy of the quarterly statement was given to Patients 1, 8, 9, 21, 30, 31, 33, 38, 43, 47, 49, 68, 69, 71 and 77 or their representatives. However, when requested, the BOMD was unable to provide copies of the quarterly statements she claimed she had provided to these patients or their representatives for review.
Patients? records were reviewed. The records indicated:
Patient 1 was admitted to the facility on XXXXXXX 14 and readmitted on XXXXXXX14.
Patient 8 was admitted to the facility on XXXXXXX13 and readmitted on XXXXXXX14.
Patient 9 was admitted to the facility on XXXXXXX12 and readmitted to the facility on XXXXXXX15.
Patient 21 was admitted on XXXXXXX08 and readmitted to the facility on XXXXXXX15.
Patient 30 was admitted to the facility on XXXXXXX16.
Patient 31 was admitted to the facility on XXXXXXX13 and readmitted on XXXXXXX17.
Patient 33 was admitted to the facility on XXXXXXX09 and readmitted on XXXXXXX15.
Patient 38 was admitted to the facility on XXXXXXX16 and readmitted on XXXXXXX17.
Patient 43 was admitted to the facility on XXXXXXX14 and readmitted on XXXXXXX15.
Patient 47 was admitted to the facility on XXXXXXX15 and readmitted on XXXXXXX17.
Patient 49 was admitted to the facility on XXXXXXX13 and readmitted on XXXXXXX17.
Patient 68 was admitted to the facility on XXXXXXX14 and readmitted on XXXXXXX17.
Patient 69 was admitted to the facility on XXXXXXX07 and readmitted on XXXXXXX13.
Patient 71 was admitted to the facility on XXXXXXX14 and readmitted on XXXXXXX17.
Patient 77 was admitted to the facility on XXXXXXX06 and readmitted on XXXXXXX16. Patient 77 expired on XXXXXXX16.
A review of Patient 77's record indicated Patient 77 was admitted to the facility on XXXXXXX06 and readmitted on XXXXXXX16. Patient 77 expired on XXXXXXX16. The "Admission Record," dated 9/8/16, indicated Patient 77 had two next of kin; a nephew and a grandson. A review of the facility?s patient trust account records titled, ?Trust Statement? was conducted. The ?Trust Statement,? dated March 31, 2017, indicated a balance of $2,549.50 in Patient 77?s trust account. The ?Trust Statement? also indicated a deposit from the Social Security Administration Office to Patient 77?s trust account in the amount of $471 on 10/1/16, after Patient 77 died.
During an interview and a concurrent review of the ?Trust Statement? with the Administrator and the BOMD on 5/15/17, at 2:45 p.m., when asked about Patient 77's money, the BOMD stated they had returned Patient 77?s money to the Social Security Administration Office. When asked to provide evidence when Patient 77?s money was returned, the BOMD was unable to provide any evidence that Patient 77's money was returned to the Social Security Administration Office.
During an interview and a concurrent record review with the Administrator and the BOMD on 5/16/17, at 10 a.m., the BOMD stated Patient 77?s money, a total of $2,549.50, had already been returned to the Social Security Administration Office. A review of the facility's Trust Account Statement was conducted with the BOMD. The BOMD presented another Trust Account Statement, dated 5/16/17, to the surveyors. The ?Trust Statement? indicated the balance of Patient 77's account was zero. When asked to provide evidence when Patient 77?s money was returned, the BOMD was unable to provide evidence that Patient 77's money was returned to the Social Security Administration Office or the Social Security Administration Office was notified of Patient 77?s death.
During an interview and a concurrent record review with the BOMD on 5/17/17, at 10:25 a.m., the BOMD presented a copy of a check (Check number 1052) in the amount of $2,549.50 (Patient 77?s money), dated 5/16/17, payable to the Social Security Administration to the Surveyor. When asked to provide evidence that this check (Check number 1052) in the amount of $2,549.50 was sent to Social Security Administration, the BOMD was unable to provide evidence that this check was sent to the Social Security Administration Office or had already cashed by the Social Security Administration Office.
During an interview with the Administrator and the BOMD on 5/17/17, at 12:30 p.m., when asked if the facility had notified Patient 77's next of kin and the Los Angeles County Administrator regarding Patient 77?s death and/or returned Patient 77's money to the Social Security Administration Office, the BOMD stated the facility did not notify Patient 77?s next of kin and the Los Angeles County Administrator regarding Patient 77?s money and/or returned Patient 77's money to the Social Security Administration Office. The BOMD further stated the facility had not notified the Los Angeles County Administrator and Social Security Administration Office regarding Patient 77?s death.
On 5/17/17, at 12:45 p.m., the Administrator stated a check had been written for returning Patient 77?s money, but she was unsure where to send the check (Check number 1025, in the amount of $2,549.50). As of 5/17/17, the check (Patient 77's money) had not been returned to the Social Security Administration Office.
During an interview and a concurrent record review with the BOMD and the Administrator on 5/16/17, at 11:15 a.m., the BOMD was unable to provide any quarterly trust account statements which should have been given to the patients listed in the trust accounts. The BOMD provided bank statements, dated from May 2016 to April 2017, to the surveyors. A review of the bank statements indicated the following checks were cashed by the facility:
- There were no withdrawals and debits from the ?Patient Trust Account? in May 2016.
- 6/16/16: check number 1002, in the amount of $40,455.99.
- 6/30/16: check number 1015, in the amount of $4,168.00.
- 8/29/16: check number 1019, in the amount of $21,917.69.
- 8/31/16: cashed check in the amount of $527.39. (No check number available)
- 8/31/16: cashed check in the amount of $170.00. (No check number available)
- 9/13/16: check number 1016, in the amount of $705.43.
- 9/13/16: check number 1017, in the amount of $1,804.00.
- 10/25/16: check number 1023, in the amount of $16,229.00.
- 11/29/16: check number 1024, in the amount of $3,658.00.
- 12/30/16: check number 1027, in the amount of $170.00.
- 12/30/16: check number 1028, in the amount of $509.92.
- 1/30/17: check number 1030, in the amount of $29,617.22.
- 2/27/17: check number 1037, in the amount of $26,920.60.
- 2/28/17: check number 1041, cashed check in the amount of $170.00.
- 2/28/17: check number 1042, cashed check in the amount of $536.00.
- 3/9/17: check number 1032, in the amount of $6,312.40.
- 3/10/17: check number 1035, in the amount of $1,891.40.
- 3/17/17: check number 1045, in the amount of $20,917.19.
- 4/5/17: check number 1033, in the amount of $2,821.97.
- 4/28/17: check number 1047, in the amount of $14,181.80.
During a concurrent interview with the BOMD, on 5/16/17, at 10 a.m., the BOMD stated the withdrawals indicated on the bank statements were for the patients? share of cost and for petty cash. When asked to provide evidence for the withdrawals indicated on the bank statements of the trust accounts, the Administrator and the BOMD were unable to provide any evidence (receipts, invoices and/or copies of checks) for these withdrawals of whom the checks were written to and for what reasons the checks were written. The BOMD further stated the Administrator was the only signatory to the account.
A review of all 15 patients? "Eligibility Response" from the Department of Health Care Services Medi-Cal, indicated 11 of 15 patients; Patients 1, 8, 21, 31, 38, 43, 47, 68, 69, 71 and 77, with a total share of costs of $10,013 per month:
- The share of cost for Patient 1 was $890.
- The share of cost for Patient 8 was $814.
- The share of cost for Patient 21 was $610.
- The share of cost for Patient 31 was $381.
- The share of cost for Patient 38 was $952.
- The share of cost for Patient 43 was $834.
- The share of cost for Patient 47 was $825.
- The share of cost for Patient 68 was $2,042.
- The share of cost for Patient 69 was $1,733.
- The share of cost for Patient 71 was $496.
- The share of cost for Patient 77 was $436.
On 5/16/17, at 10:25 a.m., the itemized statements of patients? accounts were requested. At 5:25 p.m., six hours after the itemized statements of patients? accounts were requested; the BOMD provided a document titled, "Itemization of Account," of Patients 8, 21, 31 and 77 to the surveyors. This "Itemization of Account" document was dated 5/16/17. The BOMD stated she created the "Itemization of Account" documents on 5/16/17. The BOMD stated, "I had to prepare the itemization of Account because you asked me to.? The BOMD stated the facility had not been keeping Itemized statements of patients? accounts to track how their monies were being spent. When asked about the itemized statements of other patients whom the facility manages their monies/held money for, the BOMD stated she did not have and was unable to provide the itemized statements for Patients 1, 9, 30, 33, 38, 43, 47, 49, 68, 69 and 71. A review of the "Itemization of Account? of Patients 8, 21, 31 and 77 prepared on 5/16/17 by the BOMD and provided to the Surveyors on 5/16/17, indicated the following:
For Patient 8:
- On 1/1/16, share of cost in the amount of $812.
- On 2/1/16, share of cost in the amount of $812.
- On 3/1/16, share of cost in the amount of $812.
- On 3/1/16, the bank statement indicated, ?Ade date? in the amount of $727.
- On 4/1/16, share of cost in the amount of $812.
- On 5/1/16, share of cost in the amount of $812.
- On 6/1/16, share of cost in the amount of $812.
- On 7/1/16, share of cost in the amount of $812.
For Patient 21:
- On 1/15/16, share of cost in the amount of $608.
- On 2/1/16, share of cost in the amount of $358.
- On 3/1/16, share of cost in the amount of $608.
- On 4/1/16, share of cost in the amount of $608.
- On 5/1/16, share of cost in the amount of $608.
- On 6/1/16, share of cost in the amount of $608.
For Patient 31:
- On 1/15/16, previous balance in the amount of $394.
- On 5/1/16, October 31, 2015 share of cost in the amount of $7.
- On 5/1/16, Nov 1-4, 2015 share of cost in the amount of $308.
- On 5/1/16, Dec 1-9, 2015 share of cost in the amount of $308.
- On 5/1/16, Adjustment in the amount of $373.
- On 8/1/16, share of cost in the amount of $380.
For Patient 77:
- On 2/1/16, share of cost in the amount of $436.
- On 3/1/16, share of cost in the amount of $436.
- On 4/1/16, share of cost in the amount of $436.
- On 5/1/16, share of cost in the amount of $436.
- On 6/1/16, share of cost in the amount of $436.
- On 6/16/16, payment in the amount of $2,180, and a balance forward of zero.
However, on 5/15/17, a review of the ?Trust Statement,? dated March 31, 2017, indicated a balance of $2,549.50 in Patient 77?s trust account. The "Itemization of Account? prepared and provided by the BOMD indicated a balance of zero in Patient 77?s trust account on 5/16/17 did not match the Trust Account Statement. On 5/16/17, at 2:30 p.m., the BOMD stated the account was now zero because the money was returned to the Social Security Administration Office; however, on 5/17/17, at 12:45 p.m., the Administrator had stated a check for the money left in Patient 77?s account had not been sent back to the Social Security Administrative Office.
On 5/17/17, at 10 a.m., during an interview with the Administrator and the BOMD, the Administrator stated she was the signatory of the patients? trust funds and the Business Office Manager was responsible for the patients? trust accounts. The Administrator stated there were no facility process or policy and procedures to direct how the patients? money was withdrawn or deposited into the accounts or how the patient?s funds are handled when the patient dies whom the facility held money for. The BOMD stated ?When patients? checks were received, the facility would deposit the checks in the residents? trust accounts and provide each patient with a monthly statement of the account.? When asked regarding discrepancies between the trust account documents generated by the BOMD and the bank documents dated from 5/1/16 to 4/1/17, the BOMD stated the withdrawals from the bank documents were for the patients? share of costs. The BOMD was unable to show that the patients? share of costs withdrawn from the ?Patient Trust Account? matched with the patients? ?Trust Statement? provided by the BOMD. The BOMD stated she could not explain why the amounts did not match. The patients? monthly account statements were requested for review; however, the BOMD and Administrator stated they were unable to provide copies of the patients? monthly account statements that were provided to the patients.
During an interview and a concurrent record review with the BOMD and the Administrator, on 5/16/17, at 5:30 p.m., the BOMD was only able to provide one month of the ?Trust Statements? for some of the patients. The BOMD provided the ?Trust Statements,? dated 3/31/17, for seven of 15 patients whom the facility held monies for (Patients 8, 21, 31, 38, 47, 68, and 77). The BOMD only provided petty cash receipts for Patient 31. The BOMD and the Administrator were unable to provide the ?Trust Statements? for the other seven patients (Patients 1, 9, 30, 33, 43, 49, 69 and 71). Patient 29 had no money.
The BOMD provided the ?Trust Statement? of Patient 31 to the surveyors. A review of Patient 31's Trust Statement, dated 3/31/17, indicated the following:
- 6/16/16, a miscellaneous withdrawal in the amount of $760.00. The BOMD stated on 5/17/17, at 5:30 p.m., this withdrawal was for Patient 31?s share of cost.
- 8/29/16, cash withdrawal for $7.50.
- 8/29/16, cash withdrawal for $10.00.
- 8/29/16, cash withdrawal for $11.25.
- 8/29/16, cash withdrawal for $15.00.
- 8/29/16, cash withdrawal for $10.00.
- 8/29/16, cash withdrawal for $10.00.
- 12/29/16, cash withdrawal for $20.00.
- 2/28/17, cash withdrawal for $20.00.
- 3/15/17 share of cost $639.00.
The BOMD provided petty cash receipts of Patient 31?s purchases to the surveyors, which indicated:
- 4/18/16, $10.00 for cigarette.
- 5/1/16, $10 for cigarette.
- 5/12/16, $10 for cigarette.
- 5/16/16, $11.25 for cigarette.
- 6/16/16, $7.50 for cigarette.
- 8/18/16, $15 for cigarette.
- 12/20/16, $20 for cigarette.
- 1/25/17, $20 for cigarette.
The dates for the withdrawals did not match the dates on the petty cash receipts. When interviewed on 5/17/17, at 5:30 p.m., the BOMD could not provide an explanation for the discrepancies between the dates on the petty cash receipts and the ?Trust Statement?. The BOMD stated she searched through all the files in the Business Office and that was what she found. The BOMD stated she did not know why the dates were different.
A review of website www.Medicare.gov, undated, titled, ?What Are My Rights and Protections in a Nursing Home? indicated ??The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can?t combine your funds with the nursing home funds. The nursing home must protect your funds from any loss?if a resident passes away, the nursing home must return the funds with a final accounting to the person or court handling the resident?s estate within 30 days.?
The facility's policy and procedures titled, "Deposit of Resident Funds," revised 12/09, indicated, "Should the resident permit the facility to hold, safeguard, and manage his or her personal funds; the facility will provide the resident with a confidential quarterly statement of funds on deposit with the facility, including activity since the previous statement."
The facility's policy and procedures titled, "Resident Funds," revised 12/09, indicated, "Our facility protects the resident's funds maintained or managed by the facility by providing for an individual and confidential accounting of funds received and disbursed on the resident's behalf."
The facility's policy and procedures titled, "Management of Residents' Personal Funds," dated December 2009, indicated, "Should the resident elect to have the facility manage his or her personal funds, it must be authorized in writing by the resident or the resident's representative, and a copy of such authorization must be documented in the resident's medical record."
The facility failed to:
1. Develop and implement policies and procedures to protect patients? trust accounts (monies deposited by the patients into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) and prohibit misappropriation of patients? monies;
2. Provide evidence that showed the facility was assigned or authorized to handle Patients 1, 8, 9, 21, 30, 31, 33, 38, 43, 47, 49, 68, 69, 71 and 77s? monies;
3. Surrender to the person responsible for the patient or to the executor or the administrator of the patient?s estate in exchange for a signed receipt within 30 days following a death of a patient. Patient 77 died on XXXXXXX16. The facility/Administrator continued keeping Patient 77?s money in the Trust Account and continued receiving Patient 77?s money from the Social Security Administration after Patient 77?s death; and
4. Maintain a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. The facility failed to provide accurate and detailed records of Patients 1, 8, 9, 21, 30, 31, 33, 38, 43, 47, 49, 68, 69, 71 and 77s? monies and provided these patients with quarterly statements of their trust accounts.
These violations, either separately or jointly, had a direct or immediate relationship to Patients 1, 8, 9, 21, 30, 31, 33, 38, 43, 47, 49, 68, 69, 71 and 77s? health, safety or security, or therefore constitute a Class ?B? Citation. |
| 950000249 |
Mayflower Care Center |
950013388 |
A |
27-Jul-17 |
JNWW11 |
14953 |
F309 ? 42 CFR 483.24 Quality of life
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
483.25 Quality of care
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.
On May 3, 2017 at 12:30 p.m., an unannounced visit was made to the facility to conduct a complaint investigation.
Based on observation, interview, and record review, the facility failed to provide Resident 1 with necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with his comprehensive assessment and plan of care to meet the needs of the resident with unresolved body rash by failing to:
1. Conduct an accurate assessment of Resident 1's skin condition by a dermatologist. Resident 1 was seen by a dermatologist four and half month after the initial identification of the rash with itching.
2. Identify the cause of Resident 1?s body rash.
3. Revise Resident 1's treatment orders when Resident 1?s body rash did not resolve.
These deficient practices resulted in Resident 1 developing infected scabs and sepsis (a potentially life threatening infection in which the body has a severe, inflammatory response to bacteria or other germs) of the skin due to the resident?s behavior of scratching herself and being transferred to a general acute care hospital (GACH) for evaluation and treatment.
Upon readmission to the facility, Resident 1 continued to have the body rash and the same treatments prior to the hospitalization were reordered with no marked improvement. Resident 1 continued itching and scratching, until assessed by a Dermatologist (physician who specializes in skin diseases) her on April 16, 2017, four months and a half after the facility identified her as having body rash on November 28, 2016.
A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on XXXXXXX 2016. Resident 1's diagnoses included but not limited to cellulitis (infection of the deeper layer of the skin) of the left toe, high blood pressure, diabetes (elevated blood sugar levels), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), anxiety disorder (frequently having intense, excessive and persistent worry and fear about everyday situations), and muscle weakness.
A review of Resident 1's Minimum Data Set (a standardized assessment and care planning tool), dated February 21, 2017, indicated Resident 1?s cognition was severely impaired; she was sometimes able to understand others and make herself understood; and she required extensive assistance with one person physical assistance with dressing, personal hygiene and bathing.
A review of Resident 1's admission skin assessment, dated November 11, 2016, indicated Resident 1 had skin tears to the right and left arms, and swelling to the second toe due to cellulitis. The skin assessment did not indicate that Resident 1 had rashes. This information was verified during a telephone interview with the director of nursing (DON) on June 3, 2017 at 2:22 p.m.
A review of Resident 1's Multidisciplinary Progress Record, dated November 28, 2016, indicated Resident 1's physician ordered Hydrocortisone (a medicated cream used to treat itching) cream 1 percent (%) for the resident and to apply the medicated cream daily for 30 days.
A review of Resident 1's Non-pressure Sore Skin Problem Report indicated the following:
1. On November 28, 2016, Resident 1 had scattered rash to the back, chest, arms and trunk.
2. On December 1, 8, 15, and 22, Resident 1 had scattered body rash and the resident complained of itching on and off, continue with treatment.
3. On December 28, 2016, there was a new order for scattered body rash, which was to apply Triamcinolone (a medicated cream to reduce redness, swelling and itching) 0.1 % cream daily for 30 days to scattered body rash.
4. On January 12 and 19, 2017, Resident 1 still had scattered body rash and complained of itching and scratching constantly.
5. On January 26, 2017 and February 2, 2017, Resident 1 still had scattered body rash and was itching on and off.
A review of Resident 1's Short Term Goals care plans indicated the following:
1. On December 28, 2016, Resident 1?s scattered body rash will resolve within 30 days. The approaches included to apply the treatment done as ordered; to keep affected area clean and dry; and to notify the physician if condition worsens.
2. On January 28, 2017, Resident 1?s scattered body rash will resolve within 30 days. The approaches included to apply the treatment as ordered; to assess for the resident?s skin integrity; and to notify the physician if conditions worsen.
A review of Resident 1's Multidisciplinary Progress Record indicated the following:
1. On January 28, 2017, at 9 a.m., Resident 1's body rash was reassessed; the treatment was in progress but (the body rash was) not completely healed. Resident 1's physician ordered to continue with same treatment (Triamcinolone).
2. On February 6, 2017, Resident 1's physician evaluated the resident. The physician ordered Resident 1 to be transferred to the GACH 1 for a skin evaluation.
A review of Resident 1's Multidisciplinary Progress Record, dated February 7, 2017 at 10 a.m., indicated a body assessment was done prior to the resident?s transfer to the GACH 1 and Resident 1 was noticed to have multiple skin rashes from head to toe. "Resident noted [sic] scratching on skin, educated pt. (patient) to stop scratching," which led to the physician being notified and to order the transfer of Resident 1 to GACH 1. No documentation was found, which indicated Resident 1 had infected scab areas on her body.
A review of Resident 1's GACH 1?s History and Physical, dated February 7, 2017, indicated the following:
1. Resident 1's chief complaint was: Complaint of abdominal wall infected scabs and keeps on scratching skin.
2. Abdomen Comments: Has diffuse skin lesions infected.
3. Medical Impression and Plan included:
Problem 1: Skin rash
Problem 2: Infected skin scabs/cellulitis
A review of GACH 1 infectious disease physician consultation of Resident 1 indicated the following:
1. Generalized tiny, pinkish rash involving the face, back, abdomen and limbs.
2. "Rash suggested with distant possibility of scabies."
3. May try Elimite lotion, consider skin biopsy.
A review of Resident 1's Discharge Summary from GACH 1 indicated Resident 1 was in GACH 1 from XXXXXXX, 2017 to February 15, 2017. Resident 1 was admitted to GACH 1 with general weakness and generalized itchiness. The generalized itchy rash involved the face but not the palms or soles. The resident was noted with abdominal wall infected scabs, where the resident kept scratching.
A review of Resident 1's final diagnoses from GACH 1 included but not limited to sepsis (a potentially life threatening infection in which the body has a severe, inflammatory response to bacteria or other germs), acute kidney failure, Alzheimer's dementia, scabies, dermatitis.
There was no documentation that GACH 1 had performed the skin biopsy or treated Resident 1 with Elimite.
Resident 1 was readmitted to the SNF on XXXXXXX 2017. A review of Resident 1's History and Physical, dated February 17, 2017, indicated Resident 1 was admitted from GACH 1 due to generalized skin rash with diagnosis of sepsis.
A review of Resident 1's physician's order, dated February 15, 2017, included the following:
1. Administer Acyclovir (an antiviral medication, primarily used for the treatment of herpes simplex virus infections, chickenpox, and shingles) 400 milligrams (mg) by mouth three times a day for skin infection.
2. Hydrocortisone 1% cream twice a day and as needed for itching (the same medication that was used on Resident 1 prior to the hospitalization at GACH 1).
3. Benadryl (a medication used to treat allergies and itching) 50 mg tablet every 8 hours as needed for itching.
A review of Resident 1's care plan for Scattered Body Rash, dated February 17, 2017, indicated a goal that the rash will resolve in 14 days. The approaches included but not limited to applying the treatment as ordered, keeping the affected area clean and dry, and notifying the physician if (the condition) worsens.
A review of Resident 1's Change of Condition (COC)/Interact Assessment Form, dated February 26, 2017 at 12 a.m., indicated Resident 1 was at the nursing station and did not want to go to bed. Resident 1 complained of itching on her arms and her right forearm was observed to be bleeding. Resident 1 had been scratching her arms and tore the skin off her arm. Resident 1's physician was notified and the resident's arm was cleaned with normal saline, triple antibiotic ointment was applied and the wound was covered with gauze.
A review of Resident 1's physician's orders, dated February 26, 2017, indicated the physician ordered to discontinue Hydrocortisone 1% cream and start Triamcinolone 0.5% to scattered body rash twice a day for 14 days (the same medication used at a higher concentration used on Resident 1 prior to the hospitalization in GACH 1).
A review of Resident 1's Multidisciplinary Progress Record, dated March 10, 2017, at 9 a.m. indicated Resident 1 was assessed with continued body rashes all over the body and still complaining of itchiness. Resident 1's physician was notified and a new order was received.
A review of Resident 1's physician's orders, dated March 10, 2017, indicated to apply Triamcinolone 0.5% to scattered body rash twice a day for 30 days. (This was the same treatment Resident 1 had been receiving since February 26, 2017.)
A review of Resident 1's Multidisciplinary Progress Record indicated the following:
1. On March 23, 2017, at 1:05 p.m., the facility nursing staff left a message with Resident 1's physician regarding the Triamcinolone for scattered rash since 2/17/17.
2. On April 8, 2017, at 2 p.m. the nurse practitioner of Resident 1's physician examined the resident and had no new orders.
3. On April 10, 2017, at 9 a.m., Resident 1's scattered body rash was reassessed and the resident was not responding to the treatments. Resident 1's physician was made aware and ordered to continue Triamcinolone 0.5% twice a day for another 30 days, and then reevaluate. The physician also ordered for a dermatology (physician who specializes in diseases of the skin) consult.
A review of Resident 1's Dermatology Consultation, dated April 16, 2017, indicated the following:
Diagnosis: Dermatitis (Dermatitis is a general term that describes an inflammation of the skin. Dermatitis can have many causes and occurs in many forms. It usually involves an itchy rash on swollen, reddened skin.) unspecified body rash.
Treatment: Elimite, Ivermectin (antiparasitic (organism that live off another organism) medication, used to treat scabies) and Contact Isolation (Procedures that reduce the risk of spread of infections through direct or indirect contact.)
A review of Dermatologist's Order Sheet, dated April 16, 2017, indicated the Dermatologist ordered:
1. Fluocinonide 0.1% cream (a topical medicine used to treat psoriasis, eczema, dermatitis, and other skin conditions) apply to affected area twice a day for four weeks.
2. Ivermectin 9 mg, take one dose once a week for four weeks.
3. Permethrin (Elimite) 5% cream, apply from neck down to toes, leave for 12 hours, then rinse. Repeat once a week for four weeks.
4. Contact Isolation.
A review of the Treatment Administration Record (TAR) for the month of April 2017 indicated Elimite was applied and Ivermectin was administered on April 16, 2017.
On May 3, 2017 at 2:27 p.m., an interview was conducted with Certified Nursing Assistant 1 (CNA 1). CNA 1 stated Resident 1 was forgetful and sometimes confused, and the resident had rashes on the arms, back of the legs, and on the stomach. CNA 1 stated Resident 1 would scratch from the itchiness and the resident required redirection in order to stop (the resident from scratching herself) or else she would cause injury to her skin.
During an interview, on May 3, 2017 at 2:50 p.m., the licensed vocational nurse (LVN 1) stated Resident 1 was confused. LVN 1 stated Resident 1 had scattered rashes all over her body. LVN 1 stated Resident 1 would often pick at her skin and would have to be told to stop.
On June 3, 2017 at 1:05 p.m., a telephone interview was conducted with the dermatologist. The dermatologist stated he examined Resident 1 on April 16, 2017, for the first time. The Dermatologist stated he ordered Resident 1 be placed in contact isolation and treated with Elimite and Ivermectin. The Dermatologist stated when a resident has persistent rashes and is immunocompromised, often it is one of three things: 1. An allergic reaction. 2. Eczema (a group of medical conditions that cause the skin to become inflamed or irritate). 3. Scabies.
According to the Dermatologist, residents with any of the three conditions are treated aggressively with Elimite/Ivermectin and if necessary skin biopsy would be performed.
During a telephone interview on June 22, 2017 at 9:16 a.m., Resident 1's physician stated, "We always suspected scabies. She had multiple admissions to the acute hospital." "She should have been treated for scabies with Elimite." Resident 1's physician stated that a biopsy should have been done.
During a telephone interview with the DON, on June 29, 2017, at 3:10 p.m., the DON stated that Resident 1 did not have any Elimite treatment until April after the dermatologist had seen Resident 1.
The facility failed to provide Resident 1 with necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with his comprehensive assessment and plan of care to meet the needs of the resident with unresolved body rash by failing to:
1. Conduct an accurate assessment of Resident 1's skin condition by a dermatologist. Resident 1 was seen by a dermatologist four and half month after the initial identification of the rash with itching.
2. Identify the cause of Resident 1?s body rash.
3. Revise Resident 1's treatment orders when Resident 1?s body rash did not resolve.
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 Resident 1. |
| 960002077 |
MARY'S HOUSE |
960008983 |
B |
08-Feb-12 |
L0VJ11 |
3640 |
CLASS B CITATION---ADMINISTRATION 76949(a). GENERAL MAINTENANCE. (a) The facility, including grounds, shall be maintained in a clean and sanitary condition, and in good repair at all times to ensure the safety and well-being of clients, staff and visitors.On January 25, 2012 the Department received a complaint that the facility was turning off their fire alarm system because it made a beeping noise. Based on observation and interview the facility administrative staff failed to maintain the facility in good repair to ensure safety by failing to: 1. Maintain the fire alarm systemin a functional working condition. 2.Conduct a fire watchas per its policy and procedures when the fire alarm was not functioning properly.These failures put all six clients in the facility at risk for harm and could have adversely affected the safety and well-being of them in the event of a fire emergency. During a complaint investigation on January 26, 2012 at 11:15 a.m., the evaluator observed a 1500 series fire panel located on a wall in the dining room area. At 11:25 a.m. the evaluator observed the fire alarm panel was disconnected from a power source. The evaluator proceeded to test the smoke detectors with aerosolized smoke can. All smoke detectors were in working order and activated the facility?s alarm. However the sprinkler test valve and the single manual fire alarm pull station failed to activate the alarm.On January 26, 2012 at 11:45 a.m., during an interview, Staff A stated the fire alarm panel has been inoperable for several months. At 11:50 a.m., during an interview, Staff B corroborated Staff A?s response and stated the fire alarm panel had not been functional for months. In addition both Staff A and B stated someone had deactivated the panel?s continuous audible alarm because it was signaling non-stop with a loud ?beep.? When asked if the facility conducted a fire watch secondary to the alarm being turned off, both Staff A and B stated they were not familiar with the fire watch procedure and its implementation. A review of the Life Safety Code 3.3.77, Fire Watch defined a person or persons assigned to an area for the purpose of protecting the occupants from fire or similar emergencies. Annex 9.6.1.8 states a fire watch should at least involve some special action beyond normal staffing, such as additional security guard(s) to walk the area affected. A review of the facility?s records for fire emergencies revealed the facility had a written fire watch policy. However the facility failed to implement its own policy and did not initiate a fire watch at the time the fire alarm system was malfunctioning and was not on fire watch during the complaint investigation. There were no clients present at the time of inspection. On January 26, 2012 at 12:10 p.m. during an interview, the Facility Administrator and Qualified Mental Retardation Professional, when asked about the fire watch, stated there was no fire watch in place and did not have any logs evidencing the implementation of the fire watch policy. The facility?s administrative staff failed to maintain the facility in good repair to ensure safety by failing to:1. Maintain the fire alarm system in a functional working condition. 2. Conduct a fire watch as per its policy and procedures when the fire alarm was not functioning properly.Failure of the facility to maintain the fire alarm system in an operable condition and the facility?s staff to conduct a fire watch until the fire alarm panel was returned to service had a direct relationship to the health and safety of all six clients. |
| 960001001 |
MARLINDA WEST NURSING HOME |
960009019 |
A |
06-Mar-12 |
XD3V11 |
7907 |
? 76647. General Maintenance. (a) The facility, including grounds, shall be maintained in a clean and sanitary condition, and in good repair at all times to insure safety and well-being of clients, staff and visitors.On August 26, 2011 at 7 a.m., an unannounced visit was made to the facility regarding an incident report that was received on July 1, 2011.According to the incident report, dated June 27, 2011, on June 25, 2011 Client 1 was riding in a shower chair. On her way from the shower to her room the client leaned over in the shower chair, while turning into her room, and the chair tilted over in the hallway. The client sustained a fracture of the left distal end tibia and fibula (lower leg bones). Based on observation, interview and record review, the facility staff failed to:1. Ensure the facility?s floors were in good repair at all times. The hallway floor had unleveled flooring around a metal plate in the floor outside of Client 1?s bedroom and when the shower chair rolled over the metal plate the wheels of the shower chair got caught causing the shower chair to tip over.This failure resulted in the client falling and sustaining a fracture of the left leg. The client endured pain, haddecreased ability to stand, and experienced decreased community activity as a result of the leg fracture.On August 26, 2011 at 8 a.m., a record review of Client 1's chart revealed the client was admitted to the facility on April 13, 2002 with diagnoses that included profound mental retardation (developmentally functions at one third of chronological age and can learn elementary health and safety habits), seizure disorder, a history of intractable back pain and was dependent on staff for activities of daily living care (dressing, grooming and feeding). A review of the physical therapy assessment dated June 1, 2011 indicated the client was able to step (ambulate) with assistance 25 feet. On August 26, 2011 at 7:10 a.m.,Client 1 was observed in bed with both bedrails up. Client 1?s left leg was observed to have several suture marks with mild to moderate swelling and no redness. The client was non-verbal. On August 26, 2011 at 7:15 a.m., during an interview, the LVN stated on the evening of the incident (June 25 2011), the client was returning from a shower in the shower chair and the shower chair tipped over.On August 26, 2011 at 9:50 a.m., during an interview, the qualified mental retardation professional (QMRP) stated after the client had her p.m. shower, on her way back to her room in the shower chair, the client leaned over to assist the turn into her bedroom and the shower chair tilted over. She stated Staff A was the direct care staff with the client that evening. The QMRP was asked about the client?s mobility prior to the shower chair incident; she stated the client was walking (her objective) at her day program and on the p.m. shift. This objective was discontinued as a result of the incident. When asked about the flooring, she stated the metal plate that was ?sticking out? was fixed after the client?s injury. The work order for the incident indicated the floor was repaired on June 28, 2011. On August 26, 2011 at 1 p.m., a review of QMRP notes written June 28, 2011, indicated the objective for Client 1 to take 50 steps x 2 had been discontinued until further notice. On August 26, 2011 at 12:35 p.m., during an interview with Staff B (person in charge the night the client fell) stated, that Staff A showered the client and was transporting the client to her room and the client leaned over to the right side. There was a metal plate in the hallway and the bath chair got caught in the metal plate causing the bath chair to fall over and as a result the chair tipped over and the client?s leg was fractured. Staff B stated maintenance repaired the flooring so the flooring would ?not stick out.? On August 26, 2011 at 12:55 p.m., during an interview, the director of nursing stated the client had been in the hospital for over a month and was healed when she returned to the facility. On February 27, 2012 at 4:20 p.m., during an interview and in a written declaration, Staff A stated that on June 25, 2011, after she showered the client, she was pushing the client down the hallway to her room, as she turned toward the door of the room, the client leaned to the left and the shower chair tipped causing the client to fall while seat belted into the shower chair. She stated the client was showered and transported in the shower chair every night and leans all the time in the shower chair, so she was not sure what the difference was for the shower chair to tip over. She stated it could have been the flooring, but she never noticed the problem in the flooring.On February 27, 2012 at 5:00 p.m., during an interview and in a written declaration, the maintenance person stated on Monday June 27, 2011, the DON informed him of the accident that occurred due to the hallway flooring problem. He stated he had not noticed the problem before then, he went to the area, saw the problem and had it repaired.The drain was slightly higher than the flooring. There was a raised portion of the cement flooring in between 1/8-1/4 of an inch raised on one side that caused the drain to be higher on one side of the floor. To repair the floor, a company was brought in to the facility. They removed the tile next to the drain, layered the cement around the drain, flushing (make even) the cement floor with the top of the drain. Before the repair, the flooring was uneven around the drain.On August 26, 2011 at 1:30 p.m., a review of the medication administration record indicated the client received Motrin (pain medication) 600 milligrams (mg) on June 26, 2011 at 10:45 a.m. and 4:20 p.m. (approximately five hours later) for pain. The MAR indicated the medication was ?helpful?. On August 26, 2011 a review of an undated incident report indicated the metal plate on the floor may have caused the bath chair to tip over. A review of an x-ray report dated June 26, 2011 indicated the client sustained a fracture involving the distal tibia (lower leg bone) and the fibula (lower leg bone) with mild displacement. The joint alignment was maintained. There was associated soft tissue swelling. Acute ankle fracture, acute left lower leg fracture concluded. A review of the nursing notes dated June 25, 2011 at 7:15 p.m., indicated the client fell in a shower chair while being transported to her room. Nursing notes dated June 26, 2011 at 12 p.m. indicated the client was medicated for pain, later that day swelling of the left leg was indicated and x-ray taken at 5:25 p.m.Nursing notes dated June 27, 2011 at 1 a.m. indicated a call was received regarding x-ray results showing acute fracture of left lower leg and left ankle. An orthopedic (orthopedic surgeon) evaluation was scheduled for the next morning per the nursing notes. A review of physician orders dated June 27, 2011 indicated the client was sent to the hospital at approximately 8 a.m.A review of the hospitalization records dated July 6, 2011 indicated the client was treated with open reduction and internal fixation operation of left tibia and fibula fracture on the left lower extremity (left lower leg).A review of a physician?s order dated July 27, 2011revealed that the client was re-admitted to the facility from the hospital on July 27, 2011 one month later. Failing to ensure the facility?s floors were in good repair resulted in the client falling and sustaining a fracture of the left leg. The client endured pain, had a decreased ability to stand, and experienced decreased community activity secondary to the leg fracture. 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. |
| 960002158 |
MVM Home, Inc. |
960009847 |
B |
19-Apr-13 |
None |
3410 |
W&I 4502Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a development disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds.It is the intent of the Legislature that person with developmental disabilities shall have rights including, but not limited to, the following:(b)A right to privacyBased on observation, interview, and record review the facility?s staff failed to:1. Ensure Client 1 was afforded privacy during personal care. Failure of the staff to ensure Client 1 was given privacy during private bathing and dressing caused significant humiliation, indignity andanxiety to Client 1.On March 15, 2013, during a re-certification survey the facility staff was observed transporting Client 1 through the living room to the bedroom completely nude in front of one male client and one female client.Client 1 was admitted to the facility on July 11, 2010, with the diagnosis of mild mental retardation. According to the client's Speech and Language assessment dated September 12, 2011, Client 1 was verbal and could communicate her needs; she was also identified as a functional verbal communicator.On March 13, 2013 at 3:02 p.m., during an observation while standing at the front door of the facility, the blinds at the front window were open allowing visual access to anyone passing in front of the house. While the evaluator was waiting for staff to open the door, Staff A was observed transporting Client 1, while in a Hoyer Lift, in front of the window. Client 1 was observed completely naked while strapped to the Hoyer Lift.At 3:04 p.m., during an interview with Staff A, she stated she was sorry for transporting Client 1 in front of the window naked. At 4:34 p.m., during an interview with Client 1, she stated she felt bad when staff transported her from the bathroom through the program/television room because the other clients (included a male) were seated in the room as she passed by naked. When Client 1 was asked if Staff A had transported her naked through the program room with other clients present before, Client 1 looked away, began to cry and said yes many times.On March 14, 2013 at 9:09 a.m., during an interview with the Qualified Mental Retardation Professional (QMRP), she stated Staff A should have made certain Client 1 was completely covered before bringing her out of the shower, and staff are expected to follow the facility's policy and procedure regarding privacy at all times. On March 14, 2013 at 11:00 a.m., a review of the facility's policy and procedure titled "Privacy," revealed: ?Clients have a right to privacy at all times, visual privacy for each client shall be provided in client rooms, tub, shower and toilet rooms, windows shall have window coverings and doors shall be closed as appropriate.Based on observation, interview, and record review the facility?s staff failed to:1. Ensure Client 1 was afforded privacy during personal care. The above violation caused significant humiliation, indignity, anxiety or other emotional trauma to the client. |
| 960002205 |
MIMIS HOMES |
960010497 |
A |
10-Mar-15 |
GJSO11 |
10842 |
Title 22 ?76918. Client's Rights. (a) Each client shall have those rights as specified in Sections 4502 through 4505 of the Welfare and Institutions Code and Sections 50500 through 50550 of title 17 of the California Code of Regulations.WELFARE AND INSTITUTIONS CODE SECTION 4500-4519.7 4502. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds.It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse or neglect.Based on interview and record review, the facility staff neglected Client 6 after the client had a seizure and turned purple by failing to: 1. Ensure direct care staff (Staff A and B) continued cardiopulmonary resuscitation (CPR) upon initiation until the emergency responders were able to take over- (CPR, is an emergency procedure indicated in those who are unresponsive with no breathing or abnormal breathing, performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest). 2. Ensure the client remained lying flat on the floor for CPR.These failures could have resulted in a delay in the flow of oxygenated blood to the brain and heart and presented and imminent danger or substantial probability of serious harm or death to Client 6. The clinical record for Client 6 was reviewed on February 14, 2013, at 9:55 a.m. She was admitted to the facility May 27, 2004 with diagnoses that included severe mental retardation (cognitive ability that is markedly below average level- one fifth to one third of chronological age- and a decreased ability to adapt to one's environment), seizure disorder (epilepsy, a brain disorder involving repeated, spontaneous convulsions), cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture related to the brain?s ability to control the body), and spastic quadriplegia (most severe form of cerebral palsy in which one's ability to coordinate body movements of all four limbs and the trunk are affected including problems with muscles that control the mouth and tongue, and difficulty in speaking).During an interview with Staff A, interpreted from Spanish to English by Staff C, on February 13, 2013, at 5:59 a.m., Staff A stated after dinner on January 26, 2013, at 5:40 p.m., she and Staff B assisted Client 6, to the bathroom and left her sitting on the toilet for 30 minutes. Staff A stated she did not remain with the client the entire time and when she returned to the bathroom, around 6 p.m., Client 6 began to have a seizure. Staff A saw the client stretch, stiffen, bit her tongue and both lips and below her eyes turned purple for about a minute. Staff A called Staff B to the bathroom and they put the client on the floor in the bathroom, checked for a pulse on her neck and found there was no pulse. Staff B called 911 (emergency response) and Staff B gave the client CPR as she held the phone as 911 instructed her. Staff A watched as the client's stomach started getting hard. After 7 to 10 minutes, the client had no pulse and Staff A told the 911 operator she did not feel anything and stopped giving the client CPR while she was still on the phone with 911 operator. When they heard the ambulance arrive, Staff B hung up the phone. Staff A stated, Staff B was nervous and told Staff A it would be better if the client was on the toilet.Staff A and B returned the client to the toilet. When the paramedics entered the facility, they found the client on the toilet.The paramedics connected the client to a monitor, saw the client's legs were red, and they said there was nothing they could do. During a telephone interview and written declaration with Staff B, interpreted from Spanish to English by a department interpreter, on February 20, 2013, at 10:24 a.m., she stated after dinner on January 26, 2013, at 5:40 p.m., she and Staff A took Client 6 to the bathroom and sat her on the toilet and left the client. After the client sat on the toilet for 10-15 minutes, they returned and Client 6 had a seizure where her hands and feet straightened in front of the client. After the seizure, the client looked sleepy and failed to respond to staff. This was not normal for the client after a seizure. Staff B felt for a pulse and Staff A initiated rescue breathing while the client remained on the toilet.Then Staff A and B placed the client on the bathroom floor and Staff B continued CPR, but the client did not respond. After, approximately a minute, Staff A suggested telephoning 911 (emergency response), so CPR was stopped and Staff B telephoned 911 and then Staff B returned to continue CPR again as instructed by the emergency response operator via telephone. Staff B pressed on the client's chest and put her ear to the client's mouth to listen. She heard a little noise and the emergency response operator via telephone told her the client was trying to breath. When the client did not respond to the CPR, Staff B stopped CPR and Staff A and B placed the client back on the toilet because they were nervous. Staff A held the client up on the toilet. Approximately 5 minutes later, the paramedics arrived, placed circles (EKG electrodes connect to circular clear tape) on the client's body and they said there was nothing they could do.During an interview, with the facility's owner/ Administrator / qualified mental retardation professional (QMRP)/ registered nurse (RN) on February 25, 2013 at 10:45 a.m., she stated Client 6 has a history of not being fully awake for 3 to 5 minutes after she has a seizure. The RN stated the client did not wake up after approximately 5 minutes after her seizure and she believed Staff B called 911 and Staff A called the RN via a cell phone and informed her, the client had a grand mal seizure and was not responding. She told Staff A to call 911 and Staff A informed her, Staff B had already called 911 and was guided through CPR by 911 over the telephone. The RN stated when she arrived at the facility that evening, the paramedics were there, but they were not working on the client, who had expired and was sitting on the toilet. The RN asked her staff, why was the client (back) on the toilet and the staff told her Staff B was nervous and wanted to place the client back on the toilet. The RN stated the staff were CPR trained by an outside agency representative fluent in English and Spanish and a copy of the CPR certification cards were given to the evaluator. A review of the ?Basic Nursing Skills and Recording of vital signs, First Aid and CPR Review? In-service dated September 21, 2012 and the ?Employee In-service Records?, indicated Staff A and B attended the September 21, 2012 CPR training. A review of the employee files on February 12, 2013, at 10:40 a.m., indicated Staff A and B received CPR training according to the American Heart Association (AHA) guidelines April 7, 2012 which expires 2 years later in 2014.A review of the emergency response call, dated January 26, 2013, indicated the caller (Staff B per interviews) stated, ?Client 6 had a seizure, hadn?t woken up, her lips were purple, she looked very pale and felt really stiff.? She first told the emergency response phone operator Client 6 was not breathing and was warm, but after she tilted the client?s head back and listened for breaths as instructed, she stated Client 6 was breathing a little. The emergency response phone operator instructed the staff to do CPR step by step and there was no indication CPR had been initiated prior to the phone call. When the paramedics arrived at the facility, the staff stopped CPR to answer the front door and let them into the facility. There was no indication on the response call that Staff A had taken the client off the toilet and placed her on the floor to perform CPR.A review of the Emergency Response Systems (EMS) report dated January 26, 2013, indicated the paramedics were dispatched at 5:57 p.m. and arrived at the facility at 6:03 p.m. The report indicated Client 6 was dead on arrival, sitting on the toilet leaning backward with her head tilted to the rear. The client had major lividity (black and blue) and was last seen at 5:30 p.m.A review of the death certificate indicated Client 6's date of death was January 26, 2013, due to cardiorespiratory arrest secondary to seizure disorder and cerebral palsy.According to the facility?s training manual, ?American First Aid/CPR/AED (Automated External Defibrillator)? dated, 2011 by the American National Red Cross, to perform CPR for a person who is not breathing: call 911 if the person is not responsive, check for breathing- occasional gasps is not breathing, open airway, give chest compressions by pushing hard and fast in the middle of the chest while the person is on a firm, flat surface, give rescue breaths and do not stop CPR unless there is an obvious sign of life such as breathing, an AED is ready for use, EMS personnel take over (trained responder) or the scene becomes unsafe. According to the American Heart Association, Basic Life Support for Healthcare Providers manual, dated 2011, chest compression technique, ?Make sure the victim is lying face up on a firm, flat surface. Straighten your arms and position your shoulders directly over your hands and minimize interruptions. Compressions pump the blood in the heart to the rest of the body. Do not move the victim while CPR is in progress unless the victim is in a dangerous environment or if you believe you cannot perform CPR effectively in the victim?s present position or location.The facility staff neglected Client 6 after the client had a seizure and turned purple by failing to ensure direct care staff continued CPR upon initiation until the emergency responders were able to take over and failed to ensure the client remained lying flat on the floor for CPR.These failures could have resulted in a delay in the flow of oxygenated blood to the brain and heart. The above violations presented an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm to residents would result. |
| 960001607 |
MATHARU ASSISTED LIVING #4 |
960013302 |
B |
21-Jun-17 |
GEEQ11 |
13408 |
Health and Safety Code 1418.91
Reports of incidents of alleged abuse or suspected abuse of residents
a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
b) Failure to comply with the requirements of this section shall be a class ?B? violation.
On July 21, 2016 at 2:00 p.m., an unannounced visit to the facility was initiated to investigate an entity reported incident (ERI) regarding an allegation of inappropriate touching of Client 1 by the house leader (HL).
The facility staff failed to:
1. Report an allegation of abuse immediately to the administrative staff and the department. Client 1 reported to facility staff that the HL touched her inappropriately when she was home alone in the facility with him (HL). This failure of not reporting an incident, of alleged abuse, jeopardized Client 1's safety and her well-being.
2. Implement their Abuse policy and procedure when Client 1 reported to the facility?s staff that the HL had touched her inappropriately on several occasions.
A review of the clinical record for Client 1 was initiated on July 26, 2016. The face sheet indicated the client was admitted to the facility on XXXXXXX 2004 with diagnoses of blindness, obesity, and moderate intellectual disability (developmentally functions below chronological age and can learn elementary health and safety habits).
During an interview with the qualified intellectual disabilities professional (QIDP), on July 21, 2016, at 2:00 p.m., she stated on July 20, 2016 at 2:18 p.m., she received a phone call from Client 1's day program supervisor (DP Supervisor). She stated Client 1 informed the day program supervisor, that while she was home from the day program for a month, the HL engaged in inappropriate touching and misconduct. The QIDP stated she immediately initiated an investigation regarding this matter.
During an interview with the DP Supervisor, on July 26, 2016 at 11:55 a.m., she stated Client 1 had been absent from the day program for a month (June 2016), due to problems with her wheelchair and medical issues. The DP Supervisor stated, Client 1 happily arrived back to the day program on July 20, 2016. The DP Supervisor asked Client 1 what did she do while she was at the facility for the month she was absent from the day program. The DP Supervisor stated on July 20, 2016 at 2:18 p.m., Client 1 immediately began to tell her about the HL, calling him a bad boy. The DP-Supervisor said she asked Client 1 what she meant by calling the HL a bad boy? Client 1 stated the HL would remove her diaper and sticks something into her vagina, he would put something into her mouth and tell her it was candy and direct her to lick it, and then tell her to suck it. Client 1 said that it did not taste like candy and that it made her throat hurt really badly. Client 1 said the HL touched her breast and stuck what she thinks was his finger into her vagina. Client 1 said she told Staff R, who called her a liar and told her that if she did not stop saying that about the HL that she would not talk to her anymore or be her friend. Client 1 said she stopped telling any of the staff. The DP Supervisor stated Client 1 stated she also told Staff C who called her a liar, and started repeating liar, liar, and pants on fire." The DP Supervisor said she had never talked about things of a sexual matter ever for the 20 years the client had attended the day program. The DP Supervisor stated the day program staff did not discuss anything of a sexual nature at the day program, they did not teach sex education at the day program. The DP Supervisor said the client was a concrete thinker and has only spoken to her about events that have taken place in her life. The DP Supervisor said Client 1 has been attending this same day program site for more than 20 years and she has never heard her discuss anything of a sexual nature.
During an interview with the HL, on July 21, 2016 at 2:18 p.m., he stated he had been employed with the company for 21 years and he has not changed female clients diaper or changed their clothes. When asked was he alone with the client for the month of June 2016, he stated yes. The HL stated he was the house leader from 9:30 a.m., to 2:00 p.m., HL stated he did not touch the client he only fed her lunch and carried out her program plan. The HL stated there were allegations that Client 1 said that he touched her vagina and breast and he thinks she made the allegations because she may have wanted a boyfriend. The HL was asked did Client 1 tell him she wanted a boyfriend. HL stated, ?No.? When the HL was asked were there occasions when Client 1 needed her diaper/briefs changed during the time he was alone with Client 1, the HL stated, yes but he did not touch her. The HL stated, he allowed Client 1 to remain wet until the next shift arrived at 2:00 p.m.
During an interview with Staff C, on July 21, 2016 at 3:16 p.m., she stated before now Client 1 has never spoke of anything of a sexual nature. She stated the client was blind and was not exposed to any type of television which contained sexual content. When asked if Client 1 told her about the HL touching her genitals inappropriately, Staff R stated, "No." When Staff R was asked if Client 1 told her about the HL touching her did she say, "liar, liar, pants on fire, she stated,? No.?
During an interview with Client 1, on July 26, 2016 at 1:45 p.m., in the presence of Staff X, she stated while she was home from the day program, the HL was a very bad boy. Client 1 stated the HL would tell her that he had candy for her, and to put it in her mouth, and tell her to suck and lick it. She said that it did not taste like candy and it would burn her throat. Client 1 stated he would touch and play with her breast when he changed her clothes, and when he changed her diaper, he (HL) would put something into her vagina over and over again. She said she would tell him (HL), "get off of me boy, get your body off of me boy right now." Client 1 stated she told Staff C and Staff R. Client 1 stated Staff R called her a liar and told her not to tell anyone else the story or she would not talk to her again. Client 1 stated Staff C started saying liar, liar, and pants on fire over and over again and told her she was a liar. Client 1 stated she wanted to leave the facility and find another place to live. Client 1 stated the HL told her not to tell anyone about the incident because he promised that he was going to stop. Client 1 repeated over and over again, ?he (HL) did not stop.? Client 1 stated he (HL) just kept touching her breast, putting his body on top of her, and putting that thing into her vagina.
During an interview with Staff R, on July 21, 2016 at 2:56 p.m., she stated the HL worked with Client 1 for a month alone in the facility from 9:00 a.m., until the evening shift arrived at 2:00 p.m. Staff R stated, she was not informed that the HL touched Client 1 and did not believe he (the HL) would touch the client. When Staff R was asked if she told Client 1 if she did not stop accusing the HL of touching her that she would not be her friend, Staff R stated no."
During an interview with Staff C, on July 21, 2016 at 3:16 p.m., she stated before now Client 1 has never spoke of anything of a sexual nature. She stated the client was blind and was not exposed to any type of television which contained sexual content. When asked if Client 1 told her about the HL touching her genitals inappropriately, Staff C stated, "No." When Staff C was asked if when Client 1 told her about the HL touching her did she say, "liar, liar, pants on fire, ?she stated No.
During an interview with Staff M, on January 8, 2017 at 10:10 a.m., when asked if she was aware of the HL allegedly abusing Client 1, she stated she did not believe the HL would abuse the client. Staff M stated she did not believe Client 1 was telling the truth about the alleged abuse. Staff M stated she was not sure when she initially heard about the alleged abuse neither does she recall when Client 1 told her about the abuse. Staff M confirmed that the HL was a relative.
A review of the QIDP investigation report, dated July 26, 2016, indicated on July 20, 2016 the QIDP received a phone call from the DP Supervisor who informed her of an allegation of abuse against the HL. The allegation indicated the HL touched Client 1 and she told Staff C who called her liar, liar pants on fire. The police was called and Client 1 was taken to the general acute care hospital (GACH) for evaluation. The regional center representative was notified and initiated an investigation. The documentation indicated the QIDP interviewed Client 1 who told her, "She told the (HL) to behave, and that he (HL) was her friend sometimes and if he was nice she would give him a sweet hug kiss, a sweet vacation hug.? The QIDP documented Client 1 telling the police ?no man puts his hands in my body, I told the HL no, no, no, don?t put hands in my vagina.? The QIDP documented when Client 1 was at the facility, if the HL changed her diaper Client 1 stated, ?fingers no more picking vagina.? The QIDP noted on Friday approximately 5:00 p.m., during meal time Staff C was helping Client 1 eat dinner and Staff C reported to the QIDP that she was providing hand over hand assistance to Client 1 when she placed her hand on top of Client 1?s hand, the client said don?t rape me. The QIDP concluded that the allegations stated by Client 1, although there was conflicting reports from both parties, the allegation was not ruled out. Client 1 had never made this type of allegation in the past. The HL denied any inappropriate actions against Client 1 and further states he never changed her diaper. Nonetheless the facility administrator removed the HL from the company and he would not be allowed to return.
During an additional interview with the QIDP, on August 29, 2016 at 2:45 p.m., she stated Client 1 was taken to a counseling appointment and encouraged to share her concerns. The QIDP stated the client had a difficult time expressing herself, and the counseling organization offered referrals to other establishments that may meet her needs to ensure her mental stability. When the QIDP was informed that the DP Supervisor informed her that Client 1 informed Staff C and Staff R that the HL was touching her, she stated Staff M was related to the HL. The QIDP stated Staff C and Staff R should have informed administration of Client 1's allegation whether they believed her or not. She stated the facility had a zero tolerance abuse policy and each staff is a mandated reporter. The QIDP stated if Staff C or Staff R knew anything, they should have reported the incident.
According to the Staff Schedule, the HL's normal schedule was 6:00 a.m. until 10 a.m. and 1 p.m. until 7 p.m., but his time was changed from 6:00 a.m. to 2:00 p.m., when Client 1 was home for the month of June.
The Forensic Report dated July 20, 2016, indicated Client 1 was examined for sexual assault and specimens were collected for law enforcement to use as evidence. Client 1 received medication (Azithromycin) that was given to prevent sexually transmitted diseases.
Review of the HL?s application of employment indicated the HL was hired to work for the company October 4, 1995 and transferred to work in the facility June 2015 for the position of HL. The HL responsibilities included administering medication, participating in meetings, providing care, such as feeding, oral hygiene, and toileting, reporting unusual occurrences or observations, and being responsible to follow the employee code of conduct as noted in the employee handbook. Staff A received the Competency measure: "Objectively Dealing with Sexual Behavior" (no date indicated), also the "Sexual Harassment/Abuse Complaint Procedure" April 20, 1998.
The undated policy and procedure titled "Abuse Policy and Procedure," indicated it is the facility's intent for the clients to live in a safe environment, abuse will not be tolerated in the facility and there is a zero tolerance against this. Every measure will be put in place to prevent the occurrence of abuse to any client. Immediately ensure clients health and safety. Upon witnessing or suspecting any type of abuse to a client, employee will report the suspicion of abuse to the facility?s QIDP, nurse, and Administrator immediately. The alleged perpetrator will be suspended immediately pending the result of an investigation in order to ensure that there is no further harm or endangerment to the client.
The facility staff failed to:
1. Report an allegation of abuse immediately to the administrative staff and the department. Client 1 reported to facility staff that the HL touched her inappropriately when she was home alone in the facility with him (HL). This failure of not reporting an incident, of alleged abuse, jeopardized Client 1's safety and her well-being.
2. Implement their Abuse policy and procedure when Client 1 reported to the facility?s staff that the HL had touched her inappropriately on several occasions.
The above violation had a direct relationship to the health, safety and or security of the client(s). |
| 240000029 |
Mill Creek Manor |
240013671 |
A |
7-Dec-17 |
64U711 |
8331 |
REGULATION VIOLATION
Title XXII 72311 (a) (2) Nursing Service - General
(a) Nursing service shall include, but not limited to, the following:
(2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.
FINDINGS
The facility failed to implement their care plan for one of the three sampled patients (Patient A) who was known to the facility staff for wandering into other patient's rooms and for grabbing snacks and putting them in his mouth.
This failure resulted in Patient A wandering into another patient's room, where he grabbed a sandwich, choked and collapsed. Patient A required cardiopulmonary resuscitation (CPR- an emergency procedure in which the heart and lungs are made to work by compressing the chest overlying the heart and forcing air into the lungs) and is now on a ventilator (a machine that helps someone breathe) in the acute care hospital.
The clinical record for Patient A was reviewed. A document titled, "Admission Record" dated October 13, 2017, indicated Patient A was admitted on June 8, 2015, with diagnoses of dementia (a condition of progressive memory loss), schizophrenia (a mental condition with distorted thought disorder), and depression.
During an interview with Certified Nursing Assistant 1 (CNA 1) on October 13, 2017 at 9:45 AM, she stated, "He [Patient A] goes to everybody's room, gets other patient's food and had been doing that for a long time. He was not on one on one supervision."
During an interview with CNA 2 on October 13, 2017 at 3:30 PM, he stated, "He goes from room to room. He gets trays from other patients during mealtime. Only the nurse on the floor supervises a section of the facility. He needs a one on one supervision."
A review of Patient A's care plans reflected Patient A had been identified as being at risk for choking and had three episodes of choking as follows:
a. Care plan dated March 17, 2016, reflected Patient A "...grabbing snacks from cart, will put all snacks in his mouth at one time." All interventions listed were related to attendance at activities, not at redirecting Patient A's behavior.
b. A care plan titled, "Alteration in nutrition-risk for choking", initiated November 18, 2016, listed two incidents.
1. October 6, 2017, "choked on fish," interventions included diet changed to regular, chopped, no bread. Interventions included "Removed resident's [patient's] tray and asked kitchen to chop up all of resident's [patient's] food to help prevent him from choking. Will continue to encourage to eat in dining room, eat slowly, take smaller bites and thoroughly chew his food. Encourage resident [patient] to stay in the dining room to eat his meals so that he can be closely monitored while eating as he is at risk for choking. He is impulsive and eats in a hurried manner; he walks while eating and does not like to stay in one place for very long. Diet was changed to regular, chopped diet, no bread."
2. October 8, 2017, "choked on P and J (peanut butter and jelly) sandwich."
c. Care plan dated August 25, 2017, (after the first choking incident) "Patient (Patient A) at risk for choking, impulsive, eats fast." There were no documented interventions added until after the third choking incident on October 8, 2017, when the following interventions was added: "Encourage resident [patient] to eat in dining room so that he can be closely supervised while eating as he is impulsive and eats his food very fast in large bites."
d. Care plan dated September 30, 2017, indicated, "... physical aggression, taking trays out of other resident's hands..." The interventions addressed his dementia and indicated staff were to "Redirect resident [patient] from taking other residents' trays or other food that has not been given to him by staff, as it may not be on his prescribed diet."
Further review of Patient A's care plans indicated a behavior care plan initiated August 14, 2016, for "wandering." Interventions included "Will go in and out of other residents' [patient's] room. Intervene as appropriate."
The clinical record of Patient A was reviewed. A document titled, "Speech therapy" dated August 31, 2017, indicated, "...Patient demonstrates significant confusion and is unable to follow commands. During PO (oral) trials, patient accepted food from ST (speech therapy) and started to walk, could not be redirected to sit. Patient is at risk for choking on regular texture due to possible attempt to swallow inadequately formed food bolus. Will continue with mechanical soft, ground texture and thin liquids for all oral intakes. Will benefit from supervision during all oral intakes to ensure slow rate of feeding and bolus size modification (size of bites)... Recommendations: Supervision for oral intake=close supervision ...To facilitate safety and efficiency, it is recommended the patient use the following strategies or maneuvers during oral intake: general swallow techniques/precautions, alternation of liquid/solids, bolus size modifications and rate modification, upright posture during meals and upright for > (greater than) 30 minutes after meals."
A review of the physician's orders for Patient A indicated on September 7, 2017, the physician ordered for RNA (restorative nursing aide-CNAS with specialized rehabilitation training) dining program, supervised three times a day for RNA feeding supervision.
During a review of the clinical record of Patient A from the acute care hospital dated August 25, 2017, a document titled "Patient Notes" indicated,"...Pt was seen choking by an RT (respiratory therapist), and Heimlich (emergency remove foreign object from the mouth) was attempted which was unsuccessful ...CPR was initiated ...foreign object was removed ..."
A review of the clinical record for Patient A from the acute care hospital where he was transferred on October 8, 2017, was conducted. A document titled "Hospital course" indicated, " ... [Patient A] has been known to take food from other patients in the facility ...He has issues with choking and apparently choked while eating. The staff found the patient, unresponsive and called 911. When paramedics arrived, the patient was in full arrest (not breathing, no pulse)...Patient was intubated and CPR was performed. After 25-30 minutes there was return of spontaneous circulation ...He underwent a bronchoscopy (a procedure to check the airways) with removal of the food particles from the tracheo-bronchial tree (airways going to lungs) ...He remains intubated on mechanical ventilation (machine that helps patient breathe) ...patient has remained comatose (deep unconsciousness for prolonged or indefinite period, especially as a result of severe injury or illness).
During an interview with the Director of Nursing (DON) on October 13, 2017 at 3:00 PM, she stated, Patient A preferred to eat in his room during mealtimes and was not on one to one supervision. Only the nurse assigned on the floor supervised the rest of the patients who ate in their rooms. She stated the speech therapist did not have an in-service with the staff about his recommendations, after Patient A's first choking incident.
The facility policy and procedure titled, "Assistance with Meals," dated November 2010, indicated, "Residents [patients] shall receive assistance with meals in a manner that meets the individual needs of each residents."
Because the facility failed to implement their care plan for one of three sampled patients (Patient A) for wandering into other patients' rooms and for grabbing snacks and putting them in his mouth, and failed to ensure Patient A received assistance with meals specific to his needs he suffered three incidents of choking. Two of these incidents required Patient A to have cardiopulmonary resuscitation (CPR-an emergency procedure in which the heart and lungs are made to work by compressing the chest overlying the heart and forcing air into the lungs) and Patient A is now on a ventilator (a machine that helps someone breathe) in the acute care hospital.
These facility failures presented either (1) imminent danger that death or serious harm to the patients of the long-term health care facility would result therefrom; or long-term health care facility would result therefrom. |
| 950000073 |
Monrovia Post Acute |
950013566 |
B |
24-Oct-17 |
QHWG11 |
8961 |
? 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).
? 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.
During a recertification survey on 9/12/17, it was found during record review that Resident 9 sustained an abrasion (area damaged by scraping or wearing away) to his forehead on 7/14/17 at 9:15 p.m.
Based on observation, interview, and record review, the facility failed to implement their abuse policies and procedures by failing to:
1. Thoroughly investigate an injury of unknown origin for Resident 9.
2. Send a written notification to the CDPH (California Department of Public Health), Licensing and Certification Agency, within 24 hours of an incident of Resident 9?s injury of unknown origin.
A review of the face sheet (admission record) for Resident 9 indicated that the resident was admitted to the facility on 5/11/15, with diagnoses that included heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs), difficulty walking, chronic kidney disease (condition characterized by a gradual loss of kidney function over time) and lack of coordination.
A review of the quarterly Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 8/3/17 indicated Resident 9?s cognition was severely impaired. Resident 9 had limited ability to make concrete requests and responded adequately to simple and direct communication only. Resident 9?s vision was highly impaired. Resident 9 required extensive assistance (resident involved in activity, staff provide weight bearing support) in bed mobility, transfers, walking in room and walking in corridor, dressing and personal hygiene. Resident 9 was totally dependent in locomotion on and off unit, eating and toilet use. Resident 9 required one person physical assist in performing all of his activities of daily living (ADL).
A review of Resident 9?s physician?s order dated 8/31/15 indicated that the resident may have both « side rails up for bed mobility and positioning.
A review of Resident 9?s SBAR (Situation, Background, Assessment, and Recommendation) - Acute COC (Change of Condition) communication form, indicated on 7/14/17 at 9:15 p.m., the resident was noted with an abrasion on the forehead. Resident 9 was unable to recall what happened and how he sustained the abrasion on his forehead.
A review of Resident 9?s physician?s orders dated 7/14/17 indicated the following telephone orders:
-X-ray of the skull due to abrasion on forehead.
-Forehead abrasion: cleanse with normal saline, pat dry, apply triple antibiotic ointment (TAO), and leave open to air (LOA) daily x 14 days.
-Monitor skin discoloration daily x 30days.
-May have padded side rails.
A review of Resident 9?s Licensed Personnel Progress Notes indicated the following:
On 7/15/17 at 9:30 p.m., the resident was noted with an abrasion on the middle lower forehead with purple and bluish discoloration on the surrounding area.
On 7/16/17 at 9:00 p.m., resident was still noted with purple greenish discoloration on the surrounding area.
On 7/17/17 at 10:00 a.m. the resident was on monitoring regarding abrasion and bluish discoloration.
On 7/17/17 at 6:00 p.m. resident was on monitoring for abrasion on forehead.
On 7/26/17 at 3:00pm, resident was noted with resolved forehead abrasion/discoloration.
A review of Resident 9?s X-ray report of the skull done on 7/15/17 indicated no evidence of an acute skull fracture.
On 9/13/17 at 3:50 p.m., an interview was conducted with Certified Nursing Assistant 1 (CNA 1) who stated on 7/14/17 at approximately 8:00-9:00 p.m., he went to check on the resident and saw an abrasion on his forehead. CNA 1 described the abrasion as red in color, with ?little blood?, approximately 1 and « inches in length. CNA 1 indicated he found Resident 9 sitting on the bed with both half side rails up and both feet were dangling from the bed. CNA 1 stated the side rails were unpadded. CNA 1 stated nobody saw the incident how Resident 9 got the abrasion on his forehead. CNA 1 stated Resident 9 was unable to tell how he sustained the abrasion on his forehead. CNA 1 stated he immediately notified his charge nurse of the incident.
On 9/14/17 at 7:30 a.m., an interview was conducted with the MDS coordinator who stated the side rails were ordered for Resident 9 for mobility as he was able to hold and use the bedrails to aid in mobility and positioning. MDS coordinator stated Resident 9 may have hit his forehead on the side rails but nobody witnessed it.
On 9/14/17 at 9:20 a.m., an interview was conducted with the facility?s director of nursing (DON) who stated the incident happened before she started working in the facility. DON indicated based on documentation, the incident was unwitnessed and is considered an injury of unknown origin and should have been reported to the Department of Public Health (DPH) for investigation. DON indicated there was no documented evidence that the facility fully investigated the incident.
On 9/14/17 at 9:25a.m., an interview was conducted with the facility?s administrator. The administrator indicated he started working in the facility on 6/19/17 and the incident happened on 7/14/17. The administrator indicated there was an incident report but he could not recall a full investigation was conducted. The administrator stated? I cannot remember the incident in detail as I was still acclimating to the facility when the incident happened?.
On 9/14/17 at 10:20 a.m., Resident 9 was observed up on wheelchair in his room with oxygen inhalation running at 2 liters per minute via nasal cannula (tubing used to deliver oxygen through the nares). Resident 9 was observed awake, calm and alert but was unable to form meaningful conversation. Resident 9 mumbled to self with rambling speech when interviewed.
On 9/14/17 at 10:30 a.m., an interview was conducted with Resident 9. Resident 9 was unable to recall the incident that happened on 7/14/17.
On 9/14/17 at 10:40 a.m., an interview was conducted with Resident 9?s roommate who stated he does not have any information about Resident 9?s abrasion on his forehead.
On 9/15/17 at 1:55 p.m., an interview was conducted with the DON and Administrator of the facility. Both staff indicated an investigation was conducted on 9/14/17 and 9/15/17 to follow up the incident that happened to Resident 9 on 7/14/17. The facility concluded the incident was an unwitnessed injury, a thorough investigation should have been done by the facility and the incident should have been reported immediately to DPH for investigation. DON and Administrator stated based on the recently conducted facility investigation; there was no abuse incident that happened to Resident 9.
A review of the facility?s policy and procedure titled ?Abuse Prevention Program,? revised August 2006, indicated the facility?s abuse prevention program provides policies and procedures that govern, as a minimum: (f) timely and thorough investigation of all reports and allegations of abuse.
A review of the facility?s policy and procedure titled? Reporting Abuse to State and Other Entities/Individuals?, revised December 2009 indicated all suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individual as may be required by law. Should a suspected violation or substantiated incident of mistreatment, neglect , injuries of an unknown source or abuse (including resident to resident abuse) be reported, the facility Administrator or his/her designee, will, promptly notify the following persons or agencies (verbally and written) of such incident (a) the State Licensing/Certification agency responsible for surveying /licensing the facility. The administrator or his/her designee will provide the appropriate agencies or individuals with written report of the findings of the investigation within 5 working days of the occurrence of the incident.
The facility failed to implement their abuse policies and procedures by failing to:
1. Thoroughly investigate an injury of unknown origin for Resident 9.
2. Send a written notification of to the DHS (Department of Health Services) (State survey and certification agency) agency within 24 hours of an incident of Resident 9?s injury of unknown origin.
These violations had a direct relationship to the health, safety, or security of the resident. |
| 950000076 |
Monterey Healthcare & Wellness Centre, LP |
950013632 |
B |
17-Nov-17 |
R7MN11 |
4373 |
F323
?483.25(d) Accidents.
The facility must ensure that ?
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
The Department received an entity reported incident (ERI) on 9/18/17, alleging that a resident (Resident 15) spat on Resident 4 and 5. Resident 4 did not like Resident 15's action and punched him in the mouth. Resident 15 sustained a laceration to the lower lip.
The facility failed to provide adequate supervision for residents with special needs during a smoking break on 9/17/17 at 4:15 p.m., which resulted to a resident to resident altercations. Resident 15 lost a tooth and sustained a lip laceration that needed stitches. The Facility's Abuse-Prevention Program Policy and Procedures to maintain adequate staffing on all shifts was not implemented to ensure that the needs of each resident were met.
A review of the Transfer Form, dated 9/17/17 at 6:00 p.m., indicated Resident 15 was transferred to the General Acute Care Hospital (GACH) for lower lip injury and one broken tooth. The GACH notes, dated 9/17/17 at 8:22 p.m., indicated Resident 15 received stitches (medical thread used to close a cut or wound on the skin).
A review of Resident 15's Admission Record indicated the resident was admitted to the facility on 8/11/17, with diagnoses that included Schizophrenia (a severe and chronic mental condition in which people interpret reality abnormally) and anxiety (excessive and persistent worry and fear about everyday situations).
A review of a Smoking care plan dated 8/11/17, indicated Resident 15 was safe to smoke with supervision. The intervention was to supervise resident per Facility policy while smoking.
A review of the Incident Investigation dated 9/18/17, indicated on 9/17/17, at 4:15 p.m., the certified nursing assistant (CNA) supervising the back patio heard yelling and rushed to separate the residents. The report further indicates Resident 15 got upset with Resident 5 and spat at her. Resident 4 was upset about Resident 15's action and hit him on the lip.
A Situation/Background/Appearance/Review (SBAR) communication form, dated 9/17/17 indicated Resident 15 was in the back patio before smoke break when Resident 15 spat at Resident 5 and Resident 4 did not like what Resident 15 did and punched him on the mouth. Resident 15 sustained a laceration to the middle right side of his lip and lost a central lower incisor (lower front tooth).
During a smoking break observation, on 10/5/17 at 2:15 p.m., there were a total of 26 residents in the back patio with two staff providing aprons, cigarettes and lighter. Then three additional staff came to the back patio. Supervision during the smoking break for the incident on 9/17/17 was one staff.
During a subsequent observation on 10/6/17 at 6:00 a.m., there were a total of five residents in the front patio with no staff supervision. There were three residents smoking and two ambulating around in the patio.
During an interview with CNA 4, on 10/6/17 at 9:06 a.m., he stated the day of the incident he had stayed over because the facility was short in staff. When asked about the incident he stated there were over 20 residents in the smoking patio and he was the only staff supervising the residents during the smoking break. CNA 4 further stated he was busy passing the cigarettes when he heard the altercation. CNA 4 was busy with performing a task and was not able to prevent the altercation between the resident that resulted in injury.
A review of the facility Smoking by Residents Policy and Procedure, dated 1/17, indicated the facility would develop a smoking schedule to ensure a safe environment and residents who require assistance and monitoring while smoking are not allowed to smoke unaccompanied.
The facility failed to provide adequate supervision for residents with special needs during a smoking break as indicated in the Facility's Abuse-Prevention Program Policy and Procedures. The Policy indicated to maintain adequate staffing on all shifts to ensure that the needs of each resident are met. This resulted in a resident to resident altercations with Resident 4, 5 and 15. Resident 15 lost a tooth and sustained a lip laceration that required stitches.
This violation had a direct relationship to the health, safety and security of residents. |
| 950000076 |
Monterey Healthcare & Wellness Centre, LP |
950013631 |
B |
17-Nov-17 |
R7MN11 |
5308 |
Class B Citation
F225
?483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
(2) Have evidence that all alleged violations are thoroughly investigated.
(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
On 10/3/17 at 10:50 a.m., an unannounced visit was made to the facility to investigate an entity reported incident (ERI) regarding resident-to-resident altercation between Resident 3 and Resident 15. The ERI indicated Resident 3 pushed Resident 15 to the floor for no reason by the East Wing Nursing Station.
The facility failed to ensure that an allegation of abuse was reported to the State Survey Agency immediately or not later than 24 hours for one facility reported incidents in accordance with the State law and the facility's policy and procedures. This deficient practice had the potential to put the resident's safety at risk due to under reporting alleged cases of resident abuse and/or failing to investigate resident abuse in a timely manner.
A review of Resident 3's Admission Record indicated the resident was admitted to the facility on 8/31/17 and readmitted on 9/28/17, with diagnoses that included Schizoaffective disorder with bipolar disorder (a mental disorder in which a person experiences a combination of schizophrenia [a severe and chronic mental condition in which people interpret reality abnormally] symptoms, such as hallucinations [a sensory experience of something that does not exist outside the mind, caused by various physical and mental disorders, or by reaction to certain toxic substances, and usually manifested as visual or auditory images] or delusions [a belief that is not true], and mood disorder symptoms such as mania [mental illness marked by periods of great excitement, euphoria, delusions, and over activity] and anxiety [excessive and persistent worry and fear about everyday situations])
The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 9/7/17, indicated Resident 3 scored 11 on the brief interview for mental status (BIMS, a score of 8-12 means moderate cognitive impairment) and required limited assistance in activities of daily living. The MDS further indicated the resident had delusion (misconception or belief that is firmly held, contrary to reality)
A review of the Incident Investigation dated 9/18/17, indicated on 9/16/17, at 4:05 a.m., Resident 3 and Resident 15 had an incident in the East Nursing Station. The charge nurse was inside the nursing station when Resident 3 walked by the nursing station and yelled at Resident 15 to get out the way and suddenly pushed him. Resident 15 fell to the floor and sustained no injury.
During an interview on 10/5/17, at 10:15 a.m., the Administrator stated that there were three allegations of abuse that were investigated and reported to the department in the last three months. When asked when the incident that occurred on 9/16/17 at 4:05 a.m. was reported to the Department she stated it was reported on 9/18/17 at 2:25 p.m. because she thought the office was closed and did not fax it until Monday in the afternoon.
A review of the facility's policy and procedure titled "Abuse Reporting & Investigations" dated 11/16, indicated notification of outside agencies of allegations of abuse when no serious bodily injury should be done by the Administrator or designee to law enforcement, LTC Ombudsman, CDPH Licensing and Certification by telephone immediately or as soon as practicable and in writing SOC 341 (State of California - Report of Suspected Dependent Adult/Elder Abuse) within twenty-four hours including weekends.
The state law indicates, 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.
The facility staff failed to report a resident to resident alleged abuse incident to the department within 24 hours placing the resident's safety at risk, the potential to under report alleged cases of resident abuse and/or failure to investigate resident abuse in a timely manner.
This violation had a direct relationship to the health, safety and security of residents. |
| 950000076 |
Monterey Healthcare & Wellness Centre, LP |
950013633 |
B |
17-Nov-17 |
R7MN11 |
5827 |
F323
?483.25(d) Accidents.
The facility must ensure that ?
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On 10/3/17, at 10:50 a.m., an unannounced recertification survey visit was made to the skilled nursing facility (SNF).
The facility failed to provide adequate supervision for residents with special needs to prevent a fall by not implementing the facility?s Fall Risk Prevention and Management Care Plan. The plan indicated to provide a safe environment to residents by having sufficient supervision. On 9/7/17, Resident 2 was left alone in the front patio and fell from her wheelchair. As a result, Resident 2 sustained a laceration to the left eye brow and redness to the right knee.
During initial tour on 10/3/17 at 11:22 a.m., Resident 2 was in her wheelchair with a lap buddy (cushion used to restrain the person from rising from the wheelchair) and a wheelchair tab alarm attached to the back of her shirt. A dark discoloration was noticeable around the left eye. When asked what happened, Resident 2 stated she fell.
A review of Resident 2's Admission Record indicated Resident 2 was admitted to facility on 7/21/17 and readmitted on 9/5/17, with diagnoses that included: wedge compression fracture to T9 and T10 vertebra (fracture to the lower midlevel bone of the back/spine), anxiety (excessive and persistent worry and fear about everyday situations) and psychosis (mental health problem that causes people to perceive or interpret things differently from those around them).
A review of Resident 2's fall history indicated Resident 2 had a fall on 8/12/17, in her bedroom with no injury, and a second fall on 9/7/17 in the front patio and sustained a laceration to the left upper eye and right knee abrasion.
A review of Resident 2's History and Physical dated 9/6/17 indicated Resident 2 did have the capacity to understand and make decisions.
A review of Resident 2's Minimum Data Set (MDS), a comprehensive assessment and care screening tool, dated 7/28/17, indicated Resident 2 had a brief interview for mental status (BIMS) score of 8 (8-12 indicates moderately impaired cognition), required extensive assistance with bed mobility, transfer, dressing, personal hygiene and bathing. Resident 2 did not require a mobility device (wheelchair) during the assessment period.
During an interview with the MDS Nurse (MDSN), on 10/4/17 at 1:01 p.m., she stated Resident 2 started using a wheelchair two weeks after her admission on 7/28/17. MDSN further stated a wheelchair was provided because Resident 2 would hold on to the hallway side rails.
A review of Resident 2's Fall Risk Evaluation, dated 9/5/17 indicated Resident 2 had a fall risk scale score of 13. A score of 10 and above indicated high risk for falls.
A review of Resident 2's Fall Risk Prevention and Management care plan r/t (related to) risk and actual falls, dated 9/5/17 indicated Resident 2 will be provided a safe environment to minimize complications associated with falls.
A Situation/Background/Appearance/Review (SBAR) communication form, dated 9/7/17 indicated Resident 2 fell forward from her wheelchair while wheeling herself in the front patio. Resident 2 sustained a left eye brow laceration, 1 centimeter (cm) by 0.5 cm, and complained of pain to the left knee.
During an observation on 10/4/17 at 8:02 a.m., Resident 2 was on a wheelchair being pushed by Certified Nursing Assistant 6 (CNA 6) to the East Wing television (TV) area. CNA 6 left Resident 2 in the TV area and Resident 2 closed her eyes and began to lean forward in her wheelchair.
During an interview on 10/4/17 at 8:04 a.m., with Resident 2's routine CNA, she stated Resident 2 has a behavior of rocking in her wheelchair when she is upset. The day of the fall, she stated, Resident 2 asked staff to leave her in the patio and she was rocking when she fell.
During an observation on 10/5/17 at 8:20 a.m., there were three residents in the front patio with no staff to supervise the residents. One resident was ambulating with unsteady gait while pushing his wheelchair. The Director of Staff Development (DSD 1) was opening the front door gate when asked for the staffing assignment for the front patio. DSD 1 verified there was no staff monitoring the resident and further stated one staff should always be supervising the patio.
During a subsequent observation on 10/6/17 at 6:00 a.m., there were a total of five residents in the front patio with no staff to supervise the residents. There were three residents smoking and two ambulating around in the patio.
During a concurrent interview and review of the facility's incident investigative report with the Administrator on 10/6/17 at 1:00 p.m., she verified based on her investigation, that there was no staff supervising the front patio to prevent Resident 2's fall.
According to the Centers for Medicare & Medicaid Services (CMS) State Operation Manual revised version 168, page 355, indicates "Supervision/Adequate Supervision" refers to an intervention and means of mitigating (ability to lessen the severity) the risk of an accident.
https://www.cms.gov/Regulations-and Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
The facility failed to provide adequate supervision for residents with special needs to prevent a fall by not implementing the facility?s Fall Risk Prevention and Management Care Plan to provide a safe environment to residents by having sufficient supervision. On 9/7/17, Resident 2 was left alone in the front patio and fell from her wheelchair. As a result, Resident 2 sustained a laceration to the left eye brow and redness to the right knee.
This violation had a direct relationship to the health, safety and security of residents. |
| 250000869 |
MARIAN JAMES TRANSITIONAL HOUSE |
250013509 |
B |
5-Oct-17 |
1EX411 |
2695 |
W 127 483.420(a)(5) Ensure that clients are not subjected to physical, verbal, sexual or psychological abuse or punishment.
On May 17, 2016, at 1 p.m., an unannounced visit was made to the facility to investigate a self-reported incident. It was determined that the facility failed to ensure one client (Client A) was free from physical and verbal abuse by the direct care staff (DCS 1).
Client A, a 41-year-old female was admitted to the facility on August 5, 1999, with diagnoses including moderate intellectual disability. The "SPEECH AND LANGUAGE EVALUATION" report dated July 31, 2015, revealed Client A responded to her name, understood some yes or no questions, but was inconsistent.
Observation conducted on May 17, 2016, at 3:45 p.m., indicated Client A was alert and oriented to name only. Client A was verbal, but unable to carry a meaningful conversation. Client A walked around the house without difficulty.
On May 17, 2016, at 1:20 p.m., an interview with the Qualified Intellectual Disabilities Professional (QIDP) was conducted. The QIDP stated, Direct Care Staff (DCS) 2 reported DCS 1 tapped Client A on the left leg twice with a fly swatter, and stated, "Sit your ass down." The QIDP spoke to DCS 1, and she admitted she had used inappropriate language, and tapped Client A on her left leg with a fly swatter.
An interview was conducted with DCS 2. In addition, a written declaration was received from DCS 2 on May 17, 2016 at 2 p.m. DCS 2 stated on Monday, May 2, 2016, while in the living room, Client A pulled another client's hair. DCS 2 stated she escorted Client A to the backyard to "calm down". After 15 minutes DCS 2 and Client A went inside the house. Client A sat on the couch and began "fondling herself and trying to take her clothes off". DCS 1 got up from her chair and walked toward the kitchen and retrieved a fly swatter. DCS 1 told Client A, "You stop that, you have no respect for your housemates." DCS 2 stated she observed DCS 1 hit Client A on her left leg with a fly swatter. Client A attempted to stand up, DCS 1 hit her again on her left leg, and said, "Sit your ass down and I mean it, don't move." DCS 2 stated, she "Checked her leg, noticed it was red."
DCS 2 stated she reported the incident to the QIDP on May 5, 2016, three days after the incident occurred.
A review on May 17, 2016, of the facility's policy and procedure titled, "Abuse Prevention, Abuse Investigation and Abuse Reporting Policy and Procedure", indicated "...It is the policy of...to assure that all clients of...are protected from abuse..."
This violation had a direct relationship to the health, safety, or security of Client A. |
| 250000869 |
MARIAN JAMES TRANSITIONAL HOUSE |
250013510 |
B |
5-Oct-17 |
1EX411 |
3221 |
HSC 1418.91 (a)(b)
(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of this section shall be class "B" violation.
On May 17, 2016, at 1 p.m., an unannounced visit was made to the facility to investigate a self-reported incident. It was determined that the facility failed to report an incident of physical and verbal abuse by Direct Care Staff (DCS) 1 towards one client (Client A) to the California Department of Public Health (CDPH), Licensing and Certification (L&C) immediately or within 24 hours.
Client A, a 41-year-old female was admitted to the facility on August 5, 1999, with diagnoses including moderate intellectual disability. The "SPEECH AND LANGUAGE EVALUATION" report dated July 31, 2015, revealed Client A responded to her name, understood some yes or no questions, but was inconsistent.
Observation conducted on May 17, 2016, at 3:45 p.m., indicated Client A was alert and oriented to name only. Client A was verbal, but unable to carry a meaningful conversation. Client A walked around the house without difficulty.
On May 17, 2016, at 1:20 p.m., an interview with the Qualified Intellectual Disabilities Professional (QIDP) was conducted. The QIDP stated, Direct Care Staff (DCS) 2 reported DCS 1 tapped Client A on the left leg twice with a fly swatter, and stated, "Sit your ass down." The QIDP spoke to DCS 1, and she admitted she had used inappropriate language, and tapped Client A on her left leg with a fly swatter.
An interview was conducted with DCS 2. In addition, a written declaration was received from DCS 2 on May 17, 2016 at 2 p.m. DCS 2 stated on Monday, May 2, 2016, while in the living room, Client A pulled another client's hair. DCS 2 stated she escorted Client A to the backyard to "calm down". After 15 minutes DCS 2 and Client A went inside the house. Client A sat on the couch and began "fondling herself and trying to take her clothes off". DCS 1 got up from her chair and walked toward the kitchen and retrieved a fly swatter. DCS 1 told Client A, "You stop that, you have no respect for your housemates." DCS 2 stated she observed DCS 1 hit Client A on her left leg with a fly swatter. Client A attempted to stand up, DCS 1 hit her again on her left leg, and said, "Sit your ass down and I mean it, don't move." DCS 2 stated, she "Checked her leg noticed it was red."
DCS 2 stated she reported the incident to the QIDP on May 5, 2016, three days after the incident occurred.
A review on May 17, 2016, of the facility's policy and procedure titled, "Abuse Prevention, Abuse Investigation and Abuse Reporting" indicated "...Reporting Procedure...5. All incidents of allegeded (sic) or suspected abuse of a client of the facility will be reported to the Department of Public Health, Licensing and Certification within 24 hours..."
The facility failed to report immediately or within 24 hours to the CDPH an incident of physical and verbal abuse to Client A.
This violation had a direct relationship to the health, safety, or security of Client A. |
| 920000009 |
MACLAY HEALTHCARE CENTER |
920013626 |
A |
17-Nov-17 |
GDN112 |
10069 |
?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.
?483.25(d) Accidents.
The facility must ensure that ?
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On October 11, 2017, at 11:40 a.m., during revisit survey, Resident 36 fall was investigated.
Based on observation, interview, and record review, the facility failed to ensure its residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, and failed to ensure its residents receive adequate supervision and assistance devices to prevent accidents and injury, including;
1. Failure to develop a comprehensive resident centered plan of care that included in the interventions the method of transferring Resident 36, the need to provide two-person physical assist, and the use of a mechanical or electronic lifting device to safely transfer Residents 36 in and out of bed or chair
2. Failure to implement the facility's policy and procedure on Safe Lifting and Movement of Residents by not using appropriate techniques and devices (mechanical lifting devices) to lift and move residents and by not documenting in the plan of care Resident 36's transferring and lifting needs.
As a result, on September 25, 2017, when Certified Nursing Assistant 10 (CNA 10) was transferring Resident 36 without the assistance of another staff and without the use of a mechanical transferring device, Resident 36 fell to the floor, requiring emergency transfer to a General Acute Care Hospital (GACH) for evaluation and treatment. Resident 36 was diagnosed with a fracture (broken bone) of the left humeral neck (upper part of the long bone of the arm), required application of a left arm sling, the use of a back brace while up in the wheelchair, and the administration of Norco (a narcotic medication that treats moderate and severe pain).
On October 11, 2017, at 11:40 a.m., Resident 36 was observed with arm sling on her left arm, sleeping in a low-position bed with a landing pad on the floor at the right side of the bed.
A review of the Admission Record indicated Resident 36 was originally admitted to the facility on August 11, 2015, with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (half of the body is weakened or has suffered partial loss of movement) following a stroke.
A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool), dated August 12, 2017, indicated Resident 36 had limited ability to communicate, was unable to walk, and was totally dependent (full staff performance) with two or more persons physically assisting with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and transfers (how resident moves between surfaces including to and from: bed, chair, wheelchair, standing position).
A review of Resident 36's Fall Risk Assessment dated August 12, 2017, indicated Resident 36 had moderate risk for fall.
A review of Resident 36's nursing Weekly Summary dated September 5, 2017, indicated the resident's functional status for transfer (how resident moves between surfaces including to or from bed, chair, standing position) was totally dependent.
A review of the Care Plan initiated on August 11, 2015, for Resident 36's fall risk re-evaluated every three months, had a goal for Resident 36 not to have incidents of falls/injury. The interventions included to supervise/assist with transfers and ambulation, and to use transfer/lift equipment as indicated.
A review of a care plan dated August 12, 2017, for Residents 36's risk for fall related to stroke with left sided weakness, had a goal for the number of falls to decrease during the next 90 days. The interventions included assist Resident 36 with transfers/mobility as needed. The care plan did not specify a method of transfer to be used by the nursing staff based on Resident 36's size, weight, mobility status, and weight bearing ability, in order to ensure safety during transfers.
A review of Resident 36's SBAR (Situation - Background - Assessment - Recommendation) communication form and Progress Note dated September 25, 2017, with no unspecified time, indicated Resident 36 had an incident of a fall while CNA 10 was transferring the resident alone from the bed to a shower chair.
A review of the Nurse Progress notes dated September 25, 2017, timed at 8:50 a.m. indicated Resident 36 complained of severe pain to the left shoulder and right hip after the incident. The note indicated the resident was observed having facial grimaces and grunting when trying to touch the affected area. Resident 36 continuously complained of severe pain and paramedics (911 - emergency number) was called. Resident 36 was transferred to a GACH.
A review of Resident 36?s clinical record from the GACH, x-rays of the left shoulder, arm and wrist, dated September 25, 2017, timed at 12:58 p.m., indicated Resident 36 sustained fracture of the left humeral neck (shoulder). Resident 36 had an arm sling on her left arm and returned to the facility on September 26, 2017.
A review of Resident 36?s readmission physician order dated September 26, 2017 indicated Norco 325 milligrams one tablet every six hours as needed (PRN) for moderate pain not to exceed three grams in 24-hours. Back brace to be applied when in up the wheelchair and non-weight bearing to left upper extremities.
A review of Resident 36?s Pain Assessment Flow Sheet from September 27, 2017 to October 11, 2017 indicated the resident received Norco 20 times for very severe pain, pain level of 7 to 8/10 (zero no pain, and 10/10 worst pain) to the left shoulder and back pain.
On October 11, 2017, 2:42 p.m., during an interview, CNA 10 stated she was assigned to Resident 36 on the day of the fall (September 25, 2017). Resident 36 was scheduled for shower on that day and at around 8:30 a.m., she tried to transfer Resident 36 from bed to shower chair by herself. However, when she lifted Resident 36 from the bed, was too heavy for her and she, CNA 10, could not complete the transfer and Resident 36 fell to the floor. CNA 10 stated she was not sure how the resident was previously transferred.
On October 11, 2017, at 3:30 p.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated she was the charge nurse on duty when Resident 36 fell. LVN 4 stated at the start of the shift she gave endorsement to her CNAs regarding their assigned residents. LVN 4 stated she told to CNA 10, Resident 36 needs two-person assist with transfers. LVN 4 stated CNA 10 should have used a mechanical lift.
On October 12, 2017 at 8:46 a.m., during a record review and concurrent interview, Physical Therapist 1 (PT 1) stated Resident 36 required maximum assistant for bed mobility and two-person assist and she usually recommends the use of a mechanical lift for totally dependent and heavy residents.
On October 12, 2017 at 9:40 a.m., during a record review and an interview, the Assistant Director of Nursing (ADON) stated she could not find in Resident 36's clinical record documentation addressing the need to use of the mechanical lift with two-person assistance when transferring Resident 36 in and out of bed or chair. The ADON stated the plan of care did not reflect transfer and lifting needs as indicated in the facility policy.
A review of the facility's policy and procedure titled, "Safe lifting and Movement of Residents," dated December 2013, indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this uses appropriate techniques and devices to lift and move residents. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Staff will document resident transferring and lifting needs in the care plan. Such assessment includes resident's preferences for assistance, resident's mobility, size, and weight bearing ability.
The facility failed to ensure its residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, and failed to ensure its residents receive adequate supervision and assistance devices to prevent accidents and injury, including;
1. Failure to develop a comprehensive resident centered plan of care that included in the interventions the method of transferring Resident 36, the need to provide two-person physical assist, and the use of a mechanical or electronic lifting device to safely transfer Residents 36 in and out of bed or chair
2. Failure to implement the facility's policy and procedure on Safe Lifting and Movement of Residents by not using appropriate techniques and devices to lift and move residents and by not documenting in the plan of care Resident 36's transferring and lifting needs.
As a result, on September 25, 2017, when CNA 10 was transferring Resident 36 without the assistance of another staff and without the use of a mechanical transferring device, Resident 36 fell to the floor, requiring emergency transfer to a GACH for evaluation and treatment. Resident 36 was diagnosed with a fracture of the left humeral neck, required application of a left arm sling, the use of a back brace while up in the wheelchair, and the adminstration of Norco.
The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 36. |
| 920000009 |
MACLAY HEALTHCARE CENTER |
920013516 |
B |
22-Sep-17 |
None |
9979 |
?483.12(a) The facility must?
?483.12(c)
(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
(2) Have evidence that all alleged violations are thoroughly investigated.
(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
On August 8, 2017, during an annual survey an Entity Reported Incident (ERI) was investigated regarding Resident 1?s injury of an unknown origin.
Based on interview and record review, the Department determined the facility failed to ensure all injuries of unknown source are reported immediately, but no later than two (2) hours after the event results in serious bodily injury, or no later than 24 hours if the event do not involve serious bodily injury, to the State Survey Agency, and the facility failed to thoroughly investigate an injury of unknown source, including:
1. Failure to conduct a thorough assessment of Resident 1's right hip pain to determine if an injury had occurred.
2. Failure to implement the facility's policy and procedure on Abuse Investigations by not thoroughly and promptly investigating and reporting Resident 1?s injury of unknown origin.
3. Failure to report immediately to the State Survey Agency (Department of Public Health), as soon as possible but not to exceed 24 hours after discovery of the injury of unknown origin.
As a result, Resident 1's right femoral neck (right hip) comminuted (multiple bone splinters) mildly displaced (abnormal position) fracture (broken bone) was not promptly identified (20 hours) delaying needed medical intervention.
A review of the Admission Record, indicated Resident 1 was originally admitted to the facility on March 27, 2014, and re-admitted on August 2, 2017, with diagnoses including diabetes mellitus (high blood sugar), stroke, and hemiplegia (paralysis of one side of the body).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated May 5, 2017, indicated Resident 1 was unable to make decisions, did not have mood or behavioral problems, and was totally dependent on staff for transfers, dressing, toilet use, personal hygiene, and bathing. Resident 1 had limitation of movement on both sides of upper and lower extremities.
A review of Resident 1's Nurse's Notes dated July 25, 2017, timed at 11:10 p.m., indicated Resident 1 was noted during the shift to have right leg pain and was being monitored. Medication for pain was given as needed and as ordered. There was no documentation addressing an assessment of the right leg (color of the skin, presence of swelling, tenderness, bruising, temperature, specific location the pain, joint mobility, etc.) to determine a probable cause of the pain. There was no documentation Resident 1 had sustained a fall or an injury to the right leg.
A review of the Certified Nursing Assistant (CNA) - ADL (activities of daily living) tracking form indicated Resident 1 was last transferred into a wheelchair on July 25, 2017, during the 7 a.m. to 3 p.m. shift. There were no entries on the CNA tracking form of July 25, 2017, to indicate a fall or accident took place or was reported to the licensed nurses.
A physician's order dated July 25, 2017, timed at 2 p.m., indicated to do a venous Doppler (an ultrasound that uses sound waves to produce images) of the right leg due to complaints of pain manifested by facial grimacing (facial expression indicative of pain).
There was no indication in the Nurse?s Notes, Progress Notes or Pain Assessment form of July 25, 2017 or July 26, 2017, nursing staff attempted to determine the source of Resident 1?s right leg pain and if there was a sign of trauma (bruising, swelling, tender area).
A physician's order dated July 26, 2017, timed at 10 a.m., indicated to transfer Resident 1 to a General Acute Care Hospital (GACH) for evaluation of the right leg pain.
A review of the History and Physical (H&P) examination from the GACH dated July 26, 2017, indicated Resident 1?s chief complaint was acute right hip pain. Resident 1 was evaluated due to significant pain to the hip area and x-ray disclosed a right hip comminuted mildly displaced fracture.
A review of the Physician's Progress Note dated July 31, 2017, indicated Resident 1's family members wanted to treat the injury with non-operative means (no surgery).
Resident 1 was readmitted to the facility on August 2, 2017.
On August 10, 2017, at 7:10 a.m., during an interview, Resident 1, who was alert and oriented to name and place, stated CNA 1 was with her when she fell onto the floor from her wheelchair. Resident 1 could not specify the date of the fall.
On August 10, 2017, at 8:37 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on July 25, 2017 at 1 p.m., Resident 1 was holding her right leg and was moaning and saying, "Pain, pain, pain" repeatedly and he notified the physician, and received an ordered a venous Doppler. LVN 1 stated he was not aware of a fall incident.
On August 10, 2017, at 9 a.m., during an interview, the Director of Nurses (DON) stated there was no report Resident 1 had any fall incident. The DON stated Resident 1 had an injury of an unknown origin.
According to the facility's policy and procedure titled "Abuse Investigations" dated April 2014, indicated all reports of injuries of unknown source shall be thoroughly and promptly investigated by facility management. The individual conducting the investigation will as a minimum included to review the resident's medical record to determine events leading up to the incident, interview any witnesses to the incident, interview the resident (as medically appropriate), interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, interview the resident's roommate, family members, and visitors, interview other residents to whom the accused employee provides care or services, and review all events leading up to the alleged incident. The investigator will give a copy of the completed documentation to the Administrator. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five working days of the reported incident. Residents, family members, ombudsmen, state agencies, etc. will be notified of the findings.
On August 10, 2017, at 10 a.m., 16 days after the Resident 1?s initial complaint of pain, during an interview, the Administrator stated the investigation about Resident 1?s injury was not completed and she had reported Resident 1?s injury to the Department on August 5, 2017. The Administrator submitted a copy of the investigation which did not include interviews with the resident, resident's roommates, other residents, and licensed staff members.
A review of Resident 1's facility's investigation report dated August 11, 2017, nine days after the resident was readmitted to the facility with the diagnosis of right hip fracture, indicated Resident 1 was interviewed by the Administrator. Resident 1 stated CNA 1 transferred her to the wheelchair but Resident 1?s foot slipped on water (spilled on the floor) and she (Resident 1) fell to the floor. CNA 1 put her back on the bed, then, CNA 1 transferred Resident 1 (a second time) to the wheelchair. Resident 1 stated when she was transferred back to the bed that day, she felt pain. The investigation concluded CNA 1 did not report the accident to the Charge Nurse (LVN 1) or the Registered Nurse (RN) supervisor and terminated CNA 1.
The facility failed to ensure all injuries of unknown source are reported immediately, but no later than two (2) hours after the event results in serious bodily injury, or no later than 24 hours if the event do not involve serious bodily injury, to the State Survey Agency, and the facility failed to thoroughly investigate an injury of unknown source, including:
1. Failure to conduct a thorough assessment of Resident 1's right hip pain to determine if an injury had occurred.
2. Failure to implement the facility's policy and procedure on Abuse Investigations by not thoroughly and promptly investigating and reporting Resident 1?s injury of unknown origin.
3. Failure to report immediately to the State Survey Agency (Department of Public Health), as soon as possible but not to exceed 24 hours after discovery of the injury of unknown origin.
As a result, Resident 1's right femoral neck (right hip) comminuted (multiple bone splinters) mildly displaced (abnormal position) fracture (broken bone) was not promptly identified (20 hours) delaying needed medical intervention.
The above violation had a direct or immediate relationship to the health, safety, or security of Residents 1. |