| 030000019 |
Norwood Pines Alzheimers Center |
030009124 |
B |
15-Mar-12 |
SVZE11 |
11742 |
72311 - Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (C) An unusual occurrence involving a patient, as defined in Section 72541. 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. An unannounced visit was made on 4/15/09 at 2 p.m. to initiate a facility reported event (CA00184760) concerning abuse of Patient 1. The report identified a reported event of Patient 2 being witnessed by staff hitting Patient 1 on the head with his belt buckle. As a result of the investigation, it was determined the facility failed to:1. Provide a safe environment for Patient 1 free from physical abuse. 2. Follow their policy to protect Patient 1 from physical abuse. 3. Review and revise the care plan to supervise Patient 2 to prevent Patient 1 from physical abuse by Patient 2. These failures resulted in a witnessed physical abuse from Patient 2 toward Patient 1 when Patient 2 was observed hitting Patient 1 over the head repeatedly with a belt buckle. Patient 1 required an emergency transport to the GACH (General Acute Care Hospital) for further evaluation and treatment of his injuries. On 4/15/09 at 2p.m. a tour was taken of the facility while accompanied by the DON (Director of Nursing). Patient 1 was in his room lying on his bed. When introduced to Patient 1, there was no verbal response. Patient 1 appeared awake but had no verbal communication. Patient 1 had a few puncture wounds to the top of his head. When questioned about what happened to his head, Patient 1 had no response. The DON confirmed Patient 2 had been transferred to another facility.The clinical record for Patient 1 indicated he was admitted to the facility on 11/16/05 with a readmission on 4/14/09. Patient 1's diagnoses included; Alzheimer's type dementia and seizure disorder. The most recent change in condition MDS (Minimum Data Set-an assessment tool to guide the care plan) dated 12/10/08 indicated both short and long term memory problems, he was rarely understood by others with episodes of disorganized speech and he rarely/never understood others. Patient 1 was completely dependent and required extensive assistance with activities of daily living including assistance with feeding during meal times. Patient 1 was not his own responsible party and his mother made decisions regarding his care. A review of Patient 1's clinical record on 04/15/09 was conducted. The Nurse's Note dated 4/8/09 indicated the following note: "Room change attempted as a safety measure for patient d/t (due to) roommate (Patient 2) with increased agitation. RP (responsible party) notified declined room change. Patient remains in original room/bed." There was no documentation found regarding moving Patient 2 to another room or care plan updates for Patient 1 or Patient 2.Patient 1's Nurse's Note dated 4/13/09 indicated, "Patient had peer altercation with another male patient (Patient 2). This patient sustained injuries to top of head-laceration, abrasion to left shoulder top, redness top of back near back of the neck. Injuries are sustained after another resident (Patient 2) assaulted this patient with a belt." The IDT (Interdisciplinary Team) note dated 4/14/09 indicated, "On 4/13/09 resident (Patient 1) was found sitting on wheelchair being hit with belt by male roommate (Patient 2). As C. N. A. (Certified Nurses Assistant) heard patient yell after slapping sounds, she went to room and found male peer (Patient 2) hitting Patient 1 with belt. Staff called for help and separated patients immediately. Upon assessment, patient (Patient 1) was noted to have a skin abrasion to left shoulder, belt mark on upper back, discoloration to right shoulder, top and right side of head, left forehead. No changes in level of consciousness...sent to ER for evaluation... Peer (Patient 2) has history of increased agitation, aggressive behavior..." A review of the GACH (General Acute Care Hospital) clinical record for Patient 1 indicated he had a diagnosis of mild scalp trauma. The wounds were cleansed and a tetanus booster was given. Patient 1 was transferred back to the facility.Patient 2 was admitted to the facility on 11/26/08 with diagnoses including; senile dementia, psychosis, and difficulty walking. The most recent quarterly MDS dated 3/6/09 indicated the following information: Patient 2 had a short and long term memory problems, he was moderately impaired with decision making and he required limited assistance with his activities of daily living. Patient 2 had persistent anger with others which occurred up to five days a week. He was verbally abusive toward others, physically abusive toward others and resisted care up to 3 days in a 7 day time period. Patient 2 was not his own responsible party and his son made decisions involving his care needs. A Care Plan for Patient 2 dated 4/9/09, indicated the following approach, "3. Monitor every shift closely." There was no documentation indicating safety measures for Patient 2 such as 1:1 observations. Patient 2's Care Plan titled, Alteration in Mood, dated 3/31/09 indicated the following information: "Problem- Attempted to stab caregiver. Goal- Plastic wear for meals." There was no document indicating a care plan that included keeping Patient 2 and other residents safe in the facility or following the facility policy for 1:1 observations.Patient 2's Care Plan titled, Short Term Goals dated 4/2/09 indicated the following information: Problem- "Patient has peer altercation with another male patient... Approach plan- put on every 15 minutes checks..."Patient 2's Care Plan titled, Behavior Symptoms, dated 4/2/09 indicated the following information; "Problems- Paranoia and suspiciousness may increase striking out behavior. Goal- Will decrease striking out to 2 times per week in 90 days." There was no documentation indicating a care plan for safety of Patient 2 and other patients in the facility such as 1:1 observations.A Social Services note indicated the following; "3/23/09- It was reported by nursing 3/22/09 that this patient (Patient 2) hit another patient in the back of the head. 4/2/09- Reported 4/2/09 by nursing that this patient (Patient 2) was involved in an altercation with another patient. 4/14/09- Reported by nursing on 4/13/09 patient to patient roommate involved in peer altercation. Patient was witnessed hitting roommate with a belt. Patients separated immediately and belt confiscated. Patient out to acute secondary to excessive aggressiveness." An Observation Sheet dated 4/12/09 was the document to record the Q (every) 15 minute checks of Patient 2. These documented Q 15 minute checks had been discontinued prior to the altercation without a physician's order.An interview was conducted on 4/15/09 at 2:40 p.m. with the facility BT (Behavioral Therapist). BT stated Patient 2 had episodes of "explosive behaviors". She stated medications had been adjusted with no avail. BT further stated the level of psychosis Patient 2 experienced was not safe for him or the other patients in the facility. On 4/15/09 at 2:50 p.m. an interview was conducted with the facility Administrator. The Administrator stated the type of psychosis Patient 2 was experiencing was beyond the care that could safely be provided in the facility. Patient 2 had "extreme psychosis" which made it unsafe for him, staff and other patients in the facility.On 4/15/09 at 3:40 p.m., an interview was conducted with the DON (Director of Nursing). When questioned about the Q 15 minute checks for Patient 2, the DON stated the staff was to assess Patient 2's whereabouts and his behavior and document them on the Observation Sheet. She further stated she was unaware the Q 15 minute checks had been discontinued as of 4/12/09. The DON confirmed there was no documentation ordering or directing the discontinuation of the Q 15 minute checks for Patient 2.An interview with LN 1 on 4/20/09 at 7:10 a.m. was conducted. LN 1 stated there "was a history of Patient 2 having acute delirium but never this out of control"... A facility policy outlining the three types of interventions used to observe a patient with behaviors, undated and titled, 1:1 Observation/Line of Sight/Q 15 Minute Checks indicated the following (in part): "Policy: 1:1 Observation/Line of Sight/Q 15 Minute observation is indicated for patients who exhibit behaviors that present a safety risk to self or others or staff which has or may result in injury. The patient will be placed on 1:1 observation, line of sight or Q 15 minute observation... Procedure: The resident is observed on a 1:1 staff/patient ratio when clinical assessment indicates a high level for immediate or impulsive behavior that may be harmful to self or others. Rationale for 1:1 must be specified and is limited to the following behaviors: Assaultive/Aggressive behavior Actively psychotic...and is an immediate threat to self or others. Responsibilities of 1:1 1. The staff member must remain within arm's length of the patient unless otherwise directed. 2. The staff member assigned is responsible for activities of daily living (ADL) care unless staff member is not a C.N.A. (Certified Nurses Assistant) or licensed staff member. 3. The staff member will redirect peers away from the patient being monitored. 4. The staff member will redirect the patient from areas that maybe over stimulating to the patient. 5. The staff member will complete documentation of the 1:1 on the Patient Observation/Q 15 minute Log/1:1 Log. 9. When 1:1 is no longer deemed appropriate, the patient will be reduced to line of sight observation and then Q 15 minute checks." An interview with the Medical Director (MD) was conducted on 4/29/09 at 4:25 p.m. The MD stated he was unaware Resident 2 was on Q 15 minute checks for the past 30 days and stated "this incident with Resident 1 could have been have been avoided if the 1:1 policy had been followed."The facility's policy dated 6/06 and titled, Patient to Patient Abuse indicated the following information (in part): "Policy: 2. Should a patient be observed/accused of abusing another patient, our facility will implement the following actions: e. Develop a care plan that includes interventions to prevent the recurrence of such incidents, including the appropriate management of any underlying conditions such as acute psychosis that may have caused or contributed to the problem. g. Document in the resident's clinical record all interventions and their effectiveness."By not following their policy, Patient 1 was assaulted by Patient 2 and received bodily injuries requiring medical attention.As a result of the investigation, it was determined the facility failed to:1. Provide a safe environment for Patient 1 free from physical abuse. 2. Follow their policy to protect Patient 1 from physical abuse. 3. Review and revise the care plan to supervise Patient 2 to prevent Patient 1 from physical abuse by Patient 2. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000019 |
Norwood Pines Alzheimers Center |
030010296 |
B |
13-Dec-13 |
MWL411 |
4419 |
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. An unannounced visit was made to the facility on 3/30/12 to investigate complaint CA00303879 concerning an allegation of abuse for Patient A. The Department determined the facility failed to implement its policy to report and investigate the cause of seven significant injuries of unknown origin to determine if abuse had occurred, and determine the underlying cause of the injuries. Patient A was admitted to the facility on 11/11/11 with diagnoses which included Alzheimer's disease (changes in the brain that result in progressive memory loss). Review of a Minimum Data Set (MDS - an assessment tool used in skilled nursing facilities), dated 11/18/11, described Patient A as having severely impaired cognitive skills and indicated Patient A's language as Spanish.Review of a "Weekly Progress Note" dated 11/23/11 indicated new skin tears to both forearms; a new bruise on his left forearm and hands; and new abrasions on his left forearm and hands. A "Weekly Progress Note" dated 11/30/11, indicated a new wound on the left hand and forearm, and on his right hand and forearm and a new bruise on his back/trunk. A Nurses Note, dated 12/13/11 at 9 p.m., indicated new bruising under the right lower eyelid. A Nurses Note, dated 12/14/11 at 8:10 p.m., indicated a new skin tear with a bruise on the left forearm. Review of a "Fax Request for Orders" dated 1/2/12 included, "...noted to have bruise on [right] upper side of body [approximately] 20 [centimeters-cm] by 20 cm (approximately 8 inches square)...he fell on the 24th of [December] and the resident has been reported to have resistiveness to care." There was no documented evidence staff had investigated the injury to determine the cause. Review of a Nurses Note, dated 1/11/12 at 9:55 a.m. indicated a new "bruise right ribcage and flank." A "Change of Condition" form, dated 1/25/12 described a "bruise [right] eye all around." Review of the facility policy titled, "Policies and Procedures Regarding Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property," dated July 2009, included the following: "It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source...This facility will ensure that all "alleged" or "suspected" abuse, in accordance with Federal and State laws, which involve... injuries of unknown source...are reported immediately...The facility will investigate each such alleged violation thoroughly and report the results of all investigations..." The policy also included: "The facility shall take the following steps to prevent, detect and report abuse, neglect, injuries of unknown source and the misappropriation of resident property." Under the heading, "Investigation" the policy included: "Investigations shall be conducted as designated by the Administrator or [Director of Nursing-DON]...The investigation shall include interviews of associates, visitors, or residents who may have knowledge of the alleged incident. Factual information only should be documented, not assumptions or speculations. Written statements from the involved parties should not be requested...Federal law requires the facility to have evidence of investigations of alleged violations." During an interview with the DON on 6/20/12 at 3:40 p.m., she was unable to locate or provide the investigations or reports to the Department for the injuries of unknown source sustained by Patient A on 11/23/11, 11/30/11, 12/13/11, 12/14/11, 1/2/12, 1/11/12 and 1/25/12. The DON confirmed the facility had not completed incident reports, or held interdisciplinary team conferences, and they had not conducted any investigations into the cause of these seven injuries. Therefore the Department determined the facility failed to implement its policy to report and investigate the cause of seven significant injuries of unknown origin to determine if abuse had occurred and determine the underlying cause of the injuries. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000019 |
Norwood Pines Alzheimers Center |
030010372 |
A |
29-Jan-14 |
BRMM11 |
16861 |
F-323 483.25Free of Accident/Hazard/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. The following citation was written as a result of an unannounced visit on 12/21/10 for the investigation of complaint number CA00217279. The Department determined the facility failed to provide adequate supervision or interventions to prevent Resident 1 from falling on 12/14/09, resulting in a right hip fracture and from falling on 1/22/10, resulting in a left hip fracture.These failures resulted in two unnecessary surgeries with their inherent risks and the potential to impede his ability to walk. Resident 1 was admitted to the facility on 8/12/09. He had diagnoses including dementia and Parkinson's disease. An admission Minimum Data Set (MDS - an assessment tool), dated 8/20/09, described Resident 1 as having long term and short term memory problems and modified cognitive abilities. The MDS indicated Resident 1 "required supervision" to walk, but "no physical help from staff." He was described as having "wandering" behaviors.Resident 1 was readmitted to the facility on 12/19/09 after hospitalization for a fracture of his right hip following a fall on 12/14/09. This resulted in right hip replacement surgery on 12/16/09. Resident 1 was observed and interviewed on 12/23/10 at 12:20 p.m. He was sitting in a wheelchair in the dining room eating lunch independently. Resident 1 stated, "Yes, I broke my hip." When asked about the pain, Resident 1 stated, "Yes, sharp pain." A Fall Risk Assessment, dated 8/12/09, listed Resident 1's score as 10. A note on the line for Total Score indicated "Total score of 10 or above represents HIGH RISK." Resident 1 fell 14 times between admission on 8/12/09 and his transfer to the hospital on 12/15/09 for the fracture of his right hip. After readmission to the facility on 12/19/09, Resident 1 fell 2 more times and was transferred to the hospital on 1/26/10 for a fracture of his left hip. On 8/15/09 Resident 1 had an un-witnessed fall in the front yard of the facility. AnInterdisciplinary Team (IDT) note, dated 8/17/09, included no recommended interventions to prevent further falls. A care plan titled Fall, dated 8/17/09, listed under problems/concerns: "Wandering; Unsteady gait; Poor safety awareness; Wanders without regard to fatigue; and [Resident] sits down on the ground." The goal was "Have no fall or injury daily x 3 months." Under Approach/Interventions were listed: "Out of bed as tolerated; Assist with all transfers or ambulation; Provide adequate lighting; Monitor resident location with visual check every 2 hours [as needed]; Assist in reorientation to room and facility with verbal cues; Encourage group activities and attempt to keep occupied; [Encourage] to call nurse for help; Monitor for sedation, dizziness, unsteady standing/sitting balance; Report to [Medical Doctor (MD)]; Inform MD and family if with incident of fall/injury; Encourage [Resident] to take rest periods [as needed]. On 8/18/09 Resident 1 had an un-witnessed fall in a resident room. An IDT note, dated 8/19/09, concluded "continue to observe." The Fall care plan, dated 8/17/09 and updated 8/18/09, included the following item: "Re-approach [resident] when refuses rest periods." The care plan was not modified with additional approaches or interventions. On 8/20/09 Resident 1 had an un-witnessed fall beside his bed. An IDT note, dated 8/21/09, indicated their recommendation was to continue current plan of care. Resident 1 had a Physician's Order, dated 8/26/09 to discontinue physical therapy (PT) and start Restorative Nursing Assistant (RNA) 5 days per week for 3 months for lower extremity exercises and balance activities. On 8/28/09 Resident 1 had two un-witnessed falls that resulted in an abrasion on the back of his head. An IDT note, dated 8/31/09, recommended RNA work with the resident "for 3 months for balance...and quiet time from 2-3:30." On 9/14/09 Resident 1 had a fall from catching his foot on a door. An IDT note, dated 9/14/09, did not include any recommendations or changes in care. A new care plan titled Fall, dated 9/15/09, included the following Problems: "Fall risks due to [history] of falls; Unsteady gait; Poor safety awareness; Forgetful and confused; Wanders throughout facility; Not able to remember how to use call light, [Diagnosis] Alzheimer's, Parkinson's; At risk for additional falls due to above; Resident sits down on floor/ground; [Resident] with poor safety awareness." Under Goals was listed, "Will have no decline in ADLs due to falls." Under Interventions was listed: "Assess needs as not able to use call light; Provide non-skid footwear; When restless, assist [resident] to lay down or sit in chair; Offer food and/or fluids when indicated. Keep environment consistent and alert resident to any changes. Pain management as needed. Assist to use commode as needed. Rehab services as ordered." On 9/20/09 Resident 1 had an un-witnessed fall in the hallway. An IDT note, dated 9/21/09, concluded the resident was fatigued and would assist the resident to bed when he was fatigued. The Fall care plan, dated 9/15/09 and updated 9/20/09, included the following: "Remind [resident] to take rest periods [as needed] fatigue." On 10/2/09 Resident 1 had an un-witnessed fall and was found in a resident room. He sustained skin abrasions. On 10/4/09 Resident 1 had an un-witnessed fall on the ramp between the two wings. He complained of severe neck and back pain and went to the emergency room for evaluation. An IDT note, dated 10/5/09, addressed his falls on 10/2/09 and 10/4/09. A PT evaluation was recommended. The Fall care plan, dated 9/15/09, was updated on 10/5/09 to include "PT evaluation for possible merriwalker (an enclosed walker with a seat [due to] unsteady shuffling gait and increased falls." A PT evaluation, dated 10/6/09, recommended therapy 5 days a week for 2 weeks. PT was re-ordered until it was discontinued on 12/1/09. On 10/21/09 Resident 1 had an un-witnessed fall in the hallway. The Post Fall/Trauma report, dated 10/21/09, indicated Resident 1's pants were wet and he was trying to toilet himself. Under Interventions Used Prior to Fall the report included "[wheelchair]." Under the heading Post Fall Investigation Summary Recommendations and Interventions the following items were checked: "Toileting schedule; Transfer pole in bathroom; Bed/chair alarm; [Wheelchair] positioning; Safety cues/reinforcement/reminder." An IDT note, dated 10/22/09, included "Noted with functionally (sic) decrease; ADL's, ambulation, gait unsteady" and recommended "Refer to PT for ambulation...resident reminded to ask for assistance...continue to observe." The Fall care plan, dated 9/15/09, and updated on 10/22/09, indicated "[Resident] to ask for assistance regarding ADLs and transfers." A Fall Risk Assessment, dated 10/31/09, indicated a total score of 10 for Resident 1's risk. Section B, titled History of Falls, had "0" entered, indicating "No falls." Section E, titled Gait/Balance, had "0" entered, indicating "Gait/Balance normal." The Assessment indicated "Total score of 10 or above represents HIGH RISK." On 11/4/09 Resident 1 had a fall in his room. He slipped after standing up independently. The Post Fall/Trauma report, dated 11/4/09, indicated he hit the back of his head. No interventions were documented as having been in place prior to the fall. "Ambulatory" was entered under Other. Under Post Fall Investigation Summary Recommendations, the report indicated, "Requires [wheelchair] [with] lap buddy for rest period. He is non-compliant with rest period in bed." The IDT review, dated 11/5/09, included "Resident noted with decline in functional ability, [with] poor safety awareness and abnormal posture in [wheelchair]. Will refer to PT for [wheelchair] positioning and abnormal gait." The Fall care plan, dated 9/15/09, and updated on 11/5/09 indicated "Refer [to rehab] for positioning." On 11/7/09 Resident 1 had a witnessed fall in the dining room. After standing, he fell to one knee. The IDT note, dated 11/9/09, recommended, "Will put a [wheelchair] alarm on [resident] while [up] in [wheelchair]." The Fall care plan, dated 9/15/09, was not updated following this fall. An Occupational Therapy document titled Functional Maintenance Program, dated 11/18/09, indicated, "[Patient] has progressed to be able to walk the entire distance of the building before fatiguing. He may need a reminder to sit and rest...during activities at least once in the [morning] and more often in the afternoon as he does get tired and is then at risk of falling. He no longer has a [wheelchair] assigned to him." The second page of the document was titled Bowel and Bladder Training Program. This indicated Resident 1 "is able to hold his urine for up to 3 to 4 hours without accident. He does best on the shift that routinely asked him every hour if he needed to use the toilet." Resident 1 had a Physician's Order, dated 12/1/09, to discontinue PT and start RNA program 3 days per week for transfers, exercise, and ambulation. On 12/9/09 Resident 1 had an un-witnessed fall in the hallway. The Post Fall/Trauma report, dated 12/9/09, under the heading Interventions Used Prior to Fall, indicated Resident 1 was "ambulatory." Under the heading Post Fall Investigation Recommendations, the report indicated, "Provide rest periods." The IDT note, dated 12/10/09, did not include any recommended interventions to prevent further falls. The Fall care plan, dated 9/15/09, was not updated following this fall. Physician's Orders, dated December 2009, did not include orders for any devices to be used to prevent falls for Resident 1. A Fall Risk Assessment, dated 12/10/09, indicated a total score of 16 (HIGH RISK). On 12/14/09 Resident 1 had a witnessed fall and complained of right hip pain. On 12/15/09 a right hip fracture was confirmed. This resulted in right hip replacement surgery. The Fall care plan, dated 9/15/09, was updated on 12/14/09 to include "Remind [resident] to not push other residents (in wheelchairs) [due to] impaired balance." A transfer form, dated 12/15/09, indicated Resident 1 was transferred to the general acute care hospital for treatment of a hip fracture. A Fall Risk Assessment, dated 12/15/09, indicated a total score of 19 (HIGH RISK). Resident 1 was readmitted to the facility on 12/19/09. His admitting diagnoses included aftercare for healing traumatic fracture of hip. An admission MDS, dated 12/29/09, described Resident 1 as not walking in the week prior to the assessment and self-performance of activities of daily living were described as "deteriorated." Resident 1's Physician's Orders, dated January 2010, did not include orders for any devices to be used to prevent falls. A Fall Risk Assessment, dated 12/19/09, indicated a total score of 12 (HIGH RISK). Under Section E, Gait/Balance, "[Not applicable] - not able to perform function" was marked. A care plan titled Fall/Injury Potential, dated 12/20/09, listed the following under the heading Problems/Concerns: Altered mobility; Poor safety awareness; History of falls; Impaired cognition/communication; Gait/balance impaired; and Increased weakness. The plan included the following under the heading Approaches or Interventions: Cue resident and reorient; Provide safe, secure environment clutter free pathways, well-lit room, dry floor; Use simple direction to establish consistent routine; Monitor change in level of alertness, increasing lethargy; Keep assistive device within reach; Provide non-skid shoes as needed. There were no alarms to alert staff of unassisted transfer checked off as interventions in the care plan. A Nurse's Note, dated 1/14/10, indicated, "Returned from MD appointment with full weight bearing and full activities as tolerated status." On 1/20/10 Resident 1 had an un-witnessed fall in his room. A Post Fall/Trauma report, dated 1/20/10 at 7 p.m., indicated, "Resident found on the floor on his left side next to his bedside. Un-witnessed fall, he verbalized that he wanted to go to bed, prior to incident he was sitting on his wheelchair in his room." Resident 1 was assessed to have no hip injury, but did have an abrasion on his left elbow. The section titled Interventions Used Prior to Fall listed 23 possible interventions. None were checked and only "Wheelchair" was written on the line next to the title Other. Review of Physician's Orders for January 2010 revealed no orders for assistive devices or other fall prevention measures. On 1/22/10 Resident 1 had an un-witnessed fall in his room. A Post Fall/Trauma form, dated 1/22/10, indicated Resident 1 fell when he attempted to transfer himself from his wheelchair to his bed independently. Resident 1 had a hip x-ray on 1/26/10. The report indicated, "There is a left intertrochanteric fracture (hip fracture)." The report included, "Osteoporosis (weakened bones) is present."An interview was conducted with Certified Nurse Assistant (CNA) 2 on 12/30/10 at 2:45 p.m. He stated Resident 1 sometimes tried to stand, picking himself up from his chair. Before his second hip fracture he stood on one foot. CNA 2 stated, "He's not walking at all now." An interview was conducted with Licensed Nurse (LN) 1 on 12/30/10 at 2:50 p.m. She reviewed the Post Fall/Trauma form, dated 1/22/10, which she had written and stated at the time of the fall "there was no alarm" in use for Resident 1 to alert staff when he stood up from his chair. An interview was conducted with CNA 1 on 2/9/11 at 4:30 p.m. She stated Resident 1 can stand, holding on to a transfer pole, turn around, and sit down. She stated Resident 1 did "no walking." The facility policy titled Clinical Guideline: Falls Management was reviewed. The following directions were included in the policy: "Following a resident's fall...Appropriate interventions are implemented. (See optional Resource for Resident Interventions to Prevent Falls attached) ...The IDT review the...Post Fall/Trauma and makes additional recommendations." The policy attachment titled Team Resource For Resident Interventions to Prevent Falls included the following:"Falls with Cognitively Impaired Residents": Toileting programs, schedule; Ask families to make an activity basket, memory book, photo albums; Restorative programs - exercises, ambulation; Appropriate footwear; Alarms (TABS, chair, bed) - to alert staff to changes of position. "Falls for Ambulatory Residents": Monitor, remind resident appropriate use of assistive devices; Appropriate footwear; Remind, monitor residents ability to maneuver change in flooring (ex. carpet to tile). "Residents with Multiple Falls": Trending of falls for the individual - time of day, reason for fall, location of fall, etc.; Consider room change to move resident closer to the nurses' station; Keep resident in view during high risk times if possible; Refer to therapy; Discuss at stand up, grand rounds, with interdisciplinary team; Restorative program - ambulation; Have staff members from each shift come up with individual interventions for residents with frequent falls; Discuss reasons for falls with direct care givers; Routine monitoring for implementation of interventions; Involve Recreation for activity interventions: Tai Chi/exercise/movement groups for frequent falls, favorite TV programs, radio shows for high-risk times Hydration group - activity during risk times; Assess medical condition/medication as possible causal factors; Example: Blood sugar fluctuations, blood pressure fluctuations, orthostatic (drop in blood pressure upon rising), Urinary Tract Infection or other infection process; Timing of medications in relation to falls; Assess need for restraint - least restrictive; Evaluate need for high/low bed. An interview was conducted with the Director of Nurses on 12/23/10 at 3 p.m. She stated after falls, the RN assesses the patient and notifies the MD and responsible party. The IDT does a root cause analysis within 72 hours and makes recommendations. After reviewing Resident 1's clinical record, she stated, "The IDT didn't recommend new interventions after each of his falls to prevent more falls." The Department determined the facility failed to provide adequate supervision or interventions to prevent Resident 1 from falling on 12/14/09, resulting in a right hip fracture and from falling on 1/22/10, resulting in a left hip fracture.These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. |
| 030000019 |
Norwood Pines Alzheimers Center |
030010456 |
A |
12-Feb-14 |
PW1911 |
18138 |
F-157 - Notify Of Changes (injury/decline/room, Etc.) 42CFR 483.10(b)(11) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in 483.12(a). F-279 - Develop Comprehensive Care Plans - 42CFR 483.20(d), 483.20(k)(1) 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). F-282 - Services By Qualified Persons/per Care Plan -- 42CFR 483.20(k)(3)(ii) The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care. F-314 - Treatment/svcs To Prevent/heal Pressure Sores - 42CFR 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. An unannounced visit was made to the facility on 10/26/11 to initiate an investigation of Complaint #CA00286939. As a result of the investigation, the Department determined that the facility failed to: 1. Identify a possible Clostridium difficile infection (C-diff-a contagious bacterial infection) and follow the facility's policy for testing Resident 1 for C-diff. timely and notifying Resident 1's physician when she started having frequent loose stools. 2. Identify and effectively monitor individual risks for pressure ulcers and implement preventive measures to relieve pressure from vulnerable areas. 3. Ensure early detection of skin changes and institute treatment prior to development of a stage III pressure ulcer. 4. Ensure the plan of care to monitor skin condition following diarrhea was implemented.The failures placed Resident 1 at risk of further skin breakdown, increased pain, the need for operative intervention, local or systemic infection, prolonged bed-rest, delayed healing, and death. Resident 1 was admitted to the facility on 6/8/11 with diagnoses including dementia with behavioral disturbance and Alzheimer's disease. Review of Resident 1's quarterly Minimum Data Set (MDS-a standardized assessment tool) dated 9/1/11 indicated her cognitive level was severely impaired and she needed extensive assistance with her Activities of Daily Living (ADLs-e.g. dressing, bathing, toileting). The MDS described Resident 1 as being incontinent of both bowel and bladder. She was documented to be resistive to care and frequently refused to eat or take fluids.On her admission to the facility, Resident 1's weight was 137 pounds (lbs.). An Initial Braden Scale for Predicting Pressure Sore Risk dated 6/8/11 listed Resident 1 as a "17" - indicating she was a low risk for developing pressure ulcers (a score of 12 or below indicated a high risk for developing a pressure ulcer). The Braden Scale included a section related to nutritional status. The score assigned by staff indicated her nutritional status was adequate from 6/08/11 through 6/29/11. The next Braden assessment dated 9/02/11 indicated her nutritional status was "very poor."Insufficient fluid intake and inadequate nutrition can contribute to development of pressure ulcers. An Initial Nutritional Assessment dated 6/23/11 indicated Resident 1's nutritional needs included receiving 1700 calories and 1530-1840 milliliters of fluids a day (30 milliliters is equal to one fluid ounce).During Resident 1's stay at the facility, she tested positive for the infection Clostridium difficile (C-diff) on 6/20/11 and then again on 7/18/11. C-diff is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. The associated diarrhea can compromise skin integrity and contribute to the development of pressure sores. A Care Plan for C-diff dated 6/28/11 indicated Resident 1's C-diff infection had the potential for dehydration and impaired skin integrity secondary to diarrhea. Interventions included monitoring for skin breakdown. A Care Plan for Dehydration dated 6/28/11 indicated Resident 1 was at risk for dehydration because of her dementia, having C-diff, and that she was receiving a diuretic (Lasix). Interventions included monitoring for signs of insufficient fluid intake such as: cracked lips. The staff was also to watch for abnormal laboratory values. Review of Resident 1's CNA-ADL (Certified Nursing Assistant - Activities of Daily Living) Tracking Form from August 22 through August 31 2011 (10 days) indicated the following: Resident 1 had a poor appetite for 20 meals and refused 4 meals out of a total of 27 meals. The Resident's average daily fluid intake was only 718 ml (ml. = milliliter). The Resident had 38 bowel movements. The average daily bowel movement frequency per day from 8/01/11 to 8/07/11 was 1; 08/08/11 to 8/14/11 was 1.3; 8/15/11 to 8/20/11 was 2; 8/21/11 to 8/31 was 3.9.Review of Resident 1's CNA-ADL Tracking Form for September 2011 indicated the following: Between 9/1/11 and 9/20/11 (20 days, 60 meals), the Resident refused 25 meals and had a poor appetite for 29 meals for a total of 54 meals. Between 9/1/11 and 9/20/11 (20 days) the Resident's average daily fluid intake was 754 ml. Between 9/1/11 and 9/20/11 (20 days) the Resident had 91 bowel movements. The average daily bowel movement frequency per day from 9/1/11 to 9/10/11 was 3.2 and from 9/11/11 to 9/20/11 was 4.6.However, there was no documented evidence of physician notification of the increased frequency of bowel movements to ensure early detection of C-diff until 9/16/11.Review of the Weekly Summaries (a document the licensed nurses use to update and summarize the Resident's status) dated 8/18 through 9/15/11, indicated the space where bowel frequencies were supposed to be written was blank. Review of Resident 1's Nurses Note on 8/25/11 indicated she had developed a reddened area on her perineum (The external region between the vulva and the anus in a female). A physician order dated 8/25/11 indicated an order for Lantiseptic Cream (a topical medication to protect the skin against irritants and moisture) was to be applied to Resident 1 every day until [the irritation was] resolved. There was no documented evidence that a skin care plan for prevention of pressure ulcers was developed to include preventive measures such as a pressure relieving mattress, a gel-pad liner for Resident 1's wheel chair as she became less active or efforts to ensure her position was frequently changed when she was sitting in the chair for extended periods during the day.The Braden Scale for Predicting Pressure Sore Risk dated 9/2/11, indicated Resident 1 was now listed as a "14", a moderate risk for developing a pressure ulcer due to an increase in skin exposure to moisture, going from occasionally moist to often moist. The report also indicated Resident 1 went from having adequate nutrition to very poor nutrition on the scale. At the same time there were no updates on Resident 1's Nutritional Status Care Plan (last entry was 8/12/11) and no care plan had been implemented for the higher risk for pressure ulcers. Nurses Notes dated 9/7-9/8/11 indicated Resident 1's buttocks were now reddened and being treated with the Lantiseptic cream that had been prescribed for the perineum area on 8/25/11. A Nurses Note dated 9/10/11, indicated Resident 1 had developed an open area to her left butt cheek. The note indicated Resident 1 was complaining of moderate pain (6 out of 10, where 10 is the worst pain). The Pain Management tool documented Resident 1's pain was in the left buttock cheek.A Wound/Skin Healing Record dated 9/10/11 indicated the original stage of the pressure ulcer (when the facility first discovered the pressure ulcer) was a stage III with a measurement of 4.0 by 2.5 centimeters (cm - 1 inch =2.5 centimeters) with a depth of 0.2 cm. (A stage III pressure ulcer is when there is full thickness skin tissue lost). The facility failed to assess Resident 1's buttock area and notify the medical doctor before the lesion had progressed to stage III. A stool microbiology report dated 9/16/11 indicated Resident 1 tested positive for C. diff. A Wound Nurse note dated 9/20/11 indicated risk factors for delayed wound healing included active C-difficile. The Medication Administration Record (MAR) for September 2011 indicated Resident 1 received the pain medication Norco one time on 9/11, 3 times on 9/12 and one time on 9/13/11. Resident 1's pain during the 5 times she was medicated was described as 6 out of 10. (The Pain Monitoring Tool indicated a score of 5-7 represented moderate pain).Resident 1's Weight Record dated 9/11/11 indicated her weight at 114 lbs. (a weight loss of 5 lb. in 2 weeks and 23 lbs. since admission). A Dietary Progress Note dated 9/13/11 revealed the Registered Dietitian (RD) had assessed Resident 1 and had indicated the resident's lips were dry and she was "worried about her being dehydrated". Her plan was to suggest the licensed staff get an order for a blood chemistry study to evaluate fluid loss.The Report also mentioned Resident 1 had lost 20 lbs. in 3 months. Resident 1 continued to refuse food and fluids despite documented facility efforts to encourage adequate fluids and nutritional meals and snacks. A Blood Chemistry Report (blood tests to assess a wide range of conditions and the function of organs.) ,dated 9/14/11, revealed the following: BUN was 30 which was elevated and outside of normal range (normal is 5-26) (last BUN was normal at 22 on 8/9/11). Sodium was 149 which was elevated and outside the normal range (normal is 135-145) (last Sodium was 137 on 8/9/11). Prealbumin (protein level) had decreased to 14 which was outside the normal range (normal is 18-38) (previous Prealbumin level was 20). After looking at the Blood Chemistry labs of 9/14/11 the RD stated, "She was dehydrated." A Blood Chemistry Report for Resident 1 dated 9/21/11 listed her BUN had increased from 30 to 37 which was high and outside the normal range. Resident 1's Sodium had increased from 149 to 151 which was high and outside the normal range. Resident 1's Chloride had increased from 110 to 112 which was high and outside the normal range, and her Prealbumin was 15, which was still low and outside the normal range. A physician order dated 9/21/11 ordered Resident 1 to be transferred to the acute hospital because of "critical labs". A hospital note dated 9/21/11 for Resident 1 indicated the following labs: Sodium 147 (H), Chloride 111 (H), BUN 41 (H), Lactate 2.6 (H), White Blood Count 12.7 (H) Red Blood Count 5.14 (H).The hospital evaluation dated 9/21/11 indicated because of Resident 1's elevated lactate of 2.6, and her BUN of 41 and Sodium of 147, she was dehydrated. Resident 1 was given 1000 ml. (one quart or approximately 20% of Resident 1's blood volume) of intravenous normal saline while in the hospital and then was transferred back to the facility. Review of the facility's policy titled Clostridium Difficile dated 12/2008 under Policy Interpretation and Implementation: Contact Precautions-"Residents with diarrhea associated with Clostridium difficile (i.e., residents who are colonized and symptomatic) will be placed on contact precautions for the duration of the illness." Residents at High Risk-"Resident considered at high risk of developing symptoms with clostridium difficile includes those with advancing age ...previous gastrointestinal illness caused by clostridium difficile. When residents with these risks have symptoms of diarrhea (i.e. three loose stools in twenty-four hour period), clostridium difficile should be considered as a cause. Residents with previous infection who develop diarrhea should be evaluated as soon as practical." Assessment of Resident for Dehydration-"Any Resident with diarrhea shall be assessed for dehydration regularly." The facility did not document evidence of an assessment of Resident 1 regularly for dehydration. In an interview with the Director of Nurses 1 (DON) on 2/2/12 at 11:15 a.m., she stated Resident 1 was originally a low risk for getting a pressure ulcer. She also stated a care plan for pressure ulcer was not written until 9/10/11 when her pressure ulcer (stage III) had been first discovered. In a follow-up interview with the DON on 2/3/12 at 1:30 p.m., she stated the facility did not update the residents care plans for pressure sores if the residents went from low risk to moderate risks. (Resident 1 went from low risk at admission 6/8/11 to moderate risk on 9/2/11 and the stage III pressure sore was discovered on 9/10/11). She also stated, when asked what was causing Resident 1's skin to become irritated starting on 8/25/11, "I assume it was from the diarrhea, from the C-diff."In an interview with the Nurse Consultant on 2/2/12 at 1:30 p.m., she stated Resident 1's skin was irritated from having diarrhea and that is why she was ordered the Lantiseptic cream on 8/25/11 and why the resident's bottom was reddened. She also stated the staff had not discovered Resident 1's pressure ulcer until it was a stage III. She stated, "They (the facility) should have found it (the pressure sore) at a stage II but didn't."In an interview with Certified Nursing Assistant (CNA) 1 on 2/3/12 at 12:50 p.m., she stated the CNA staff writes in a bowel book if the residents are having frequent stools. In an interview with Licensed Nurse (LN) 1 on 2/3/12 at 1:15 p.m., when asked about checking residents' bowel movements, he stated that if the residents had frequent stools that are smelly they would notify the resident's physician. In an interview with LN 2 on 2/7/12 at 2:15 p.m., she stated she remembered Resident 1 and remembered that her skin was irritated and that she had frequent stools. She also stated the "licensed staff were supposed to look at the ADL form the CNAs had fill out each shift but sometimes the licensed staff were too busy to do this". She stated the nurses should have been aware of Resident 1's frequent stools and that the licensed nurses were supposed to be checking the residents' skin on a twice weekly basis with their baths. In an interview with CNA 2 on 2/7/12 at 2:35 p.m., she stated she remembered taking care of Resident 1 in August of 2011. She stated she remembers Resident 1 having "diarrhea and smelly stools. She stated she "notified the charge nurse when this happened and wrote this in the Bowel Book".In an interview with LN 2 on 2/7/12 at 3:05 p.m., after showing her documentation that the Resident had four stools on 8/23/11 during the PM shift in which LN 2 was in charge, she stated. "I should of told someone about this and she (the resident) should have been tested (for C-diff). I didn't do it." In an interview with LN 4 on 2/24/12 at 2:45 p.m., she stated she had taken care of Resident 1 in the past. When shown the ADLs for 8/24/11, which documented that Resident 1 had 4 stools during the evening shift, she stated she could not remember if anyone had told her about the stools. When asked about the Weekly Summaries she had filled out for Resident 1 leaving the slot for frequency of bowel movements empty, she stated, "I did not fill out the frequency, I should have". Between 8/23 and 9/10 there was no documented evidence that the frequent loose stools was addressed by the licensed nursing staff.In an interview with DON 2 on 11/30/12 at 10:30 a.m., she stated after reviewing Resident 1's clinical records, that residents with stage III pressure ulcers can experience pain from the wound itself and also from the dressing changes. She stated that Resident 1's need to start using a narcotic pain medication on 9/10/11 was probably due to her developing the Stage III pressure ulcer. The Department determined that the facility failed to: 1. Identify a possible Clostridium Difficile infection (C-diff-a contagious bacterial infection) and follow the facility's policy for testing Resident 1 for C-diff. timely and notifying Resident 1's physician when she started having frequent loose stools.2. Identify and effectively monitor individual risks for pressure ulcers, implement preventive measures to relieve pressure from vulnerable areas. 3. Ensure early detection of skin changes and institute treatment prior to development of a stage III pressure ulcer. 4. Ensure the plan of care to monitor skin condition following diarrhea was implemented. These violations presented either (1) imminent danger that death or serious harm to the Residents or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to Residents or residents of the long term health care facility would result therefrom. |
| 030000019 |
Norwood Pines Alzheimers Center |
030011816 |
B |
30-Oct-15 |
UFRL11 |
8702 |
F203 42 CFR 483.12(a)(4)-(6) Notice Requirements before Transfer/Discharge Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons in the resident's clinical record; and include in the notice the items described in paragraph (a)(6) of this section. Except as specified in paragraph (a)(5)(ii) and (a)(8) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. Notice may be made as soon as practicable before transfer or discharge when the health of individuals in the facility would be endangered under (a)(2)(iv) of this section; the resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (a)(2)(i) of this section; an immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (a)(2)(ii) of this section; or a resident has not resided in the facility for 30 days. The written notice specified in paragraph (a)(4) of this section must include the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident is transferred or discharged; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. F206 42 CFR 483.12(b)(3) Policy to Permit Readmission Beyond Bed-Hold A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services. An unannounced visit was made to the facility on 8/20/15 to investigate complaint CA00454986.The Department determined the facility failed to: 1. Provide Resident 1's legal representative/responsible party a written notification as soon as practicable upon transfer to an acute care facility that included the above requirements and; 2. Establish or follow a written policy that required Resident 1's readmission to the facility upon the first available bed when his hospital stay exceeded the 7 day bed-hold period.According to the Record of Admission, Resident 1 was readmitted to the facility on 11/7/11 with multiple psychiatric diagnoses and brain damage. On 5/28/15, Resident 1 was transferred to an acute care facility for a significant change in health status.1. Resident 1's Resident Admission Agreement, signed in 2011 by Resident 1's legal representative, revealed under section "XI. Termination, Transfer and Discharge" that "The facility shall notify the resident or legal representative at least 30 days in advance of transfer or discharge, except in cases of emergencies...then only such notice as is reasonable under the circumstances shall be provided."The facility provided the Department with a document from Resident 1's medical record titled, "Transfer/Bed-Hold Notification Informed Consent". This document was mailed to the resident's legal representative upon transfer but did not contain: 1. the reason for transfer; 2. a statement that the resident has the right to appeal the action to the State; 3. the name, address and telephone number of the State long term care ombudsman or; 4. the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. During a phone interview with the facility's Administrator on 8/21/15 at 9:15 a.m., she acknowledged neither Resident 1 nor his responsible party received a notice upon transfer to the acute facility that met all the requirements.A 2007 facility policy and procedure titled "Documentation of Transfers/Discharges" indicated, "Documentation from the Care Planning Team concerning all transfers or discharges must include, at a minimum, and as they may apply...that an appropriate notice was provided to the resident and/or representative." Documentation that was provided to the Department did not contain this information. 2. Resident 1's Resident Admission Agreement, signed in 2011 by Resident 1's legal representative, revealed under section "XII. Readmission-Bed Hold Policy" that "Under certain circumstances, a Medicaid beneficiary is entitled to have the facility keep his bed available for his return to the facility (bed-hold) for up to 7 days after transfer to an acute care hospital..." The resident's right to readmission, if their hospital stay exceeds the 7 day bed hold period, was not included in the Agreement. Resident 1's hospital stay exceeded the 7 day bed-hold.On 9/2/15 at 9:20 a.m. Resident 1 was observed at the acute care hospital on a Medical Unit. Resident 1 was observed sleeping in a low padded bed. A Certified Nursing Assistant (Sitter), assigned to Resident 1, was observed sitting in the room. No restraints or intravenous lines were noted.According to a review of the hospital Case Management Notes, Resident 1 was determined both medically and behaviorally stable for readmission to the facility on 6/17/15.Resident 1's hospital clinical record was further reviewed. A clinical social work note dated 7/10/15 read, "[Social Worker] participated in placement hearing with [skilled nursing facility] who has declined to have patient return to their facility." The clinical record also contained note from a case manager, dated 7/17/15, indicating the "State" made the decision that Resident 1 "goes back to [the facility] in the first available bed." During an interview with the acute care Case Management Supervisor (CMS) and Administrative Director of Adult Inpatient and Emergency Services (AD) on 9/2/15 at 8:30 a.m., the CMS stated that Resident 1 was medically cleared for discharge but the skilled nursing facility could not readmit him because: 1. the facility did not have an available bed and 2. the facility could not provide the care and services Resident 1 required. The AD said the legal representation for California Advocates for Nursing Home Reform (CANHR) at the hearing made the argument that regardless of the facility's inability to meet the care and services for Resident 1, the facility was still obligated to readmit him and then, if appropriate, transfer him elsewhere. In an interview with the Director of Nursing (DON) on 8/20/15 at 12:15 p.m., the DON explained she had to weigh the risks and benefits of Resident 1's readmission. Resident 1 required care and services the facility could not provide. The DON explained Resident 1's readmission would put other residents and Resident 1 himself at increased risk of injury. Therefore, in her professional judgment, with support of the facility Administrator, a decision was made to decline Resident 1's readmission to the facility.During a phone interview with the Administrator on 8/21/15 at 9:15 a.m., she stated that the facility did not have a policy that specified resident readmission rights. In a phone interview with Administrative Director of Integrated Quality Services on 10/29/16 at 10:52 a.m., she confirmed that Patient 1 remained in the hospital.Therefore, the Department determined the facility failed to provide Resident 1's legal representative/responsible party a written notification as soon as practicable upon transfer to an acute care facility that included all requirements and establish or follow a written policy that required Resident 1's readmission to the facility upon the first available bed when his hospital stay exceeded the 7 day bed-hold period.This violation had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000019 |
Norwood Pines Alzheimers Center |
030012599 |
B |
30-Sep-16 |
1BHH11 |
3222 |
F206 42 CFR 483.12(b)(3) Policy to Permit Readmission Beyond Bed-hold A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services. An unannounced visit was made to the facility on 7/7/16 to investigate complaint numbers CA00494290 and CA00494348. The Department determined the facility failed to establish or follow a written policy that required Resident 1's readmission to the facility upon the first available bed when medically stable. Resident 1 was admitted to the facility on 11/13/15 with diagnoses of mood affective disorder and psychosis. On July 3, 2016, Resident 1 was transferred out of the facility to an acute care hospital for a mental evaluation, after having an altercation with another resident that resulted in injuries. In a telephone interview with the hospital's Case Manager (CM) on 7/7/16 at 9:40 a.m., she said that the resident was evaluated, was medically cleared and was ready to return back to the facility. But, when the skilled nursing facility (SNF) was notified, the facility refused to take him back. In a subsequent, onsite visit to the hospital, in a personal interview with the resident, Resident 1 indicated that he was feeling much better and wanted to return back to the facility. On 7/11/16, in correspondence with the Hospital's CM, she indicated having spoken with the resident's brother and RP. In conversation with him, he expressed to the CM, being somewhat reluctant in having his brother return back to the SNF, in fear that, "Intentional or unintentional consequences may follow the patient, if he returned to the SNF." Thus, choosing/preferring his brother, not return there. During an interview with the facility's Administrator on 7/7/16 at 1:45 p.m., although the facility has had 3 available male beds since 7/4/16, she stated that she would not permit Resident 1 to return, for fear of him being a "danger to others." Review of the facility documents titled Available and Unoccupied Beds dated 7/4/16, 7/5/16, 7/6/16, and 7/7/16 indicated three available unoccupied male beds were noted on each date. Review of the facility's policy titled Bed Hold revised 1/1/12 indicated that the purpose of the policy is to ensure that the resident and their representative are aware of the facility's bed-hold policy, and that such policy complies with state and federal law and regulations. It further indicated in part that the facility "...will hold the resident's bed for up to seven (7) days...will communicate with acute care hospital staff to monitor the resident's medical progress and expected date of return to the facility." As of 09/16/16, the facility continues not to follow their written Bed Hold policy and Resident 1 remains as a patient at the acute care hospital awaiting transfer. This violation had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000324 |
New Hope Post Acute Care |
030012604 |
B |
30-Sep-16 |
OFKR11 |
3959 |
Health & Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation is written as a result of entity reported incident #CA00498778. An unannounced visit was made to the facility 8/18/2016 to investigate an allegation of abuse. The Department determined the facility failed to report an allegation of abuse within 24 hours as required, when Patient 3 told two CNAs that Patient 3 had witnessed CNA 3 hit Patient 1 on 7/10/2016. This violation potentially placed facility patients at risk for continued abuse. Patient 1 was admitted to the facility with diagnoses including dementia (a permanent decline of a person's ability to think, reason and manage his/her own life) with behavioral disturbances, psychosis (a loss of contact with reality) and anxiety. His/her most recent quarterly MDS (Minimum Data Set, an assessment tool), dated 6/20/2016 indicated he/she had moderate impairment of his/her mental status and needed extensive assistance with 1 staff for his/her ADL's (Activities of Daily Living). He/she was able to make themselves understood and usually understood others. During an interview with Director of Staff Development on 8/18/2016 at 10:53 a.m., the allegation of abuse towards Patient 1 was discussed. She said the incident was not reported to her until 8/10/2016 because Patient 3, CNA 5 and CNA 6 thought it (abuse allegation on 7/10/2016) had been reported. During an interview with the administrator on 8/18/2016 at 11:10 a.m., the allegation of abuse towards Patient 1 was discussed. He said, "...some staff are not reporting per our policy and procedure..." During an interview with Social Services Director on 8/18/2016 at 12:03 p.m., she was asked what the expectation was regarding mandated reporters. "All staff report to the Executive Director any alleged abuse: physical, verbal, sexual, isolation, financial..." During an interview with CNA 5 on 8/23/2016 at 1:06 p.m., the allegation of abuse towards Patient 1 was discussed. She said, "[Patient 3] told me that night. It happened on 7/10/2016 around 3 to 4 p.m... He said [CNA 3] hit [Patient1] after [Patient 1] hit [CNA 3]. I thought [Patient 3] would report it... In the morning [Patient 3] told [CNA 6] when he was shaving him..." During an interview with CNA 6 on 8/24/2016 at 9:02 a.m., the allegation of abuse towards Patient 1 was discussed. He said, "If I hear [an incident of abuse], I'm not a witness. The one who saw it should report it..., I'm not a witness. I thought everyone was a mandated reporter. I didn't know patients weren't mandated reporters. [Patient 3] mentioned to me one time he saw [CNA 3] hit [Patient1] back...I assumed he would report it." Review of CNA 6's personnel file revealed he was given a verbal warning in 4/2011 and a written warning on 9/20/2011. "Employee failed to uphold the company's resident [patient] rights and abuse prevention protocols..." Review of the facility time keeping records, dated 7/10/2016 - 8/18/2016, indicated CNA 3 worked 20 shifts after the 7/10/2016 incident, putting the patients at further risk of abuse. Review of the facility policy and procedure titled, "Abuse Prohibition Notification to Staff, Residents [Patients] and Family", updated March 2012, established, "Alleged violations involving mistreatment, neglect or abuse...should be reported immediately... in accordance with Federal and State law...The alleged victim is protected to prevent harm during the investigation..." Immediately was defined as not to exceed 24 hours. Therefore, the Department determined the facility failed to report an allegation of abuse within 24 hours as required, when Patient 3 told two CNAs that Patient 3 had witnessed CNA 3 hit Patient 1 on 7/10/2016. |
| 100000324 |
New Hope Post Acute Care |
030012611 |
A |
7-Oct-16 |
34TL11 |
9878 |
F323 483.25(h) Accidents. The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The following citation is written as a result of entity report incident #CA00486000. Unannounced visits were made to the facility on 5/10/16 and 5/20/16 to investigate an unusual occurrence involving an unwitnessed fall. On 4/23/16, the facility did not provide Resident 1 1:1 supervision as ordered by her physician. Resident 1 was found unsupervised on the floor bleeding from lacerations over her eye and hip. She was transferred to an acute care hospital on 4/23/16 and was returned to the facility on 4/28/16. The Department determined the facility failed to provide Resident 1 adequate supervision on 4/23/16 when an unwitnessed injury of unknown origin occurred. The violation potentially placed the resident at risk for injury or death. Resident 1 was admitted to the facility with diagnoses which included fracture of left hip with a hemiarthroplasty (joint replacement with a prosthetic, artificial body part), dementia (decline in mental ability), anemia (a deficiency of red blood cells in the blood, resulting being tired), diabetes (a group of diseases that result in too much sugar in the blood), and psychosis (a mental disorder characterized by a disconnection from reality). Fall Evaluations for Resident 1, completed on 3/18/16 and 4/23/16 each specified a score of 23 (a score of 13 or greater is a high potential for falls). Resident 1's "Discharge Care Plan" dated 3/16/16 indicated resident has 1:1 staff due to wandering and poor safety awareness. During a review of the clinical record for Resident 1: 1. The April 2016 Treatment Sheet indicated staples were removed from the left hip surgical incision on 4/5/16 and a pain medication was administered twice for a headache and general body pain; 2. The Vital Sign Flow Sheet indicated all vitals (blood pressure, temperature, pulse, and respirations) were with in normal limits; 3. The 24 Hour Report did not have any documentation of falls since Resident 1 was placed on 1:1 sitter or left hip having any swelling, pain, or redness; 4. The Nurse's Notes did not have documentation of left hip having any swelling, pain, or redness; 5. The acute care hospital indicated on the day of Resident 1's fall and surgery, Resident 1's white blood cell (help fight infections by attacking bacteria) count was 6.9 (normal range is 4.5-11 with a higher number indicating an infection); and 6. The Minimum Data Set (a resident assessment tool) dated 4/23/16 indicated in Section J Health Conditions; Resident 1 had one fall with injury since admission or prior assessment. During a clinical record review, a physician's order dated 4/15/16 at 6:05 p.m. indicated, "1:1 sitter for [Resident 1] Don't D/C [discontinue] order she is high risk for falls." A physician's "Progress Notes" dated 4/15/16 indicated. "Pt [patient] is getting up & [and] started walking doing [sic] all times high risk for falls ...", "Need sitter 1:1", and "Falls precautions..." In a concurrent interview and record review on 5/10/16 at 11:55 a.m. with the Administrator (ADM), the ADM indicated he was aware of the physician's order for Resident 1 to have a 1:1 sitter. The ADM acknowledged there was not a physician order obtained to discontinue the 1:1 sitter for Resident 1. The ADM acknowledged the Discharge Care Plan dated 3/16/16 indicated, " ...1:1 staff ... " , physician's notes dated 4/15/16 indicated, 1:1 sitter, and nurses notes dated 4/15/16 indicated, "Pt [patient] keeps getting out of w/c [wheelchair] & [and] starts walking" and physician provided 1:1 sitter for Resident 1's poor safety awareness. The ADM acknowledged on 4/22/16 he requested the Director of Staff Development (DSD) to inform the staff Resident 1 would no longer have a 1:1 sitter. In an interview with Licensed Nurse (LN) 1 on 5/10/16 at 12:30 p.m., Resident 1's unwitnessed fall on 4/23/16 was discussed. LN 1 verified she was the afternoon supervisor on 4/23/16. LN 1 said LN 2, the nurse assigned to Resident 1, reported she was found on the floor bleeding and had lacerations (deep cuts or tears in skin or flesh) over her left eye and hip. She further reported Resident 1 said she was in pain. LN 1 stated she questioned LN 2 about the location of the 1:1 sitter and was informed the 1:1 sitter was discontinued. LN 1 stated she was aware there was an order for a 1:1 sitter and when she checked the physician orders in Resident's 1 clinical record, there were no orders to discontinue the 1:1 sitter. LN 1 stated 911 was called and Resident 1 was transferred to an acute care hospital. In an interview on 5/10/16 at 1:55 p.m., with the Director of Nursing (DON), the DON confirmed Resident 1 was admitted to the acute care hospital on 4/23/16 and returned to the facility on 4/28/16. On 5/10/16, Resident 1's clinical record from the acute care hospital was reviewed. A history and physical dated 4/23/16 indicated, "Patient [resident] was also noted to have an open wound at the site of the hemiarthroplasty. CT scan [series of x-rays taken at different angles] of the left leg worrisome for infection and air tracking in the thigh." The operative report dated 4/23/16 indicated, Resident 1 was taken from the emergency department to the operating room because of the potential for deep involvement which went below the fascial (a layer of connective tissue to stabilize bones and internal organs) layer. Resident 1 underwent an urgent exploration, irrigation, debridement (the removal of damaged tissue from a wound) and closure, and was noted to have left hip postoperative wound dehiscence (wound ruptures along a surgical incision) which extended down into the prosthetic area. The surgeon noted the wound went completely through the fascia and could feel the femoral neck (area below the top of the thigh bone) part of the implant without difficulty. The surgeon noted there were no fluid collections or pus pockets throughout hip. Resident 1 was started on antibiotics (to treat and prevent infections). In an interview on 5/12/16 at 3 p.m. with Resident 1's physician (MD), he confirmed he wrote an order on 4/15/16 for a 1:1 sitter because Resident 1 was a high risk for falls. MD stated he wrote on the orders not to discontinue the order because she was a high risk for falls so the facility would not discontinue the order. MD stated the facility did not notify him Resident 1's 1:1 sitter was discontinued on 4/22/16. MD stated a 1:1 sitter was to provide 24 hours of having someone watch the resident to ensure her safety. MD stated he did not give an order to discontinue the 1:1 sitter for Resident 1. In a concurrent interview and record review on 5/20/16 at 10:23 a.m. with the DSD, the DSD stated she was aware of a physician's order for the 1:1 and advised the ADM of the order. The DSD stated she received direction from the ADM to inform staff Resident 1's 1:1 sitter was being removed. The DSD stated Resident 1's physician was in the facility on 4/22/16 so the DSD requested the 1:1 sitter be discontinued. The physician said no. The DSD verified the 4/15/16 order for a 1:1 sitter was for high risk of falls. In a concurrent interview and record review on 5/20/16 at 12:05 p.m. with the ADM, the ADM stated "ridiculous to order 1:1 sitter" and "who will pay?" The ADM confirmed the DSD spoke with Resident 1's physician on 4/22/16, and requested to discontinue the 1:1 order and the physician said no. The ADM acknowledged he gave the direction to discontinue the order for the 1:1 sitter for Resident 1. In an interview on 5/25/16 at 1:22 p.m. with LN 2, LN 2 stated she was aware of a physician's order for a 1:1 sitter for Resident 1 and was informed on 4/22/16 by the DSD the 1:1 sitter was being discontinued. LN 2 stated on 4/23/16 she heard an alarm going off and went to Resident 1's room where she found Resident 1 face down on the floor bleeding with a laceration over her left eye and on her left hip. LN 2 stated she notified her supervisor LN 1 that Resident 1 was found on the floor in her room. LN 2 stated she called 911. Resident 1 was transferred to an acute care hospital. LN 2 stated an order was not received from the physician to discontinue the 1:1 sitter. Review of physical therapy evaluation and plan of treatment dated 4/29/16 for Resident 1 indicated prior levels of function was bed mobility and transfers independent, unlimited distance on level surfaces with no assistive devices. Resident 1 was receiving previous physical therapy services and made good progress where Resident 1 needed supervision for safety and needed someone close for functional mobility. Resident 1 currently referred to physical therapy, "due to exacerbation of decrease in strength, decrease in functional mobility, reduced ability to safely ambulate, increased need for assistance from others, reduced static [static balance is the ability to maintain one's balance when not moving] and dynamic balance [maintaining balance when the body is moving], reduced functional activity tolerance and decreased skin integrity." Fundamentals of Nursing 7th Edition, copyright 2009, Chapter 14 Older Adult indicated under Falls, "Falls lead to fear of additional falls, withdrawal from usual activities, and loss of independence.", "Among older adults, complications from falls are the leading cause of death.", and "...nearly 85% of death from falls were among people 75 and older." Therefore, the Department determined the facility failed to provide Resident 1 adequate supervision on 4/23/16 when an unwitnessed fall occurred. 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. |
| 040000059 |
NorthPointe Healthcare Centre |
040011866 |
B |
24-Nov-15 |
XCN811 |
12216 |
CFR (Code of Federal Regulations) 42 CFR 483.12 (a) (2) Reasons For Transfer/Discharge Of Resident The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; The health of individuals in the facility would otherwise be endangered; The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or The facility ceases to operate. The Complaint # CA00458057 was investigated during an unannounced on-site visit on 9/17/15. The facility failed to provide a safe transfer and discharge, necessary for the resident's welfare when Resident 18 was transferred to a Board and Care (B&C) residential home (lower level of care without nursing services provided), on 9/2/15, without medical justification. Resident 18 had a history of dysphagia (difficulty swallowing due to abnormal nerve or muscle control) and was on a pureed (food had a consistency of a thick pudding) diet. On 9/3/15 during the night, at the Board and Care home, the staff found Resident 18 eating food from the refrigerator and exhibiting signs of choking. On 9/3/15 at 8:36 a.m., Resident 18 was transported from the B&C to the hospital emergency department (ED) for agitation.Review of Resident 18's "Face Sheet" (document containing resident's profile information) indicated Resident 18 was admitted to the skilled nursing facility (SNF) on 11/24/14 with diagnoses which included, Difficulty Walking, Dementia (term for a decline in mental ability severe enough to interfere with daily life) with behavioral disturbances, Dysphagia and Seizures.The Physician's orders dated August, 2015 indicated additional diagnoses of Schizophrenia (psychotic disorder marked by severely impaired thinking, emotions, and behaviors), Senile (relating to having diminished cognitive function), Psychotic (severe mental disorders that cause abnormal thinking and perceptions) Condition, and Developmental Delay (the condition of being less developed mentally or physically than is normal for age).On 9/17/15 at 9:45 a.m., during an interview, Licensed Nurse (LN) 1 stated Resident 18 had needed prompting and supervision by staff during meals or snacks, and was on a pureed diet because of the difficulty with swallowing. LN 1 stated Resident 18 was not capable of administering own medications. Resident 18 required close monitoring due to behavior issues and was developmentally delayed.On 9/17/15 at 10:15 a.m., during an interview with the Social Service Director (SSD), the SSD stated Resident 18 had been in a B&C home prior to being admitted to the facility on 11/24/14. The SSD stated Resident 18 had, during the first stay at the B&C, had difficulty swallowing, and as a result had been admitted to the acute care hospital, and then the Skilled Nursing Facility (SNF).On 9/17/15 at 2 p.m., during an interview with Resident 18's family member (FM), the FM stated, Resident 18 had resided in the SNF for 6 months before being transferred to the B&C home. The FM stated the facility had been trying to find a place to transfer Resident 18 for the past several months. The FM stated she was told at a resident care conference, the facility staff thought the resident was better suited in a smaller place where the resident could receive one-to-one care. The FM stated she had thought the facility meant to transfer the resident to a different type of facility rather than a board and care home, as that was where he had been admitted to the SNF from. The FM stated, prior to 2012, Resident 18 had been in a board and care, but when he began to have problems swallowing there, he was then transferred to the hospital and then admitted to the SNF for nursing care. The FM stated on 9/1/15, the SSD informed her they had found a place for Resident 18, a board and care. The FM, who is the responsible party, stated the facility, "Shipped him off" the next day (9/2/15). The FM stated, "He needs nursing care." On 9/23/15 at 3:30 p.m., during an interview, the Medical Director (MD) stated physicians do not perform the assessment for residents who are being discharged. The nurses complete the form. The MD stated, "We depend on other people to do that." The MD stated, "Sometimes we only see the residents once a month." Review of Resident 18's clinical record titled, "InterDisciplinary Team Conference," dated 9/1/15, indicated Resident 18's transfer request was accepted by a Board and Care Home. The record indicated attendance of interdisciplinary team members was the Administrator, Social Services Director, Dietary Services Supervisor and the Assistant Director of Nursing. There was no documented evidence of a physician being present at the conference to discuss the resident's welfare.Review of Resident 18's "Physician's Report for Residential Care Facilities for the Elderly" undated, contained a stamp with the physician's name, address and license number. The form was unsigned and contained a printed facsimile (fax) date at the top of the form of 9/20/15 at 10 a.m. The document indicated Resident 18 required supervision, a pureed pudding thick liquid diet, and medications to be administered by staff. The report indicated Resident 18 had a wound to the left buttock. A second copy of this report was faxed to the SNF medical director on 9/20/15, stamped with medical director's name and license number but undated.Review of Administrative document titled, "Discharge and Transfer of Residents" dated 1/1/12, indicated, "Purpose- To ensure that discharge planning is complete and appropriate..." Section titled, "Discharge Documentation VIII." Indicated, "The medical record will contain written documentation from the resident's Attending Physician if the resident is discharged because: ii. The resident's health has improved and he/or she no longer needs the Facility's services..." Review of Resident 18's clinical record untitled and undated, typed with a statement, "Resident was discharged to Board and Care this am via (by) ...medical transportation..." On 9/24/15 at 8:15 a.m., during an interview with the Director of the Board and Care to which Resident 18 was transferred, the Director stated the staff at the B&C were unable to adequately care for Resident 18. The Director stated they were unable to administer medications for the resident and unable to provide the appropriate diet. The Director stated the facility didn't tell him anything about the diet and he did not know what a pureed diet was. The Director stated, "I noticed that when he (Resident 18) was eating he was choking a little bit." The Director stated he took Resident 18 to the emergency department after Resident 18 was found pounding on the walls and yelling. The Director stated the hospital case manager called him to inform him Resident 18 needed a higher level of care. The Director stated Resident 18 was then admitted to the hospital.On 9/24/15 at 10:15 a.m., during an interview the Speech Therapist (ST) stated Resident 18 had a severe swallowing deficit, thin liquids were not safe for him, and he needed the thick pudding like consistency liquid. The ST stated the Administrator conferred with him upon Resident 18's discharge and wanted to know if Resident 18 could eat independently. The ST stated he told the Administrator Resident 18 needed nursing care on a "24 hours per day/7 days per week" basis and needed one-to-one supervised care. The ST stated Resident 18 needed to stay on a pureed diet because he had difficulty swallowing.9/24/15 at 10:49 a.m., during an interview, the SSD placed a call to the primary care physician responsible for Resident 18's care. The physician did not return the call. On 9/25/15 at approximately 3 p.m. a second telephone call was placed to the primary care physician. A message was left on the physician's voice mail requesting a return call with a phone number referenced for a return call. The physician did not return the call.Resident 18's clinical record contained the document, "Notice of Proposed Transfer and Discharge," dated, 9/1/15. The document contained, "Reason for Discharge" was blank and had not indicated why Resident 18 was being transferred to a lower level of care.Resident 18's "Discharge Summary" dated 9/1/14 indicated Resident 18 was admitted on 11/24/14 and was discharged on 9/1/15. The section on the document, "Safety Needs/Precautions: (Fall Risk, Assistive, Sensory Aides)" was left blank.Resident 18's "Physician's Orders" dated August 2015, indicated, 8/31/15, Resident 18 was discharged to a board and care home. There was no medical justification documented on the discharge order by the primary care physician (P) 2.Review of Resident 18's acute care hospital record, untitled, and undated, under "Miscellaneous" indicated the resident was admitted to the hospital ED on 9/3/15 at 8:36 a.m. The document indicated Resident 18 came in with an abscess (a localized collection of pus in the tissues of the body), on the right buttock. The document indicated Resident 18 was unable to provide a history due to being non-verbal. The record indicated, "Clinical Impression: Psychiatric disorder, Left buttock lesion (healing old abscess), Gravely disabled." The record indicated, "Hospital Course: Patient was evaluated by speech/swallow for dysphagia and recommended to get alternate mean of feeding based on video fluoroscopic study (VFSS) (A study done by using x-ray to produce real-time video images. After the x-rays pass through the patient, instead of using film, they are captured by a device called an image intensifier and converted into light. The light is then captured by a TV camera and displayed on a video monitor.) The VFSS performed on 9/8/15 indicated, "Severe oropharyngeal dysphagia with evidence of silent penetration and aspiration with puree solids and honey thick liquid. As per Speech Language Pathologist (SLP) patient is at high risk for aspiration... Disposition: Skilled nursing facility..." The active discharge diagnoses included dysphagia, schizophrenia, pressure ulcer, and developmentally delayed.Review of Resident 18's SNF clinical record titled, "Speech Therapy" dated, 7/30/15 indicated, "Precautions: Aspiration, Pudding liquids and Puree diet. Swallowing abilities= Moderate to severe level of impairment. Discharge Plan: Patient to reside in this long term care facility. Continued skilled SLP [Speech, Language Pathology] service is necessary to assess/evaluate least restrictive oral intake...reduce aspiration w/training in postural maneuvers... safely consume least restrictive diet..." Review of a letter from the acute care hospital dated 9/5/15 at 10:30 a.m., by the ED case manager, indicated, "Patient was discharged from SNF on 9/2/15 to a room and board...Patient was pounding on wall, got into refrigerator during night and was eating food and almost choked on food... Patient also has a healing abscess on left buttock... Patient appears to be inappropriate for room and board level of care, is incontinent (inability to control function of urination or defecation). Has wound on buttock that patient does not appear to be able to manage wound care. Felt to be unsafe discharge from facility."The facility failed to allow the resident to remain in the facility, to provide medical justification for transfer to a lower level of care, and to prevent an unsafe transfer and discharge when the resident needed skilled nursing care for care of his swallowing disorder and care for a pressure ulcer wound.The above violation both jointly, separately or in any combination, had an immediate direct relationship to the Resident's health, safety and well-being and, therefore, constitutes a Class "B" Citation. |
| 060000131 |
NEWPORT SUBACUTE HEALTHCARE CENTER |
060008887 |
B |
09-Jan-12 |
6H9511 |
10046 |
72311 (a) (1) (B) 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. Patient A was admitted to the facility on 4/11/08, and transferred to the emergency room on 10/29/11 at 0320 hours, following a fall from a window on 10/28/11, resulting in a right arm fracture and abrasions to his left and right knees and elbows. The facility failed to develop a care plan to address Patient A's need for close supervision, which resulted in multiple falls and a fracture. Health record review for Patient A was initiated on 11/21/11. Patient A was admitted to the facility on 4/11/08, with diagnoses including cerebral vascular accident (stroke), psychosis and altered mental status.Review of Patient A's Minimum Data Set (MDS, an assessment tool) dated 9/19/11, shows he requires limited assistance from one staff member for his activities of daily living (ADL) care. Review of Patient A's history and physical dated 3/17/11, showed diagnoses including organic brain syndrome and documentation Patient A does not have the capacity to understand and make decisions. Review of Patient A's Fall Risk Assessments dated 6/6/11, 6/21/11, and 9/20/11, showed a score of 18 (a score of 10 or above represents a high risk for falls). Review of Patient A's care plan problems dated 4/11/09, 9/15/10, 2/15/11, and 3/25/11 (reevaluated and revised date 9/11), showed he is at risk for falls. Approach plans included frequent visual checks, and to maintain a safe and hazard free environment. Review of an Incident Report dated 10/28/11 at 2015 hours, showed Patient A was forgetful and had episodes of confusion. Patient A was found lying on the ground in the alley outside his room, complaining of right shoulder pain. He had abrasions to his right and left knees. Review of Patient A's Investigation of Incident/Accident/Injury of Unknown Origin report dated 10/28/11 at 2015 hours, showed Certified Nursing Assistant (CNA) 2 found Patient A on the ground by the alley outside his room, calling for help. Patient A's window was found open. Patient A sustained a 1.5 centimeter (cm) x 1.5 cm abrasion to his right lateral knee (site #1); a 1.5 cm x 2 cm abrasion to his right lateral knee (site #2); a 1 cm x 0.5 cm abrasion to his right lateral knee (site #3); a left knee abrasion; a 2 cm x 1 cm left elbow abrasion (site A); a 2 cm x 1 cm left elbow abrasion (site B); and multiple bilateral toe redness. Patient A complained of pain in his right upper extremity. The corrective action plan taken was to provide frequent visual checks, reorientation and redirection as needed. Review of Patient A's Interview Record dated 10/28/11 at 2045 hours, showed CNA 2 stated she was down the hallway caring for another patient, in Room A, when she heard someone outside yelling for help. She looked out the window and saw a man lying on the ground. She notified the nurse, and the nurse ran outside to help (him). Review of the facility's floor layout, showed Room A is located on a different unit, seven rooms down the hallway from Patient A's room. Review of Patient A's right shoulder x-ray results dated 10/28/11 at 2258 hours, showed an impacted humeral neck fracture (a fracture in which ends of the upper arm bone are wedged together). Review of Patient A's Licensed Nurses Progress Notes dated 10/29/11 at 0140 hours, showed Patient A's physician was notified of the x-ray results showing an impacted right shoulder humeral fracture, and at 0320 hours, Patient A was transferred to the emergency room for further evaluation. On 10/29/11 at 0915 hours, Patient A returned from the emergency room with an order for a half-cast to his right shoulder and to have a sling in place to his right arm at all times.Review of Patient A's Nurse's Admission Record dated 10/29/11 at 0915 hours, showed Patient A was very anxious, confused and hallucinating. Patient A was constantly attempting to take off his half cast and arm sling to his right arm, mimicking to himself, talking to a picture of a family member and to unseen people in the picture. On 10/29/11 at 0950 hours, Patient A had increased confusion, very agitated and was constantly attempting to remove his right arm immobilizer. At 1850 hours, Patient A was found on the floor. At 1930 hours, a physician's order was obtained for Patient A to have a sensor alarm, elevated side rails, a low bed and floor mats and to continue to monitor Patient A for safety. Review of Patient A's Interdisciplinary Team (IDT) notes dated 10/31/11, showed Patient A is an unavoidable risk for further falls and injuries due to a history of falls, right arm fracture, noncompliant with his care, attempts to get up unassisted and episodes of confusion. Patient A is to use a low bed with floor mats for safety and a personal alarm. Continue to provide a safe environment, and monitor the patient closely for safety. Review of Patient A's Licensed Nurses Progress Notes dated 11/12/11 on the 3-11 shift, 11/13/11 on the 11-7 shift and the 3-11 shift, and 11/14/11 on the 11-7 shift, showed Patient A had frequent visual checks. On 11/14/11 at 1700 hours, Patient A was found lying on the bathroom floor. At 1720 hours, a physician's order was obtained for Patient A to have a sensor alarm (alarm to alert the staff of Patient A attempting to get up) in place while he is in the bed and wheelchair.On 11/14/11 at 2030 hours, Patient A's sensor alarm sounded and he was assisted to the bathroom and back to bed. At 2100 hours, Patient A was found on the floor with the sensor alarm deactivated. Patient A sustained a right eyebrow laceration and steri-strips (adhesive strips for wound closure) were applied. On 11/15/11 at 1100 hours, a physician's order was obtained for the use of a low bed and floor mats.Review of Patient A's Nurses' Weekly Progress Notes dated 11/14/11, showed Patient A had episodes of confusion and needed frequent visual checks. During an interview on 11/21/11 at 1115 hours, the Director of Nurses (DON) stated on 11/14/11 at 2100 hours, Patient A was yelling for help and was found on the floor. She said Patient A's bed alarm was deactivated by the patient and he sustained a laceration to his right eye.During an observation on 11/21/11 at 1305 hours, Patient A was lying in his bed. The left side of his bed was against the wall. No floor mat was visible in his room. Patient A's sling was on his bedside table. Patient A has slurred speech and was able to follow simple commands.During an interview on 11/21/11 at 1310 hours, CNA 1 stated Patient A is to have a floor mat on the right side of his bed. He stated the last time he had seen a floor mat in Patient A's room was a couple of days ago. During an interview on 11/21/11 at 1315 hours, Registered Nurse (RN) 1 stated Patient A is to have a floor mat to the right side of his bed. She was unable to locate a floor mat in Patient A's room. RN 1 stated someone must have taken the floor mat out of Patient A's room. During an interview on 11/21/11 at 1545 hours, LVN 1 stated Patient A has episodes of confusion and behavior episodes of yelling out, mocking his roommate and striking out at the staff. She stated on the evening of 10/28/11, a CNA heard someone yelling, looked outside the window and found Patient A lying on the ground. LVN 1 stated Patient A has a history of falls and no preventative fall precautions were put into place until after Patient A's fall on 10/28/11. In addition, LVN 1 stated, since Patient A was found on the ground outside on 10/28/11, Patient A had fallen two more times.During an interview on 11/21/11 at 1620 hours, the DON was asked if Patient A had floor mats in place prior to his falls. She stated, "No, we did not have a physician's order for floor mats until after his second fall." During an interview on 11/21/11 at 1650 hours, CNA 2 stated on 10/28/11, while she was caring for another patient in Room A, she heard someone yelling out for help. She stated she looked out of the window in Room A and saw a man outside on the ground, and she immediately called for the nurses to assist with the man. Review of Patient A's Medication Administration Record (MAR) for dates 12/1/11 through 12/14/11, showed Patient A continued with two episodes of yelling out and one episode of having an angry outburst.During an interview on 12/15/11 at 1605 hours, when LVN 3 was asked how often visual checks are performed on a patient, she stated at least every hour.During an interview on 12/15/11 at 1610 hours, when RN 1 was asked how often visual checks are performed on a patient, she stated it depends on the patient. She said today there are six patients on frequent visual checks. RN 1 stated there is no specific time the visual checks are done. She stated every staff member does visual checks on Patient A.During an interview on 12/15/11 at 1615 hours, when LVN 4 was asked how often he performs visual checks on a patient, he stated during medication pass he checks on each patient as he goes up and down the hallway. He stated the patients are checked a minimum of every hour.During an interview on 12/15/11 at 1620 hours, RN 2 stated the staff knows which patients need frequent visual checks. RN 2 stated Patient A is on frequent visual checks, but no documentation is available to show the frequency Patient A is checked.During an interview on 12/15/11 at 1625 hours, RN 1 stated Patient A is on frequent visual checks. She stated there is no documentation to show how often Patient A's visual checks are done. The facility's failure to develop a care plan to address Patient A's specific need for close supervision had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients. |
| 060000131 |
NEWPORT SUBACUTE HEALTHCARE CENTER |
060009361 |
B |
11-Jun-12 |
00U811 |
1099 |
72501(a)(b)(c) (a)Licensee shall be responsible for compliance, (b)Licensee shall appoint an administrator to carry out the policies of the licensee, (c)Licensee shall delegate to the designated administrator...the day to day operations.The facility failed to have a designated administrator or an interim (temporary) administrator for more than 30 days. Findings: On 4/13/12, the Department received a letter from the facility showing their administrator's last day of employment was 4/14/12.On 5/25/12 at 1500 hours, during an interview with the Director of Nurses (DON), the DON confirmed the administrator's last day was 4/14/12. The DON stated the facility did not currently have an administrator or an interim administrator. A follow-up telephone interview was conducted with the DON on 6/6/12. The DON revealed the facility was in the process of hiring an Administrator. However, the facility remained without an interim administrator during the time they've been without a designated administrator.The above violation has a direct relationship to the health, safety and security of patients. |
| 060001558 |
New Horizon Integrated Care - Trojan |
060009599 |
B |
16-Nov-12 |
DI5U11 |
5363 |
Welfare and Institutions Code, 4502(d)(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: (d) A right to prompt medical care and treatment. (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The above statue was NOT MET as evidenced by: On 9/13/12, an unannounced visit was made to the facility to conduct the annual recertification survey. Based on clinical record review and interview, the facility failed to ensure the facility's registered nurse (RN) acted timely and acted proactively when abnormal blood work was reported to the facility three separate times within a six month period. The results of the blood work were indicative of diabetes. Findings: On 9/14/12, the clinical record of Client 4 was reviewed. Client 4 had blood work ordered on a routine basis. A review of the laboratory tests results revealed the following: - On 2/9/11, the blood glucose was 86 mg/dL (normal value is 65 to 100 mg/dL [milligrams per deciliter]). - On 3/1/12, the blood glucose was 148 mg/dL. - On 3/1/12, the urinalysis showed a 3+ glucose in the urine (normal value is zero).- On 6/6/12, the blood glucose was 170 mg/dL., and the hemoglobin A1c (HbA1c) was 8.5 (normal value is between 4% and 5.6%). - On 8/7/12, the blood glucose was 197 mg/dL, and HbA1c was 8.8%. According to webmd.com, a blood glucose test measures the amount of a type of sugar, called glucose, in your blood; and the hemoglobin A1c test, also called HbA1c, is a test that provides an average of your blood sugar control over a six to 12 week period.According to livestrong.com, under normal circumstances, you do not have sugar in your urine. Sugar in your urine, or glycosuria, only occurs if your blood sugar levels exceed a certain threshold. It is a sign that your body is struggling to keep your blood sugar levels under control by trying to get rid of the sugar in your urine.Review of the nurses' notes showed no mention of the abnormal laboratory test results noted above. Therefore, it was unclear if the RN noted the pattern of the client's blood sugar steadily rising, the glucose in the urine and the high HbA1c on two separate occasions.Documentation in the clinical record showed Client 4 saw the physician on 6/26/12. At that visit, the physician noted in his progress notes "noted lab check A1C." However, there was nothing documented by the physician at this visit about the elevated HbA1c result of 8.5%, which had been done on 6/6/2012.Documentation in the clinical record showed Client 4 saw the physician again in July 2012 and on 8/2/12; however, there was no mention of the abnormal blood work. It was also unclear if the physician was aware of the above abnormal values as no action had been taken by the physician and little to nothing about the abnormal laboratory test results were addressed in his progress notes, even though the client continued to see the physician monthly. The blood work was not repeated until 8/7/12, seven weeks later. Documentation in the clinical record showed the facility's dietician noted in her visit dated 7/8/12, "history of elevated FBS (fasting blood sugar) and A1C hyperglycemia already on no added sugar diet. Would also benefit from more weight loss. Recommend MD consider Metformin (drug used to decrease blood sugar)." On 9/14/12, the Facility Manager was asked about Client 4's abnormal blood work. She stated the RN was out of the country; however, the RN was able to be contacted by phone.During a telephone interview, the RN stated the physician was aware of the high HbA1c. The RN also stated the physician had called the facility after seeing the results from the 8/7/12 blood draw, and had made an appointment for the client for 9/26/12. There was no documentation as to the physician's phone call. The RN stated that she should have documented these results in her notes. When asked about the dietician's note, the RN stated she had not seen the note. Further interview with the Facility Manager revealed the primary care physician for Client 4 was also out of the country and would not return for another week. The RN failed to advocate for the client when the physician failed to evaluate the client timely when the client showed 3+ glucose in her urine; had blood sugars which continued to rise from March 2012 through August 2012; and had high HbA1c results twice that were indicative of diabetes. The failure of the RN to advocate for her client, led to a delay in the treatment of hyperglycemia, which can lead to other health concerns such as blindness, poor circulation, and greater risk to the client's coronary health. The above violations either jointly, separately, or in any combination had a direct or immediate relationship to the client's health, safety or security. |
| 060000765 |
NEW ORANGE HILLS |
060013348 |
B |
17-Jul-17 |
1J0P11 |
20234 |
F314: 42 CFR 483.25(c) Pressure Ulcers:
(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 ensure the necessary care and services were provided to prevent the development of a pressure ulcer for two of two sampled residents (Residents 1 and 2). Residents 1 and 2 were admitted to the facility without pressure ulcers but developed pressure ulcers after admission to the facility.
* Resident 1 was admitted to the facility without a pressure ulcer. The facility failed to follow Resident 1's plan of care to turn the resident every 2 hours and administer a moisture barrier cream treatment as ordered by the physician. As a result, Resident 1 developed a Stage II pressure ulcer (Stage II pressure ulcer is a partial thickness loss of the skin presenting as a shallow open ulcer with a red pink wound bed) to his coccyx (coccyx is the bone at the base of the spinal column) on 3/1/17, which on 3/14/17 was identified to have deteriorated to a Stage IV pressure ulcer (Stage IV pressure ulcer is a full thickness tissue loss with exposed bone, tendon, or muscle). Resident 1 was confined to bed and his physical therapy was delayed as a result of the development of a Stage IV pressure ulcer while in the facility. Resident 1 stated he felt depressed as the wound was delaying his ability to be discharged home.
* Resident 2 was admitted to the facility without a pressure ulcer. The facility failed to reposition Resident 2 and perform treatments as ordered for the skin redness to the coccyx discovered on 4/5/17. On 4/26/17, Resident 2's coccyx wound had worsened to a Stage II pressure ulcer.
Findings:
Review of the facility's policy and procedure titled Wound Care Suggestions and Documentation dated September 2014, showed residents who are unable to independently turn will be repositioned at the minimum of every 2 hours. Preventative skin care program includes application of a moisture barrier ointment to protect the skin if indicated. All residents will have a complete skin assessment performed by licensed staff a minimum of weekly and charted on the weekly summary. The wounds should be measured and evaluated weekly for improvement or decline.
1. Medical record review for Resident 1 was initiated on 5/10/17. Resident 1 was admitted to the facility on XXXXXXX17, with a diagnosis of paraplegia (paralysis of the legs and lower part of the body) of the bilateral lower extremities.
Review of the Minimum Data Set (a standardized assessment tool) dated 3/3/17, showed Resident 1 had no cognitive impairment, could communicate his needs and required extensive assistance from two or more persons for bed mobility.
Review of Resident 1's Resident Admission Skin Assessment Form dated 2/22/17, showed Resident 1's coccyx was within normal limits and without abnormalities (no skin breakdown or open areas).
Review of Resident 1's care plan problem titled Skin Breakdown dated 2/22/17, showed a potential for skin breakdown related to decreased mobility. The care plan problem showed a goal for Resident 1 to be free from skin breakdown. Interventions included to turn Resident 1 every two hours while in bed.
Review of the medical record showed no documented evidence the resident was consistently turned and repositioned every two hours as care planned to prevent the pressure ulcer development.
Review of the Interdisciplinary Wound Care Committee record dated 3/1/17, showed Resident 1 had developed a new in-house pressure ulcer to his coccyx. Documentation showed the pressure ulcer on Resident 1's coccyx was first identified on 3/1/17, as a Stage II pressure ulcer. There was no documentation of the size of the pressure ulcer.
Review of Resident 1's physician's order dated 3/1/17, showed an order for a low air loss mattress (a low air Loss mattress is a mattress used for prevention or treatment of skin breakdown) for pressure ulcer and to apply moisture barrier cream every shift and as needed to the Stage II pressure ulcer on the coccyx.
Review of Resident 1's Treatment Administration Record (TAR) for March 2017, showed an entry to apply moisture barrier cream to the Stage II pressure ulcer on the coccyx. Further review of the TAR for the month of March 2017, showed no documented evidence the moisture barrier cream was applied from 3/1/17 through 3/10/17, during the 7 PM to 7 AM shifts and on 3/8 and 3/9/17, during the 7 AM to 7 PM shifts; all of these dates were blank and with no nurses' initials documented to show the treatments had been performed as ordered.
Review of a physician's order dated 3/11/17, showed Resident 1's Stage II pressure ulcer had deteriorated. The treatment order was changed to apply Santyl ointment. Santyl ointment contains an enzyme which breaks up dead skin and tissue.
A physician's order dated 3/13/17 showed to "Please turn" resident every two hours and document it.
However, review of the medical record showed no documented evidence the resident was consistently turned and repositioned every two hours as care planned and ordered to prevent further deterioration of the Stage II pressure ulcer on the coccyx.
Review of Physician 1's progress note dated 3/14/17 showed Resident 1's Stage II pressure ulcer to his coccyx was first identified on 3/1/17, which was assessed to have deteriorated to a Stage IV on 3/14/17. Documentation showed the measurement of the Stage IV pressure ulcer on the coccyx was 3 centimeter (cm) (length) x 2.5 cm (width). Physician 1 documented the wound care nurse had notified her on 3/13/17, that Resident 1's Stage II coccyx pressure ulcer had deteriorated on 3/11/17, to an unstageable wound. Physician 1 documented it was unclear as to how the wound had rapidly deteriorate that quick, and was unfortunate set back as resident's therapy with slide board transfers was now delayed. The physician's progress note also showed Resident 1 had told Physician 1 he was not being turned every 2 hours and sometimes was sitting in stool.
On 5/10/17 at 1629 hours, an interview and concurrent record review was conducted with the ADON (acting DON as of 4/1/17). The ADON was asked if Resident 1 reported to her that he was not being turned. The ADON stated Resident 1 informed her on 4/20/17, two Certified Nursing Assistants (CNA) on the night shift were giving Resident 1 an attitude about being turned. The ADON was asked if she had investigated Resident 1's concern. The ADON stated she conducted an interview with CNA 6 and CNA 7, as she felt based on the time frame provided to her by Resident 1. The ADON stated CNA 6 and CNA 7 told her they turned Resident 1 as per his turning schedule. The ADON stated she also spoke with six or seven additional CNAs, and they denied failing to turn the resident. The ADON was asked if she documented any of her interviews with these CNAs. The ADON stated, "I wrote some notes on a census sheet." The ADON provided a copy of the census sheet notes. The census sheet dated 4/20/17, showed the following documentation, "c/o turning PM shift (sometime day) CNA 6 and CNA 7 - attitude." The ADON stated there was no additional documentation in regards to this.
Review of Resident 1's Nursing Assistant Daily Flow Sheets (used by the CNAs to document turning the residents every two hours) for the months of February, March, and April 2017 showed the following documentation for the bed mobility/position every two hours:
a. Blank areas with no charting were noted on the following dates:
- Night Shift: 2/24, 3/28, 3/29, 4/2, 4/4, 4/6, 4/16, 4/19, 4/21, 4/22, 4/23, and 4/26/17.
- AM Shift: 3/29, 4/1, 4/5, 4/7, and 4/10/17.
- PM Shift: 4/9, 4/15, and 4/16/17.
b. "N" ("No" according to the charting code) on the following dates:
- Night shift: 3/3 through 3/7/17 and 3/9 through 3/27/17.
c. "S" (supervision/cueing according to the charting code) on the following dates:
- AM Shift: 3/1 through 3/9/17.
On 5/10/17 at 1629 hours, an interview and concurrent record review was conducted with the ADON. The ADON verified on 3/1 through 3/9/17 (the time frame in which the pressure ulcer deteriorated from a Stage II to a Stage IV), the AM shift documentation showed Resident 1 was given supervision/cueing with repositioning. The ADON acknowledged the resident could not reposition himself and required staff assistance with turning and repositioning. The ADON verified on 3/3/17 through 3/14/17 (the time frame in which the pressure ulcer deteriorated from a Stage II to a Stage IV) the night shift had documented Resident 1 was not being turned. The ADON stated "N" as per the document charting code indicated "No," the resident was not being turned. The ADON stated she was unable to determine if Resident 1 was being turned on the dates and shifts listed above due to the the lack of documentation.
On 5/11/17 at 0800 hours, an interview was conducted with Resident 1. Resident 1 stated he was admitted to the facility with no pressure ulcers. Resident 1 stated staff on all shifts failed to turn him, with an increased incidence on the night shift. Resident 1 stated he had told approximately six different facility licensed nurses and CNAs since his admission that he was not being turned. Resident 1 stated after the development of the coccyx pressure ulcer, he was confined to bed for several weeks. Resident 1 stated he felt depressed because the wound prevented him from attaining his goal of being discharged home. Resident 1 stated, "I know I could have been home if was not for this wound. I can not even get onto my own chair. This has prevented me from being independent and caring for myself, instead of enjoying time out of bed and learning how to live and move after my accident." The resident was asked at what time barrier cream was applied to his coccyx. Resident 1 stated the barrier cream was applied during the day shift.
An observation of Resident 1's pressure ulcer and interview was conducted with Treatment Nurse 1 on 5/11/17 at 0905 hours. Resident 1 was observed with full thickness tissue loss to his coccyx, measuring 4 cm (length) x 3 cm (width) x 3.5 cm (depth). Treatment Nurse 1 assessed the resident's pressure ulcer and stated the measurement of the tunneling was 4.8 cm at 9 o'clock (Tunneling is a passageway of tissue destruction under the skin surface that has an opening under the skin from the edge of the wound). Treatment Nurse 1 stated Resident 1's coccyx area was clear and without skin breakdown or tissue injury on admission to the facility. Treatment Nurse 1 stated the redness on the resident's coccyx area developed and was treated with a moisture barrier cream. Treatment Nurse 1 stated Resident 1 had developed a Stage II pressure ulcer and was placed on a low air loss mattress. Resident 1's wound then deteriorated to a Stage IV pressure ulcer. Treatment Nurse 1 stated Resident 1 was bed bound for two weeks when he developed a Stage IV pressure ulcer. Treatment Nurse 1 stated the resident had told her he was very sick of being in bed. Treatment Nurse 1 stated before the Stage IV pressure ulcer was developed, Resident 1 spent approximately three hours a day in his wheel chair.
On 5/16/17 at 0831 hours, an interview and concurrent record review was conducted with CNA 5. CNA 5 had cared for Resident 1 during the night shift on 3/3, 3/4, and 3/6/17 (the time frame the Stage II had deteriorated to Stage IV pressure ulcer). CNA 5 verified he charted "N" on these dates. CNA 5 stated "N" meant "no," Resident 1 was not turned and he could not turn himself. CNA 5 was asked if Resident 1 had ever refused to be turned. CNA 5 stated Resident 1 refused to be turned a handful of days he worked. CNA 5 stated he was uncertain of the exact dates, stating sometime between the end of February 2017 and early March 2017. CNA 5 stated when a resident refused to be turned he circled his entry on the Bed Mobility/Position form and documented the refusal on the back of the page. CNA 5 stated he was also required to inform the Licensed Vocational Nurse (LVN) charge nurse of the refusal who would then then co-sign his documentation. CNA 5 stated he did not document Resident 1's refusals because he was told by the LVN charge nurse, the LVN would document the refusals on the MAR. CNA 5 stated he did not verify if the LVN charge nurse documented Resident 1's refusals. CNA 5 was asked if Resident 1 had reported to him that he (Resident 1) was not being turned. CNA 5 stated the resident told him the AM and PM shifts failed to turn him because they were too busy. CNA 5 stated he reported the resident's complaint about not being turned to his supervisor, LVN 3.
Review of Resident 1's Medication Administration Records (MAR) for the months of February and March of 2017, did not show documentation Resident 1 was refusing to be turned. The MAR for March 2017, failed to show documentation Resident 1 was being turned and repositioned every two hours from 3/1/17 through 3/12/17 and 3/13/17 through 3/31/17. In addition, there were 23 times where there was nothing documented.
On 5/22/17 at 0832 hours, an interview and concurrent record review was conducted with CNA 8. CNA 8 cared for Resident 1 during the night shift on 3/7, 3/12, 3/13 (time frame Stage II deteriorated to Stage IV) 3/24, and on 3/26/17. Review of the Nursing Assistant Daily Flow Sheet (bed mobility/position every 2 hours section) for March 2017, showed CNA 8 documented "N" ("N" indicated no, the resident was not turned every 2 hours) on 3/7, 3/12, 3/13, 3/24, and 3/26/17. CNA 8 stated, "Y" indicated yes, the resident was turned every 2 hours. CNA 8 stated Resident 1 did not refuse to be turned during the times she cared for him.
Review of the Interdisciplinary Team Conference Record - Wound dated 5/24/17, showed Resident 1 had developed an avoidable pressure ulcer on his coccyx based on the National Pressure Ulcer Advisory Panel guidelines.
On 5/24/17 at 1100 hours, an interview and concurrent record review was conducted with Physician 1. Physician 1 stated she informed the DON on 3/14/17, of Resident 1's complaint of facility staff not turning every two hours and that he was sometimes left sitting in stool. The DON had informed Physician 1 an action plan would be developed and the DON would speak to the nurses. Physician 1 stated she was not informed Resident 1's treatment was not administered on 3/1/17 through 3/10/17 during the 7 PM - 7 AM shifts, and 3/8 and 3/9/17 during the 7 AM - 7 PM shifts. Physician 1 stated failing to carry out the treatment order could have contributed to development/worsening of Resident 1's pressure ulcer on his coccyx.
On 5/24/17 at 1232 hours, an interview and concurrent record review was conducted with Treatment Nurse 1. Treatment Nurse 1 was asked if Resident 1 reported to her that he was not being turned. Treatment Nurse 1 stated Resident 1 had told her a CNA on night shift, sometime last week, had failed to turn or reposition him and let him sleep. Treatment Nurse 1 stated she reported the resident's complaint to her supervisor, Registered Nurse (RN) 1. Treatment Nurse 1 verified there was no documentation as to why the treatments were not done from 3/1/17 through 3/10/17 during the 7 PM to 7 AM shifts and on 3/8 and 3/9/17 during the 7 AM to 7 PM shifts. Treatment Nurse 1 unable to determine if the treatment was administered on these dates.
On 5/24/17 at 1635 hours, an interview was conducted with RN 1. RN 1 stated Treatment Nurse 1 did not report to her last week or at any time Resident 1 was not being turned by a CNA on the night shift. RN 1 stated if it had been reported to her Resident 1 was not being turned, she would have conducted interviews with Resident 1, CNAs, nurses, and followed up with the Quality Assurance Committee inquiring as to any reports of residents failing to be turned. RN 1 stated she had not conduct interviews or follow up with Quality Assurance because Treatment Nurse 1 did not report to her Resident 1 was not being turned.
On 5/25/17 at 1603 hours, an interview was conducted with LVN 3. LVN 3 was asked if Resident 1 or any staff had reported to her that Resident 1 was not being turned every two hours. LVN 3 stated Resident 1 told her that sometime during the month of March 2017 that the AM shift staff did not turn the resident every two hours while he was in bed. LVN 3 stated she reported the resident's complaint about not being turned to the AM shift nurse; however, she could not remember who the nurse was. LVN 3 stated aside from Resident 1, she was never informed by anyone else the resident was not being turned.
Review of Resident 1's Pressure Skin Condition Record dated 3/1/17, showed Treatment Nurse 1 was the first to identify the Resident 1's coccyx pressure ulcer on 3/1/17. There was no documentation of the stage of the pressure ulcer. On 5/24/17 at 1232 hours, an interview and concurrent record review was conducted with Treatment Nurse 1. Treatment Nurse 1 confirmed she did not document the stage of Resident 1's coccyx pressure ulcer on 3/1/17.
Review of Resident 1's Pressure Skin Condition Record dated 4/15/17, showed Resident 1 had a Stage IV pressure ulcer to his coccyx which measured 4.7 cm (length) x 4.0 cm (width) x 3.3 cm (depth) with tunneling of 4 cm at 9 o'clock.
The Pressure Skin Condition Record dated 4/21/17, showed the Stage IV coccyx pressure ulcer was increasing in size, it now measured 5.0 cm (length) x 4.0 cm (width) x 3.3 cm (depth). The documentation did not show the measurement for tunneling. On 5/24/17 at 1232 hours, an interview and concurrent record review was conducted with Treatment Nurse 1. Treatment Nurse 1 stated she was unsure why she had not documented the measurement for tunneling. Treatment Nurse 1 stated documentation of tunneling was necessary to determine if wound was improving or worsening.
On 5/24/17 at 1310 hours, an interview was conducted with Treatment Nurse. Treatment Nurse 1 stated photographs of Resident 1's coccyx pressure ulcer were taken on admission and when there was a change in the condition of his pressure ulcer. She said the photographs were taken when the Stage II pressure ulcer was identified, and when it deteriorated to a Stage IV. Treatment Nurse 1 stated she recalled taking the photographs of Resident 1's Stage II pressure ulcer as she was the first to identify the wound. The treatment nurse stated Resident 1's wound photographs were printed from the facility's camera, placed in the resident's medical record under the progress note section, and then the photographs were deleted from the camera. There were no photographs of Resident 1's wound in his medical record. The treatment nurse was unable to locate the photographs in the medical record or on the facility's camera.
On 5/24/17 at 1310 hours, a request was made to the ADON to review any and all photographs of Resident 1's pressure ulcer. No photographs were ever provided.
On 5/24/17 at 1350 hours, an interview was conducted with Resident 1. Resident 1 confirmed facility staff had photographed the wound to his coccyx on several occasions.
On 5/24/17 at 1436 hours, an interview was conducted with the Administrator. The Administrator stated the facility does not have a policy and procedure for taking photographs of resident wounds. The Administrator stated the facility practice was to take photographs on admission and when requested by a physician.
This violation had a direct or immediate relationship to the health, safety or security of patients or residents. |
| 010000940 |
Novato Healthcare Center |
110007964 |
B |
07-Dec-12 |
I5HC11 |
11576 |
F323 ?483.25(h) Accidents & 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. The facility failed to ensure adequate supervision and assistance devices to prevent injury to Resident 1 on two occasions when: 1) Staff did not provide adequate supervision to Resident 1 to prevent Resident 1 from falling on 11/5/10. Resident 1 sustained a fractured clavicle (collar bone) and required hospitalization for three days and 2) Staff did not ensure adequate supervision of Resident 2 when staff failed to evaluate and manage Resident 2 's wandering behaviors and staff failed to provide sufficient assistance to prevent a fall during ambulation of Resident 1 on 1/22/11. Resident 2 knocked down Resident 1 when Resident 2 wandered into Resident 1's room unsupervised. Resident 1 sustained a closed head injury with a complicated facial laceration that required extensive sutures. Findings: Incident of 11/5/10: CNA E found Resident 1 on the floor on her right side by the door of her room on 11/5/2010. Resident 1 was agitated, combative, grimacing, and moaning. She was admitted to an acute care facility with a black and blue mark on her right forehead, a hematoma on the right side of her forehead, and a new right clavicle fracture. 1. During an interview on 2/11/11 at 3:15 p.m., Certified Nursing Assistant (CNA) E stated Resident 1 tried to stand but was unstable and could not balance herself without help. CNA E stated she discovered Resident 1 on the floor near the door of her room with the right side of her head touching the floor sometime before dinner on 11/5/10. Resident 1's clinical record was reviewed on 2/11/11 at 11 a.m. and 2/14/11 at 4:30 p.m.A minimum data set (MDS) assessment tool, dated 10/20/10, showed Resident 1 needed an interpreter. Her hearing was adequate and her speech was clear. She was sometimes able to understand others and sometimes able to make herself understood. Resident 1 suffered both long and short term memory problems and wandered daily. The MDS indicated she required supervision and setup assistance from staff to transfer between surfaces, walk in room and corridor, and to move between locations. The MDS indicated her balance during transitions and walking was "not steady." She was "only able to stabilize with human assistance". Resident 1 required assistance to steady herself when moving from seated to standing and transferring between bed and chair. Resident 1 did not use any mobility devices (i.e. walker, WC, cane). The MDS of 10/20/10 indicated Resident 1 had had one fall with injury since the previous assessment and Resident 1 did not receive physical or occupational therapy or restorative nursing services including transfer or walking. A "Fall Injury Prevention" care plan dated 5/11/09 indicated Resident 1 had a history of falls. The care plan identified interventions to assist with ambulation and transfers as needed. A Change in Condition Assessment, (CIC) dated11/5/10, indicated Resident 1 was at risk for falling due to poor safety judgment, side effects of medications, disorientation/confusion, unsteady gait, and the need for assistance to the restroom. The CIC indicated CNA E found Resident 1 on the floor on her right side by the door of her room agitated, combative, grimacing, and moaning. The CIC further indicated Resident 1 had a hematoma (localized swelling, filled with blood) that measured three centimeters (cm) x three cm. and a bleeding abrasion on her right forehead that measured 0.2 cm x 0.2 cm.Physician's order of 11/5/10 read to send Resident 1 to an acute care facility emergency room for CT-scan (computer imaging exam) of her head after the fall. The acute care admission history & physical (H & P), dated 11/5/10, indicated Resident 1 was admitted due to a black and blue mark on her right forehead, a hematoma on the right side of her forehead, and a new right clavicle fracture.A "Nursing Admission Assessment", dated 11/8/10, indicated Resident 1 was re-admitted to the Skilled Nursing Facility (SNF) from the acute care hospital after a fall on 11/5/2010. The assessment indicated Resident 1 had a right clavicle fracture. There was a green/yellow bump on her right forehead that measured 4 cm x 3.6 cm, and green / yellow discoloration on her right face, right neck, right shoulder and her clavicle. The assessment showed a dry scab from a skin tear below the right knee and blue discoloration on the left foot. The assessment further indicated Resident 1's right arm was kept in a sling at, "All times." When interviewed on 2/15/11 at 11:05 a.m., Resident 1's physician stated Resident 1 had fallen a number of times prior to 1/22/11. He indicated the ecchymosis from the head injury usually took 8 weeks to clear and the center of the hematoma may never clear. He stated Resident 1 ambulated independently for short distances, had "pretty good" balance, but was also weak, had "mild" dementia. Resident 1's physician stated that after dinner and breakfast there were a lot of people walking around in the facility and, "That confusing mass migration may contribute to some of the falls." Resident 1's physician stated Resident 1 may have needed to reside in an area where there were not a lot of people "milling around" and the rooms to doors were not all open.The facility policy, "Fall Prevention and Incident Management," dated 9/8/09, indicated it was the facility policy to plan interventions and implement procedures to prevent falls and / or accidents. Incident of 1/22/11: On 1/22/11 at 2:40 a.m., Resident 2 entered Resident 1's room, tried to get in Resident 1's bed, and knocked down Resident 1 and CNA C. Resident 1 fell to the floor face first and suffered a closed head injury, with a complex facial laceration which required approximately 22 sutures. On 2/14/11 at 10:10 a.m., Resident 2 lay in bed in the fetal position, making chewing motions. Resident 2 stared straight ahead and was non-responsive to questions. Resident 2 was unattended and there was no Velcro barrier on her door. On 2/14/11 at 11:50 a.m., the Social Services Director (SSD) stated Resident 2 wandered into other residents' rooms and got in their beds every day during all shifts.On 2/14/11 at 4:50 p.m., Licensed Nurse (LN) G stated Resident 2 wandered and needed to be redirected by staff at, "All times." LN G stated Resident 2 was forgetful and tended to get lost when trying to find her room. LN G stated Certified Nursing Assistants (CNA) were successful at preventing Resident 2 from getting into other residents' rooms, on a "few occasions."Resident 2's clinical record was reviewed on 2/14/11 at 1 p.m.The Minimum Data Set (MDS) assessment tool, dated 9/9/10, indicated Resident 2 had short and long term memory problems, severely impaired cognitive skills, rarely understood others, was restless, made repetitive physical movements, and wandered. The MDS indicated Resident 2 required supervision while moving in corridors.The Resident Assessment Protocol (RAP), dated 9/24/10, generated from the 9/9/10 MDS indicated Resident 2's wandering behavior triggered a nursing care plan for mood/behavior. The "Mood and Behavior," care plan, dated 6/10/10, indicated Resident 2 wandered and, "Throws herself in bed when she wants to go to bed."The care plan lacked documented evidence of any specific approaches to address the wandering or the "throwing" of herself into bed. The care plan document had a typewritten choice of an approach to evaluate the need for wandering management and assist with ambulation as needed, however this approach was not checked as an active intervention.The "Change in Condition," (CIC) note, dated 12/8/10, indicated Resident 2 was confused, wandered, and "jumped" into bed whenever she (Resident 2) tried to lie down. "Resident Weekly Summary," (RWS) notes for 1/18/11 - 1/24/11, dated 1/24/11, indicated Resident 2 was confused and forgetful, but there was no significant change in Resident 2's condition. The 1/24/11 note lacked documentation of the incident related to Resident 2 wandering into Resident 1's room and knocking her (Resident 1) down on 1/22/11. RWS notes, dated 6/28/10 - 2/9/11, lacked documentation related to monitoring Resident 2's episodes of wandering and/or throwing herself into bed.On 2/14/11 at 11:40 a.m., CNA C stated Resident 2 tried to get into other resident's beds every day. CNA C signed a declaration which documented "On...1/22/11 at 2:40 a.m., I took (Name deleted - Resident 1) to the restroom, on the way back to her bed, I was holding her by her upper arm when (Name deleted - Resident 2) ran toward (Name deleted - Resident 1's) bed.... (Name deleted - Resident 2) bumped me from behind and knocked us forward. (Name deleted - Resident 1) fell to the floor face first... (Name deleted - Resident 2) tries to get in other resident's beds everyday..."During an interview on 2/15/11 at 4:40 p.m., the Director of Nursing (DON) stated Resident 2 wandered, did not know where her room was, and required assistance from staff to redirect her (Resident 2). The DON stated she was not aware Resident 2 went into other residents' rooms.On 2/11/11 at 9:55 a.m., Resident 1 had a black scab in the middle of her forehead and there was bruising on her left cheek. Resident 1 moaned and pointed her finger in response to greeting, but did not form words. During a closer observation on 2/14/11 at 10:20 a.m., Resident 1 had green and purple discoloration around both of her eyes, green discoloration in her hair line, and a black scab on her forehead. An acute care emergency department (ED) report, dated 1/22/11, indicated Resident 1 suffered a closed head injury, and a complex facial laceration (about 10 centimeters) which required approximately 22 sutures in Resident 1's scalp. The ED report indicated closing the laceration was difficult due to the complexity of the laceration and the large amount of trauma. A computerized tomography (CT) scan (CT scan - uses x-rays to make detailed pictures of the inside of the body) of Resident 1's head, dated 1/22/11, indicated Resident 1 suffered soft tissue swelling on her frontal scalp. A, "Change in Condition Assessment," (CIC) dated 1/22/11 at 2:40 a.m., indicated Resident 1 fell to the floor when a CNA that was assisting Resident 1 lost her grip on Resident 1's right arm due to another resident rushing past. The CIC indicated Resident 1 sustained a laceration to her forehead.An interdisciplinary conference note, dated 1/24/11, indicated the 1/22/11 fall was, "Best attributed to...CNA pushed by another resident who walked into the room accidentally." When interviewed on 2/11/2011 at 10:30 a.m. Licensed Nurse B stated there was no padded mat next to Resident 1's bed on 1/22/11. Therefore, the facility violated the regulation when: 1. Facility staff did not provide supervision to prevent Resident 1 from falling and suffering a fractured clavicle (collar bone) on 11/5/10, resulting in a three day admission to an acute care hospital and, 2. Facility staff did not evaluate, manage or assist Resident 2 for unsafe wandering behaviors. This resulted in Resident 2 wandering into Resident 1's room and knocking Resident 1 down to the floor on 1/22/11. Resident 1 sustained a closed head injury and a complicated facial laceration that required approximately 22 sutures. These failures had a direct or immediate relationship to the health safety and security of Resident 1 and Resident 2. |
| 010000940 |
Novato Healthcare Center |
110008780 |
B |
01-Mar-12 |
LRK411 |
7905 |
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 violated the regulation by failing to protect a resident from an abusive situation when the facility's business office staff (Business Staff A) verbally abused a resident in an effort to have the resident (Resident 1) complete a Medi-Cal (Medicaid) insurance form. On 11/03/11, the Department received a Report of Suspected Dependent Adult/Elder Abuse (SOC-341), indicating "Resident reported on 11/2/11, during an IDT (interdisciplinary team) meeting, which included the Admin (Administrator) and Ombudsman, that she (Resident 1's name) had a verbal argument with (Business Staff A's name) and that she was abusive." A copy of a hand written statement, dated 10/19/11, signed by Resident 1's roommate (Resident 2) was also included in the Self-Reported Incident. The statement was a document of what Resident 1's roommate's had witnessed on the 10/19/11, during the conversation between Business Staff A and Resident 1. The conversation was regarding money owed to the facility by the resident. On 11/4/11, Resident 2's witnessed statement indicated that Business Staff A came into the room to tell Resident 1 that "Tomorrow is October 20th and they need payment now." Resident 1 attempted to explain to the business office staff that she had three insurances.The document indicated that the business staff did not listen and stated she had heard this before. The document further indicated that "(Business Staff A's name) replied by saying (in a disrespectful tone and passive-aggressive body language), the past is done, it only matters from today, and today she wants to see the Medi-Cal application." Resident 1 then told the business staff she had started to work with HICAP (Health Information Counseling Advocacy Program) about her primary insurance.The document indicated that Business Staff A, in a loud voice, wanted the name and phone number of the HICAP person helping her. Resident 1 and Business Staff A looked through the resident's paper work and as Resident 1 attempted to show her paperwork which showed she had other insurance coverage.Business Staff A said angrily, your Medi-Cal application is not here and continued to state that the Medi-Cal application needed to be completed. "Almost yelling at (Resident 1) Business Staff A stated that (Resident 1) has only paid "two times", and owes around $24,000." Resident 2 indicated, in her statement, that this was the third conversation put upon Resident 1 however this was the most aggressive one. Resident 2 concluded her written document by indicating that she was a teacher and accountant and that it was very hard to understand how Business Staff A was handling Resident 1's situation. On 11/4/11 at 9:42 a.m., Resident 2 was interviewed. She stated that she stood by her hand written document and had forgotten to include that Business Staff A was defensive about Resident 1 informing her that she had gone to the, organization across the street, which is called HICAP (Health Information Counseling Advocacy Program) for help with her insurance information issue. She stated that Business Staff A told Resident 1 to walk across the street and find out who she talked to and Resident 1 just sat down like she was overwhelmed. "[Resident 1's name] tried to show [Business Staff A] what paper work she had" however, Business Staff A was only concerned about getting Resident 1 to fill out the Medi-cal application she had for her. Resident 2 stated that no matter what Resident 1 showed her, the business office staff was not satisfied. "(Business Staff A) raised her voice several times and threw up her hands and walked out." Resident 2 indicated that she was disturbed by the treatment that Resident 1 received "I felt it was disrespectful - to the point of abuse." On 11/4/11, review of Resident 1's clinical record included demographic information which indicated that the resident was admitted to the facility, for rehabilitation. The resident's history and physical examination, upon admission, indicated that the resident had the capacity to understand and make decisions. The resident's clinical record included an initial admission assessment and a quarterly assessment Minimum Data Set (MDS, a tool used to provide a comprehensive assessment of each resident's functional capabilities to assist staff to identify health problems) dated 6/29/11 and 9/29/11 respectively. The MDS's indicated the patient had no cognitive impairments and she was able to understand others and made herself understood. On 11/4/11 at 10:05 a.m. Resident 1 was interviewed regarding the 10/19/11 meeting with Business Staff A. She stated that the more she thought about that meeting, the more she felt like the business staff was verbally "abusive" towards her. Resident 1 stated "Her body language was leaning forward to me, shaking fist and finger waving her arms raising voice. She was accusatory. I was irritated at the way she talked to me. She was totally inappropriate." Resident 1 stated that although one of her insurance companies had informed her that her coverage had ended in 07/19/11, she had two other insurances that could possibly cover the cost of the charges for her stay and had the paperwork in her room. She ended the interview by stating "I would tell anyone who is to talk to (Business Staff A) to have someone in the room with them." On 11/4/11 at 11:40 a.m., Social Service Staff B was interviewed. Although Social Service Staff B stated she had tried to help Resident 1 to fill out the application for the Medi-Cal insurance, she did not discuss the issue regarding the Resident's other insurance coverage's in detail with the resident. On 11/4/11 at 12:55 p.m. Business Staff A was interviewed. She stated that Resident 1 had been sent a letter from her primary insurance indicating that her insurance coverage had ended as of 7/18/11. Business Staff A stated she had tried to help the resident complete the Medi-Cal application and also had asked Social Service Staff B to do the same. She stated she did not remember being mad at Resident 1 on 10/19/11. Upon inquiry as to whether Business Staff A had tried to help the resident locate the paperwork for the other alleged insurance coverage's, she stated she did not remember. On 11/8/11 at 11:05 a.m., Resident Care Coordinator C was interviewed. She stated she was aware about the resident's insurance coverage that had ended in July and stated that the letter provided the resident with appeal rights. She was asked if she assisted the resident in contacting the primary insurance who had issued a denial letter to her in July regarding her insurance coverage ending. She stated she believed she told the resident she could contact the primary insurance carrier. The Resident Care Coordinator C stated that if a resident needs help with contacting insurance carriers, she refers them to the business office. "They know more about this than I do." The facility's policy titled Abuse Reporting, last revised on 10/1/02 was reviewed on 11/4/11. The policy indicated a description of Abuse of Elder or Dependent Adult. The description indicated "Physical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment with the resulting physical harm or pain or mental suffering." The above caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 010000940 |
Novato Healthcare Center |
110009322 |
B |
07-Dec-12 |
I5HC11 |
5174 |
F323 ?483.25(h) Accidents & 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. The facility violated the regulation when facility staff did not monitor Resident 1 when the diet order was changed and a swallow evaluation was ordered by the physician, two days prior to Resident 1 choking on a large piece of an orange, resulting in Resident 1 being sent to an acute care facility when she (choked) on a large piece of an orange. Review of Resident 1's clinical record on 2/11/11 at 11 a.m., revealed Resident 1 was admitted to the facility on 4/25/08.A minimum data set (MDS) assessment tool, dated 10/23/09, indicated Resident 1 had long and short term memory problems and required supervision while eating. During an interview and concurrent record review on 2/15/11 at 11:55 a.m., Licensed Nurse (LN) B reviewed a Change in Condition (CIC) assessment, dated 3/19/10, and stated Resident 1 was sitting in front of the nurse's station on 3/19/10 at 11:50 a.m. when he (LN B) noticed Resident 1 was pale and weak. The CIC indicated the Oxygen content of Resident 1's blood was 87 - 88%. LN B stated he called Resident 1's physician and received an order to keep the Oxygen content of Resident 1's blood above 90%. LN B stated Resident 1 spat at LN B, Certified Nursing Assistant (CNA) F, and the floor. LN B further stated CNA F tried to feed Resident 1 at lunch but Resident 1 refused and continued to spit. CNA F checked the Oxygen content of Resident 1's blood a second time and it was, "Still in the 86, 87, 88% range." LN B stated Resident 1 was sent to the acute care hospital via 911. LN B reviewed physician orders and stated Resident 1 was on a mechanical soft diet (dated 3/17/10) two days before Resident 1 turned pale and weak. An acute care emergency department (ED) note, dated 3/19/10, indicated Resident 1 suffered a hypoxic (insufficient Oxygen in the blood) event from a large piece of an orange obstructing her airway that was unrecognized by staff at the Skilled Nursing Facility (SNF). The ED note indicated paramedics removed the piece of orange from Resident 1's mouth when they arrived at the skilled nursing (SNF) facility. The ED note further indicated the Oxygen content of Resident 1's blood on room air was 97%, without hypoxia, and Resident 1 did not show signs of airway obstruction or distress after the slice of orange was removed from Resident 1's airway. During an interview and concurrent record review on 2/15/11 at 1:15 p.m., the Speech Language Pathologist (SLP) reviewed physician orders: 1. Change to mechanical soft diet, NAS, fortified, dated 3/17/10 (Wednesday, two days before Resident 1 choked on a slice of orange). 2. Refer to SLP for screen, dated 3/17/10, two days before Resident 1 chokedon a slice of orange. 3. SLP evaluation and treatment secondary to choking, dated 3/19/10. 4. Check Oxygen saturation (Oxygen content of blood) every shift for three days, dated 3/19/10. 5. Send to acute care emergency room via 911 for further evaluation andtreatment, dated 3/19/10. 6. D/C mechanical soft diet, dated 3/19/10. 7. Puree, NAS, fortified diet, dated 3/19/10. 8. SLP clarification order: SLP three times per week for four weeks for diet strategy/trials, safety assessment, following directions, recall, training / education, dated 3/23/10, six days after Resident 1 choked and the SLP evaluation order, dated 3/17/10. A rehabilitation notification form for a SLP evaluation and new treatment orders, for choking was dated 3/19/10, two days after the physician order for SLP screen, dated 3/17/12. The SLP stated Resident 1 was on a mechanical soft diet, NAS, fortified on 3/19/10 when Resident 1 choked. The SLP stated she did not receive a referral for a swallow evaluation per the physician order, SLP for screen on 3/17/12, and did not perform a swallow evaluation until 3/23/10, after Resident 1 returned from the acute care hospital for choking. The SLP stated Resident 1 had dysphagia and orange slices were not part of a mechanical soft diet. During an interview and concurrent document review on 2/15/11 at 3:40 p.m., the Dietary Supervisor (DS) stated the cycle 2 menu reflected the same diets served during the week of 3/14/10 - 3/20/10. The DS stated canned fresh oranges were not part of the mechanical soft diet. During an interview on 2/15/11 at 4:40 p.m., the Director of Nursing (DON) stated she expected licensed nurses to follow up and monitor residents when a diet order was changed. The DON further stated SLP evaluations were to be completed within 24 hours of the physician order.Therefore the facility violated the regulation when facility staff did not monitor Resident 1 when the diet order was changed and a swallow evaluation was ordered by the physician, two days prior to Resident 1 choking on a large piece of an orange, resulting in Resident 1 being sent to an acute care facility when she (choked) on a large piece of an orange. This failure had a direct or immediate relationship to the health safety and security of Resident 1. |
| 110000046 |
Napa Valley Care Center |
110009855 |
A |
25-Apr-13 |
D5FU11 |
8038 |
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 violated the regulation by failing to ensure that Resident 1, who was at risk for falls and known to make ongoing attempts to get out of the wheelchair unassisted, was assessed for adequate supervision, and the nursing care plans were revised to include effective interventions related to Resident 1's getting out of the wheelchair unassisted. These failures resulted in Resident 1 sustaining a cervical fracture of the second vertebrae (Cervical spine fractures of the second vertebrae occur mainly when the face or chin strike an unyielding object with the neck extended), and Resident 1's forehead laceration from the fall the day before reopened when she attempted to get up unassisted and fell from her wheelchair. Resident 1 was a 90 year old female admitted to the facility on 4/28/09, with diagnosis including dementia with delusions, osteoporosis (a disease of bones that leads to increased risk of fracture). The Minimum Data Set (MDS) dated 4/19/10 and 7/15/10 revealed that Resident 1's cognitive skills for daily decision making were severely impaired and Resident 1 required extensive assistance for transferring and ambulation. First Fall A Fall Risk Assessment, completed upon admission dated 4/29/09, revealed that Resident 1's score was 18 (A total of 10 or above represents high risk for falls).The Interdisciplinary progress notes, dated 7/6/09, included a review of the Resident's fall on 7/3/09 and revealed that Resident 1 was at the nurse ' s station in a wheelchair and attempted to stand and walk. The resident fell before staff could reach her.The nursing care plan, dated 7/6/09, indicated a referral to physical therapy for evaluation for possible ambulation and a wedge cushion to be used in the wheelchair to decrease risk of falls. There were no effective measures considered regarding adequate supervision to prevent Resident 1 from attempting to get out of the chair unassisted. Second Fall The resident assessment protocol (RAP - a tool used to identify patient concerns and develop an individualized nursing plan of care) dated 7/14/10, indicated that Resident 1 was at risk for falls due to an unsteady gait, joint pain, a previous hip fracture, osteoporosis, impaired hearing, delirium and Alzheimer's disease.The Interdisciplinary progress notes dated 7/21/09 included a review of Resident 1's fall on 7/20/09. Resident 1 stood up and got her feet tangled in the wheelchair foot rests and fell before staff could reach Resident 1. Resident 1 was seated at the nursing station at the time of the fall. The nursing care plan dated 7/21/09 indicated that Resident 1's wheelchair was switched by physical therapy for wheelchair with a comfortable position. There was an undated entry to include a wheelchair alarm (to alert staff when residents stood). There were no effective measures considered regarding adequate supervision to prevent Resident 1, whose cognition was severely impaired, from attempting to get out of the chair unassisted. A Fall Risk Assessment dated 7/29/09 was conducted 8 days after the fall and Resident 1 scored 16, indicating a high risk for falls. Third Fall A Fall Risk Assessment dated 4/15/10 revealed Resident 1's fall risk score was 15. A total of 10 or above represents high risk for falls. The Interdisciplinary progress notes, dated 8/3/10, included a review of Resident 1's fall on 8/2/10 at 4:35 p.m. Resident 1 had a witnessed fall, by visitors. The resident was seated in a wheelchair at the nursing station. Resident 1 stood up while holding the wheelchair and fell forward. Resident 1 was found by nursing staff lying prone with head facing left. Resident 1 was noted to have a 3 centimeter laceration to the mid forehead with significant bleeding and bone exposure. The plan included "continue with wedge cushion and wheelchair alarm, will have medications reviewed by the physician." There were no effective measures considered to prevent Resident 1 from attempting to get out of the chair unassisted and providing adequate supervision to prevent accidents. During an interview on 4/8/12 at 1:40 p.m., Licensed Nurse C stated that Resident 1 had a wheelchair alarm and made multiple attempts to get out of the wheelchair triggering the wheelchair alarm. Licensed Nurse C stated that she redirected Resident 1 to sit down. Resident 1 was sent to the emergency department via ambulance for evaluation and for the open laceration. Resident 1 received sutures to close the forehead laceration. Resident 1 returned to the facility the next morning on 8/3/10 at 8:30 a.m. Fourth Fall The Interdisciplinary progress notes dated 8/4/10 revealed that Resident 1 had a fall on 8/3/10 at 7:10 p.m. This was approximately 10 hours after Resident 1 returned to the facility from the acute care hospital and the skilled nursing facility resumed care of Resident 1. "Resident had a fall in hallway outside of resident own room near the emergency exit. Resident was lying face down when staff arrived. Previous laceration to forehead reopened ......Resident was transferred to emergency room via ambulance at 7:35 p.m." During an interview, on 4/8/12 at 1:40 p.m., LN C stated that Resident 1 was propelling the wheelchair with her feet around the facility as usual on her shift. When LN C was in another residents ' room she heard a loud boom noise and went to investigate. LN C stated that Resident 1 was found face down on the floor near her room, wedged into the exit door. "We had to open the exit door to get to her."During an observation on 4/7/12 at 1:30 p.m.,Resident 1's room was near the end of the hallway. The hallway was carpeted which changed to tile approximately 15 feet leading to the exit door. The acute care hospital emergency room notes, dated 8/3/10, revealed a large jagged 5 cm laceration on the frontal region of the head, and a CT scan of the cervical spine revealed a complex fracture of second cervical vertebra. Resident 1 was transferred to another acute care hospital for neurological surgery evaluation and as a result of the traumatic cervical injury Resident 1 required a higher level of care. During an interview, on 1/31/13 at 3 p.m., when asked how the facility provided adequate supervision and effective interventions to prevent falls, Administrative Staff D stated that they had attempted to keep Resident 1 close to the nursing station where nurses could see Resident 1. The nurses sometimes kept Resident 1 beside the medication cart, while passing medications to other residents, to observe and redirect attention as soon as possible. Resident 1 was always restless and propelled the wheelchair around the facility and into residents ' rooms with her feet. Administrative Staff D also stated that it was difficult to keep Resident 1 in one area.The Fall Prevention Program Policy, undated, included: Frequent observation of the resident...providing timely intervention to minimize risk...being able to identify causative factors, should a fall occur, and then accelerate the care plan with new interventions to prevent further falls.The facility violated the regulation by failing to ensure that Resident 1, who was at risk for falls and known to make ongoing attempts to get out of the wheelchair unassisted, was assessed for adequate supervision and the nursing care plans were revised to include effective interventions related to Resident 1's getting out of the wheelchair unassisted. These failures resulted in Resident 1 sustaining a cervical fracture of the second vertebrae and Resident 1's reopening the forehead laceration sustained in a fall the previous.The violation of this regulation/these regulations presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000980 |
Northgate PostAcute Care |
110009981 |
B |
16-Jul-13 |
NO5Z11 |
891 |
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.Based on interview and record review, the facility failed to report allegations of abuse within the required time frame of 24 hours.Findings: Nurses notes on 6/7/2013 at 11:35 p.m., indicated that Resident 1 made an allegation of abuse to facility staff on 6/7/2013 at 11:30 p.m. The CDPH ERI intake form and the faxed documents from the facility indicated the facility did not report to CDPH until 6/9/2013 at 8:19 p.m.In an interview with the Administrator, on June 11, 2013 at 12:40 p.m., The administrator stated that Resident 1 was out of the facility on the weekend of June 8 and June 9 thus the reason for her not finishing her investigation of the ERI and reporting. |
| 110000046 |
Napa Valley Care Center |
110010226 |
A |
03-Jul-14 |
DF9111 |
10911 |
F309 ? Provide Care/Services for Highest Well Being - 483.25Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility violated the regulation by failing to: 1. Ensure that the Licensed Staff provide continued nursing assessment, 2. Develop the Resident's plan of care for treatment of a penile cut, 3. Notify the attending physician promptly of changes to the skin, and 4. Document treatments and findings in the resident's medical record of the changes to Resident 1's cut on the head of his penis, resulting in a full erosion of the penile shaft down to the scrotal sack.Findings: Resident 1 was admitted on 4/11/13 with a diagnosis of urinary obstruction with an indwelling catheter (catheter is a hollow flexible tube that is used to drain urine from the bladder) inserted. Physician orders, dated 4/11/13, "Please exchange Foley catheter every month.? It was last exchanged 3/28/13." During an interview on 11/6/13 at 11:30 a.m., Physician L stated that Resident 1's order was for the catheter to be changed on or around the 28th of each month. Physician L stated that the last catheter change was on 3/28/13 and the next catheter changes should have been on 4/28/13, 5/28/13, 6/28/13, 7/28/13,... Physician L also stated that the facility should have called the medical provider on 7/21/13 due to the cut. "The cut falls under wound care which takes everything to another level."During an interview on 8/20/13 at 10 a.m., Administrative Staff A stated that indwelling catheters are only changed out on as needed basis and not once a month. Administrative Staff A stated that Resident 1 was not taken to a higher level of care, by the facility, as his current medical provider would not cover the cost without a specific order. Nursing notes dated 7/19/13 at 5:30 a.m., indicated that License Staff F wrote "Spoke to previous NOC (night shift licensed nurse) nurse about the redness on penis, stated that AM's was aware and were addressing the issue. They will continue to monitor." Nursing notes dated 7/21/13 at 5:31 a.m., revealed, "Reported to AM's that get treatment nurse to evaluate redness and inflammation on penis, resident is combative and difficult to assess. No temps. vitals WNL (within normal limits), faxed MD and left in rounder (file)." On 7/22/13 at 5:40 a.m., "Redness on penis noted, inflammation, some drainage, Foley draining cloudy urine, no blood, resident combative, resistive to assessment, will have AM's follow up with FAX and visual inspection with MD today."During an interview on 8/26/13 at 2:50 p.m., Licensed Staff F stated that she first noticed the cut on the head of the penis on 7/21/13 and sent a fax to Resident 1's physician at 7:00 a.m. Licensed Staff F stated that she would have day shift nurses follow up with the fax that she sent, as she was going off duty and would not be back until 7/28/13. During an interview on 8/20/13 at 2:45 p.m., Licensed Staff E stated that she noticed a cut on the head of the penis of Resident 1 on 7/21/13 at 7 a.m. but did not document anything. Licensed Staff E stated that she received a faxed order to change the Resident 1's indwelling catheter on 7/22/13. No notes were completed as she did not change the indwelling catheter, she had another nurse do it and she only assisted. Licensed Staff E stated that she relies upon the Certified Nursing Assistant (CNA) to tell her if there are any problems with the residents.During an interview on 8/23/13 at 1:30 p.m., Licensed Staff G stated that he was asked by Licensed Staff E to change Resident 1's indwelling catheter on 7/22/13. Licensed Staff G stated that he did not remember what Resident 1's penis looked like or what size catheter was placed. Licensed Staff G stated that he did not chart on Resident 1 as Licensed Staff E indicated that she would chart everything. Licensed Staff G also stated that he should have charted what he saw and what he did as that is a nursing requirement and facility policy. During an interview on 8/30/13 at 2:15 p.m., Nurse Practitioner D stated that she first observed the cut on the head of the penis of Resident 1 on 7/22/13. Nurse Practitioner D stated that she wrote orders for the care of Resident 1 on 7/22/13 assuming they would be carried out, and if there was a problem she would have received a report from the facility?s licensed staff. A Nurse note indicated that on 7/22/13 at 2:12 p.m., that Licensed Staff E wrote, "Resident noted with redness and drainage from penis [Nurse Practitioner named], assessed and additional orders to change F/C (Foley catheter), collect UA (urinalysis), C&S (culture and sensitivity), clean penis daily with mild soap & water apply bacitracin to tip of penis, urine sample collected and placed in ref (refrigerator) for pickup." No documentation of assessments of Resident 1 were noted in the medical record concerning the cut or the redness on the head of the penis or that Licensed Staff E completed an assessment with the Foley catheter in place or that the Foley catheter had been changed.A fax was noted from Nurse Practitioner D dated 7/22/13 to "Change out F/C, send UA C&S per protocol, clean penis daily with mild soap and water, apply bacitracin ointment to outer tip of penis."Nursing plan of care for penile erosion, dated 8/2/13, a nursing plan of care was developed 5 days after staff identified the changes in Resident 1's skin. The plan of care indicated that staff were to change the Foley catheter every month and as need if the Foley was leaking, plugged or pulled out.During an interview on 8/26/13 at 3:45 p.m., Licensed Staff H stated that she was on duty for three days, 7/25/13, 7/26/13 and 7/27/13, during the day shift. Licensed Staff H stated that Resident 1 was not improving and the Resident 1's penis had started to split open but she did not document anything. Licensed Staff H stated that she was told by other staff that Nurse Practitioner D was taking care of it. The physician's orders to "Change out F/C (Foley catheter), send UA (urinalysis), CS (culture and sensitivity) per protocol, clean penis daily with mild soap and water, apply bacitracin ointment to outer tip of penis" were not carried out from 7/22/13 to 7/28/13. During an interview on 9/3/13 at 2:10 p.m., Licensed Staff I stated that she was on duty during the night shift on 7/26/13 and 7/27/13. Licensed Staff I stated that she was not concerned about Resident 1 as Nurse Practitioner D and the other nursing staff knew about Resident 1. Licensed Staff I stated that she failed to chart assessments or observations of Resident 1. No physician orders were carried out.During a record review on 8/19/13, a nursing note made by Licensed Staff F, in Resident 1's medical record, indicated that on 7/28/13 at 6:28 a.m., "Foley draining well, clear yellow urine, cath intact protruding from penis. Penis is still red swollen with what appears to be a slit down the side with Foley cath protruding. The base of the penis has open area that was cleansed with warm soap and water, bacitracin applied, Resident complaining of pain."During an interview on 8/26/13 at 2:50 p.m., Licensed Staff F stated that upon her return on 7/28/13 she assessed the penis of Resident 1 and discovered that "His penis was spit open like a sausage." Licensed Staff F stated that she also relies on CNA's to inform her of resident problems. During an interview on 8/19/13 at 1 p.m., Family Member C stated that she was informed by the facility of a cut on the head of Resident 1's penis on 7/30/13. Family Member C stated that upon visiting Resident 1 on 7/31/13, she requested to see Resident 1's penis. Family Member C stated that the indwelling catheter was still inserted in the penis and Resident 1 had a cut on his penis the entire length of Resident 1's penile shaft. Family Member C stated that she confronted Administrative Staff A and Nurse Practitioner D who were both not aware that there was a cut the entire length of Resident 1's penile shaft. During an interview on 8/30/13 at 2:15 p.m., Nurse Practitioner D stated, ?I did not see Resident 1's penis again until 7/28/13,? when she was informed of the cut on Resident 1's penis. During an interview on 10/22/13 at 2:55 p.m., Physician K stated that if the penile erosion were found sooner a suprapubic (A suprapubic catheter is a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the abdomen, a few inches below the navel in the abdomen) catheter could have been placed and the penile erosion could have been prevented. The facility's policy titled "Catheter Care, Urinary", dated October 2010, indicated that "The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual (s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 5. Any problems or complaints made by the resident related to the procedure. 6. How the resident tolerated the procedure. 7. The signature and title of the person recording the data". The facilities Policy and Procedure does not indicate how staff will follow up on conditions pertaining to drainage, redness, bleeding, irritation, crusting, or pain. During an interview on 10/9/13 at 1:30 p.m., Administrative Staff J stated that the facility does not have a policy for skin assessments or wound care but does have a policy for Pressure Ulcer Risk Assessment. The policy "Pressure Ulcer Risk Assessment", dated 10/2010, indicated that "Staff will maintain a "Skin alert", performing routine skin inspections daily or every other day as needed, Nurses are to be notified to inspect the skin if skin changes are identified", and "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."Therefore, the facility violated the regulation by failing to: 1. Ensure that the Licensed Staff provide continued nursing assessment, 2. Develop the Resident's plan of care for treatment of a penile cut, 3. Notify the attending physician promptly of changes to the skin, and 4. Document treatments and findings in Resident's medical record of the changes to Resident 1's cut on the head of his penis, resulting in a full erosion of the penile shaft down to the scrotal sack. The violation of this regulation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 110000046 |
Napa Valley Care Center |
110011054 |
A |
09-Oct-14 |
J5B111 |
10448 |
B820 T22DIV5 CH3 ART 3-72311(a)(1)(B) 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. The facility violated the regulation by failing to ensure staff developed an effective fall prevention nursing plan of care for Resident 1 who was at high risk for falls and known to get up unassisted. This failure resulted in the resident walking out of the facility unsupervised to an outside patio, falling, and sustaining multiple facial fractures and other injuries.Resident 1's demographic record data, undated, indicated Resident 1 was admitted on 5/16/12 with multiple diagnoses which included muscle weakness and difficulty in walking. Fall Risk Assessments, conducted on 5/17/12 and 8/22/12 scored Resident 1 at "14" (10 or greater is considered high risk). MDS (an assessment tool), dated 5/23/12, indicated Resident 1 was not steady walking and needed stabilization with staff assistance from a sitting to a standing position. Resident 1 needed extensive assistance with ambulation with 1 person assist. Resident 1's "Fall Risk" care plan, dated 5/17/12, indicated, under "Concerns," the resident had a history of falls, had cognitive deficits and poor safety awareness, decline in function and impaired mobility. The interventions indicated staff were to anticipate needs and identify unsafe behaviors. A box was checked next to the statement that "Bed/Chair alarms for residents who exhibit unsafe behaviors/unassisted transfers/ambulation." The nursing plan of care did not specify how staff were going to provide supervision to keep the resident safe so the resident would not get up without assistance or walk inside and outside the room without asking for support. The goal was Resident 1 would not experience any falls or injuries from falls daily. On 6/25/14 at 10:15 a.m. during an interview and record review of the resident's "Fall Risk" care plan of 5/17/12, Licensed Staff B stated the care plan did not specifically identify the resident's unsafe behaviors of walking without an assistive device or removing the alarms."Nurses Notes," dated 5/24/12 indicated the resident was seen transferring himself from the wheel chair to his bed. The notes indicated a wheel chair alarm was "put on for precaution." IDT (interdisciplinary team) progress notes dated 6/28/12 and 7/5/12 from physical therapy described the resident's gait as being able to walk 150 feet two times a day with the assistance of a caregiver and a cane. Transfers were to be done with stand by assistance. There were no unsafe behaviors identified in the notes even though the resident had been seen transferring himself without assistance on 5/24/12. The IDT note did not indicate that the resident's care plan was updated to include stand by assistance for transfers or that the resident needed an assistive device and another staff in order to walk safely. "Nurses Notes," dated 7/18/12, indicated the resident was observed slowly walking inside his room without calling for assistance. The resident was reminded to ask for help. The Physical Therapy (PT) Discharge Summary, 7/11/12, indicated that after two months of therapy the resident required stand-by assist when moving from a sitting to a standing position and required a front wheel walker with stand by assistance when ambulating. The "Fall Risk" care plan indicated interventions were not updated to include information from the physical therapy discharge summary: stand by assistance when transferring or an intervention to require the resident to use a front wheel walker and stand by assistance when ambulating. An IDT note, dated 8/20/12, indicated the resident was alert and normally ambulated independently in just the ST 3 (nursing station 3) hallway. During an interview on 6/25/14 at 10:15 a.m., Licensed Staff B stated that PT and nursing staff can update the care plans and that staff discuss recommendations with IDT.During an interview on 10/10/13 at 1:48 p.m. Unlicensed Staff C stated she worked with the resident two days a week but not on the day the resident fell. Unlicensed Staff C stated that the resident had a bed alarm. Unlicensed Staff C stated the resident needed help getting out of the bed but not out of the chair. Unlicensed Staff C stated the resident learned very quickly how to detach the alarm. Unlicensed Staff C stated the resident's legs were fine but sometimes he felt dizzy when he walked..During an interview on 6/25/14 at 8:45 a.m. Unlicensed Staff C stated she had informed licensed staff that when the resident got up he felt dizzy. Unlicensed Staff C stated the resident wanted to be independent. Unlicensed Staff C stated the resident did not like to stay in his room. Unlicensed Staff C stated he walked with a RNA (restorative nurse aide) but he did not like to stay in his room and walked, not just with the RNA. Unlicensed Staff C stated he would walk by himself and she had told licensed staff that he would walk without assistance by himself. Unlicensed Staff C stated he took his alarms off and other staff also knew this. When asked how the alarms prevented the resident from falling, Unlicensed Staff C stated that when he took the alarm off they did not help.During an interview on 8/22/12 at 9:44 a.m., Licensed Staff A stated that she had seen him walk up and down Hallway 3 using his cane but had never gone outside on his own before. Licensed Staff A stated he was a "furniture walker" in his room (held onto furniture for support). Licensed Staff A stated the resident needed to be reminded to ask for help and did not listen. Licensed Staff A stated that 10 minutes before the accident she observed Resident 1 in his room by the window, sitting in the wheel chair joking with her.During an interview on 6/25/14 at 1:10 p.m., when asked about what kind of supervision the resident received, Licensed Staff A stated the supervision was adequate. Licensed Staff A stated that she could not ensure that the resident would ask for assistance or wait for staff because she could not be there 24/7 and no one could because the resident had a mind of his own. Licensed Staff A stated she reminded staff to "keep an eye on him" which she defined as "looking into his room when going past [sic] in hallway." Licensed Staff A verified that the resident was known to remove his alarm and stated she reminded him to leave the alarm on so staff knew he was doing okay. Licensed Staff A stated the resident's unsafe behaviors centered on his behavior in his room; he did not do the unsafe behaviors all the time, it was just when he was in one of his moods. Licensed Staff A, when asked if she knew what triggered his moods, stated she did not know of any triggers. During an interview on 6/25/14 at 9:50 a.m., Licensed Staff B stated staff were concerned with him walking around in his room without using an assistive device and had to be reminded to ask for help. Licensed Staff B stated he had seen the resident walk outside his room for a short distance a couple of times, and estimated the distance as 20 feet. The resident was by himself but used either a cane or a walker. Licensed Staff B stated that having alarms for the resident helped alert staff to the resident's movement but did not prevent the resident's behaviors of getting up unassisted or ambulating without assistive devices.Anonymous Complainant (AC) stated he was outside the facility (on 8/20/12), heard moaning and saw a person (Resident 1) lying on the ground face down. There was "a lot of blood around him," and he "saw blood on his face and on the ground." AC stated he went to try and get help from staff and banged on a locked door at the nursing home and also called 911 at 9:30 a.m. AC stated he did not see a walker outside with the resident but thought he saw a cane.On 8/22/12 at 9:44 a.m., Licensed Staff A stated she went to provide assistance to the resident. The resident was lying on his left side in a pool of blood and had a laceration above his left brow and his nose was bruised and swollen. A review of the Emergency Room Report, dated 8/20/12 indicated Resident 1 was transported by ambulance to an acute care emergency room on 8/20/12. A Computerized tomography scan (CT- a series of X-ray views taken from many different angles which create cross-sectional images of the bones and soft tissues) indicated multiple fractures of the face "and severely comminuted fracture of the nasal bones, [nose]" significant nose bleed after facial trauma, closed head injury, and lacerations to the face and scalp. On 8/22/13 at 9:29 a.m., Licensed Staff B stated Resident 1 was found outside on the south side closer to the back of the building. Licensed B stated it was quite a walk from the lobby to where the resident was found on the ground. After the fall on 8/20/12, Resident 1 had 3 more falls. The IDT post fall note, dated 8/27/12 indicated the resident was found on a mat on the floor next to the bed. The note indicated the resident had shut off the alarm and got out of bed without assistance. An IDT note, dated 9/28/12 indicated the resident was found sitting on the floor in front of his wheel chair. The resident wheel chair cushion had slid off while the resident was self-propelling in his room. A post fall IDT note, dated 10/2/13, indicated the resident was found sitting on the floor. He had bumped his forehead, and had a small abrasion on his left knee.The facility policy "Managing Falls and Fall Risk" indicated staff would identify interventions related to the resident's specific risk and causes to prevent the resident from falling." The facility violated the regulation by failing to ensure staff developed an effective fall prevention nursing plan of care for Resident 1 who was at high risk for falls and known to get up unassisted. This failure resulted in the resident walking out of the facility unsupervised to an outside patio, falling, and receiving multiple facial fractures and other injuries. 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. |
| 110000046 |
Napa Valley Care Center |
110011524 |
B |
18-Sep-15 |
CPD211 |
2880 |
1418.91 (a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.1418.91 (b) Health & Safety Code 1418 (b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report an allegation of abuse within 24 hours. Random Resident 40 was an alert and oriented female resident with a BIMS (Brief Interview of Mental Status, an assessment of resident's attention, orientation and ability to recall information) of 14 (a score of 13-15 indicates cognitively intact).During an interview on 5/13/15, at 11:35 a.m., with Random Resident 40, she stated a night shift CNA (Certified Nursing Assistant), put his hands in her pants during a transfer.Random Resident 40 stated she told the CNA to "Get your hands the hell out of my pants".Random Resident 40 stated she felt abused and reported the incident to Social Services.During an interview with Random Resident 40, on 5/18/15, at 8:48 a.m., she stated she reported to Unlicensed Staff DD that a CNA had put his hands down her pants.Unlicensed Staff DD was interviewed on 5/18/15, at 2 p.m.. She stated she reported the incident involving Random Resident 40 to Human Resources staff, who then reported the incident to Licensed Nurse B.During an interview on 5/18/15, at 2:05 p.m., Licensed Nurse B stated she felt the incident had only made Random Resident 40 uncomfortable and did not consider it abuse and did not report the incident. Licensed Nurse B also stated the CNA was removed from Random Resident 40's care, but the incident was not reported or investigated further.Facility's document dated 4/9/15, untitled, indicated that Resident 40 was sitting in her wheelchair. She stated she felt uncomfortable when the CNA provided care; he would try to give her a hug without her authorization. The document was signed by Unlicensed Staff DD and does not specify the date of the incident. The facility policy and procedure titled "Reporting Abuse to Facility Management", dated March 2013 indicated: "4. When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, or his/her designee, will immediately (within twenty-four hours of the alleged incident) notify the following persons or agencies of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services; e. Law Enforcement Officials." Therefore, the facility failed to report and fully investigate an allegation of staff to resident abuse.The above violations had direct relationship to the health, safety or security of the resident. |
| 110000046 |
Napa Valley Care Center |
110011771 |
B |
27-Oct-15 |
CPD211 |
28634 |
F441 ?483.65 Infection Control, Prevent Spread, Linens The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.(a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.The facility failed to maintain an effective infection prevention and control program designed to prevent the development and transmission of disease and infection for the residents in the facility, when: 1. Staff did not implement contact precautions correctly and did not follow infection control policy and procedures for 2 of 24 sampled residents (Residents 13 and 15) with Clostridium difficile (C diff, a bacteria in feces that causes watery diarrhea and is a frequent cause of antibiotic associated diarrhea), with the potential for widespread exposure of pathogenic organisms to all residents. (Contact precautions are rules and procedures that staff and visitors must follow when they are in the room of a resident who has been diagnosed with an infectious disease that can be spread from person to person by direct contact [touching the infected person] or by indirect contact [touching surfaces or objects that the infected person has touched].),2. Staff failed to care plan, analyze, trend or report the recurrent urinary tract and C diff infections and failed to notify the Quality Improvement Committee of the recurrent infections for 4 of 24 sampled residents (13, 14, 15, and 20).There were 23 positive cultures for Clostridium difficile (C diff) between 1/1/15 and 5/14/15 and 1 of 24 sampled residents (Resident 20) had been treated for 9 urinary tract infections between 1/1/14 and 5/15/15), and 3. Staff failed to disinfect rooms and surfaces contaminated by C diff with the appropriate bleach solution with the potential for widespread exposure of C diff to all residents.1. During an observation during the initial tour on 5/11/15, at 9 a.m., there was a sign at Resident 13's door which indicated an infection control alert, and included a cart (isolation cart) outside the door that contained personal protective equipment (PPE) which included gowns, gloves and resident specific supplies for that room. On the top of the isolation cart was a container of disinfection wipes titled "Super Sani Cloth", (a disinfectant which does not contain bleach). During a concurrent interview, when asked what type of precautions were in place for Resident 13, Administrative Staff E stated the precautions were for C diff. infection. During an observation on 5/11/15, at 12:25 p.m., Unlicensed Staff C was at the bedside assisting Resident 13 with care while wearing a gown and gloves. Unlicensed Staff C removed the gown and gloves and placed them in a plastic bag in the trash can in the room. Unlicensed Staff C went into the bathroom and returned to the room, moved the over-bed table over Resident 13 and handed Resident 13 items from the bedside table with bare hands, Unlicensed Staff C's clothing touched the bed and linens. Unlicensed Staff C then tied the plastic bag that contained contaminated items with bare hands and took another plastic bag from the pocket of the uniform, with bare hands, and placed that in the trash container. Unlicensed Staff C then picked up the trash in the plastic bag and the dirty laundry with bare hands and proceeded out of the room and walked down the hall and picked up the cover to the laundry container with a contaminated bare hand and dropped the laundry in and then proceeded to the trash bin by the nurses station desk and picked up the cover of the trash bin with a contaminated bare hand and disposed of the plastic bag. Unlicensed Staff C did not wash hands with soap and water and did not use a sanitizing hand product after disposing of the contaminated items. Unlicensed Staff C then proceeded into another resident ' s room without washing hands with soap and water. During an observation on 5/15/15, at 12:10 p.m., Resident 15's room had a sign indicating precautions and an isolation cart was beside the doorway. Unlicensed Staff D was observed opening the door with the gloved hand while wearing contaminated gown and gloves. Unlicensed Staff D picked up the cover to the laundry container outside the doorway with a contaminated glove and dropped the dirty linen inside and then shut the door to the room with the contaminated glove. At 12:25 p.m., Unlicensed Staff D opened the door with bare hands, without PPE, and carried the plastic bag containing contaminated trash and picked up the cover of the trash container with a contaminated bare hand and placed the trash inside. Unlicensed Staff D then used the sanitizing gel mounted on the wall outside the room and rubbed the gel over the bare hands and went into another residents room without washing hands with soap and water. When asked what type of isolation Resident 15 was on, Unlicensed Staff D stated contact precautions for C diff. Review of Resident 13's clinical record revealed Resident 13 had diagnoses that included history of urinary tract infections, obesity, and C diff. Resident 13 had been admitted to the facility in December of 2014 following a hospital stay for urinary tract infection. Resident 13 was readmitted to an acute care hospital on 2/8/15 for altered mental status, diarrhea and a fever of 104.4 degrees Fahrenheit (F), with a final diagnosis at discharge back to the facility of Norovirus (contagious virus affecting the stomach and intestines), acute diarrhea and urosepsis (bacterial infection in the blood caused by a urinary tract infection). Resident 13 was readmitted to the facility on 2/21/15. Laboratory reports included stool cultures positive for C diff on 3/8/15, 4/2/15 and 4/23/15. There was a current physician order, dated 4/4/15, for contact isolation for C diff for continued loose stools. A repeated stool culture, for loose stools on 4/23/15 indicated C diff. On 5/13/15 at 4 a.m., Resident 13 developed a fever of 102 degrees F and dropped oxygen levels in the blood to 66 % (normal range is 92 - 100%) and was transferred to the acute care hospital. The emergency room report for this admission indicated recurrent C diff and recurrent urinary tract infection. Review of Resident 15's clinical record on 5/14/15 at 9:30 a.m., revealed Resident 15's diagnoses included stroke, diabetes, high blood pressure and kidney disease. Laboratory data revealed a urinary tract infection (UTI) on 2/16/15 and 4/2/15, and positive stool cultures for C diff on 4/17/15 (with contact precautions) which was clinically resolved on 5/2/15. Resident 15 had a recurrence of diarrhea and a stool culture showed C diff on 5/11/15 with Resident 15 placed on contact precautions again. Resident 15 continued to have diarrhea.2. During an interview on 5/14/15, at 4 p.m., with Licensed Nurse (LN) B, the infection control nurse/educator for the facility, the facility infection control program was discussed. LN B stated culture reports were reviewed on a daily basis to determine if a resident required isolation precautions. LN B stated nursing staff could start isolation based upon symptoms, such as diarrhea, until the culture report came back.When asked about the infection control inservice education to staff, LN B reported providing the following inservices since 1/1/15:A. Infection control and Clostridium difficile - January 2015. This inservice included information that the bacteria spores were transferred to patients primarily via the hands of health care workers who have direct contact with infected patients or have touched a contaminated surface or item; B. Managing Infection control in utility rooms - 1/26/15; C. Infection Control: Environmental and equipment protection and disinfection - 2/10/15; D. Infection control: Norovirus planning, prevention, documentation, standard precautions and contact precautions, washing hands - 2/13/15; and E. Infection Control - using PPE when working in isolation rooms - 3/18/15 When asked how monitoring was done to ensure staff knowledge, after the education sessions, LN B stated observations of care were done, such as hand washing and care of incontinent residents to ensure perineal care (washing of the genital and rectal areas) was done correctly and the staff did a return demonstration. These sessions were not documented, but staff was informed immediately if they did not follow the appropriate process.During a review on 5/12/15 at 3 p.m., the Infection Control Policies and Procedure Manual located at the nursing station included a policy, dated revised October 2009, titled: Isolation - Categories of Transmission Based Precautions, which included: "...Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted by others...2. Based on CDC [Center for Disease Control] definitions, three types of Transmission-Based precautions (airborne, droplet and contact) have been established...Contact Precautions: In addition to standard precautions, implement Contact Precautions for residents with known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment...(2) diarrhea associated with Clostridium difficile;...b. Resident placement:...(2) if a private room is not available, the Infection Control Coordinator will assess various risks associated with other resident placement options (e.g., cohorting)...c. Gloves and Hand washing...(2) While caring for a resident, change gloves after having contact with infective material (for example, fecal material and wound drainage). (3) Remove gloves before leaving the room and wash hands with an antimicrobial agent or a waterless antiseptic agent. (4) After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces...Gown: (2) After removing the gown do not allow clothing to contact potentially contaminated environmental surfaces..." The Center for Disease Control and Prevention: Frequently Asked Questions about Clostridium difficile for Healthcare Providers:.." How is Clostridium difficile transmitted? Clostridium difficile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item... How can Clostridium difficile infection be prevented in hospitals and other healthcare settings?Use antibiotics judiciously,Use Contact Precautions: for patients with known or suspected Clostridium difficile infection:Place these patients in private rooms. If private rooms are not available, these patients can beplaced in rooms (cohorted) with other patients with Clostridium difficile infection. Use gloves when entering patients' rooms and during patient care. Perform Hand Hygiene after removing gloves. Because alcohol does not kill Clostridium difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs... Preventing contamination of the hands via glove use remains the cornerstone for preventing Clostridium difficile transmission via the hands of healthcare workers; ... If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients with Clostridium difficile infection.Use gowns when entering patients' rooms and during patient care.Dedicate or perform cleaning of any shared medical equipment. Continue these precautions until diarrhea ceases...Because Clostridium difficile-infected patients continue to shed organism for a number of days following cessation of diarrhea, some institutions routinely continue isolation for either several days beyond symptom resolution or until discharge, depending upon the type of setting and average length of stay...Implement an environmental cleaning and disinfection strategy:Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. Consider using an Environmental Protection Agency (EPA)-registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used. (Note: Standard EPA-registered hospital disinfectants are not effective against Clostridium difficile spores.)...Over the past several years nationwide, states have reported increased rates of C. difficile [C Diff] infection, noting more severe disease and an associated increase in mortality. C. diff infection remains a disease mostly associated with healthcare (at least 80%) Patients most at risk remain the elderly, especially those using antibiotics..."During an interview on 5/14/15 at 4 p.m. LN B, the facility infection control nurse provided an overview of the facility infection control report and data reported monthly to the Quality Improvement Committee. When asked if recurrent infections were reported, using Resident 20's 9 UTI's since 1/1/14 as an example, LN B stated the data reported did not include recurrent infections. LN B concurred that just infections per month, both acquired while a resident at the facility (facility acquired) and those where the residents were admitted with an infection were reported to the Quality Improvement Committee. LN B stated that in January 2015 the primary focus of infections for the Quality Improvement Committee were respiratory infections due to the increased number during the flu season. When asked if there was a report for total number of residents with recurring urinary tract infections and/or positive for C diff, or recurring C diff, LN B stated there was no report and this had not been evaluated. LN B agreed to provide this data the following day. The data run by the laboratory utilized by the facility indicated that for calendar year 2014 there were 9 positive cultures and 8 negative cultures for C diff.The 2015 data was run from 1/1/15 to 5/14/15 and indicated 23 positive cultures and 19 negative cultures for C diff.This data indicated:Resident's 13 and 14 had three positive cultures; 4 residents had two (included Resident 15); and 10 residents had one positive culture. Data by month: Residents with positive C Diff cultures January 2015 - 10 residents (two residents on 1/28/15 and 2 residents on 1/30/15); February 2015 - 2 residents; March 2015 - 4 residents; April 2015 - 6 residents; and May 2015 - 1 resident (Resident 13 had another positive culture for C diff during the hospital admission on 5/13/15 - per the emergency room report). People getting medical care can catch serious infections called healthcare-associated infections (HAIs). One type of HAI - caused by the germ C difficile - was estimated to cause almost half a million infections in the United States in 2011, and 29,000 died within 30 days of the initial diagnosis. Those most at risk are people, especially older adults, who take antibiotics and also get medical care. The Center for Disease Control: Healthcare Associated Infections, Clostridium difficile. http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html Review of Resident 20's clinical record on 5/14/15, at 11:15 a.m., revealed that Resident 20 had a Foley catheter (tube into the bladder to empty urine) and the following laboratory reports: (cultures containing more than 100,000 colonies/ml (milliliter) are indicative of infection). 1). On 1/18/14, Urine culture, indicated [greater then] 100,000 colonies/ml of Escherichia Coli (E Coli: bacteria in lower intestines), treated with Cipro (an antibiotic) for 7 days; 2). On 4/7/14, Urine culture: 100,000 colonies/ml Providencia stuarti (bacteria in lower intestines) and treated with Bactrim (an antibiotic) for 10 days; 3). On 4/17/14, Urine culture: 100,000 colonies/ml E coli and treated with an antibiotic; 4). On 5/2/14, stool culture: positive for C diff, treated with Deficid 200 mg twice a day for 10 days (antibiotic for C diff associated diarrhea); 5). On 6/5/14, Urine culture: 100,000 colonies/ml Providencia stuarti (bacteria in lower intestines) and treated with Bactrim (an antibiotic) for 10 days; 6). On 10/2/14, Urine culture: 2 bacteria present 100,000 colonies/ml Providencia stuarti and 100,000 colonies/ml of E Coli which were treated with Cipro (an antibiotic) for 10 days; 7). On 2/2/15, urine culture: 2 bacteria present with100,000 colonies/ml of E Coli and 100,000 colonies/ml staphylococcus aureus which were treated with Bactrim (an antibiotic) for 10 days; (Staphylococcus aureus is frequently isolated from urine samples obtained from long-term care patients. S. aureus is a cause of urinary tract infection among patients with urinary tract catheterization. Clinical Infectious Disease. 2006 Jan 1;42(1):46-50. Epub [electronic publication] 2005 Nov 23.) 8). On 2/16/15, stool culture: Positive for Norovirus (a very contagious virus, which causes the stomach or intestines or both to get inflamed - acute gastroenteritis - causes nausea, vomiting and diarrhea); 9). On 4/12/15, urine culture: 100,000 colonies/ml Klebsiella pneumoniae (bacteria normally found in the intestines) and treated with Cipro 500 mg twice a day for 7 days; and 10). On 5/6/15, urine culture:100,000 colonies/ml of E Coli treated with Bactrim (an antibiotic) for 10 days During an interview on 5/14/15, at 4 p.m., when asked if the recurrent UTI's for Resident 20 had been evaluated, LN B, the facility infection control nurse, stated that Resident 20 was a very difficult and demanding resident and the family member demanded urine cultures stating that Resident 20 was agitated and confused which usually indicated an infection, but staff did not agree that this was a behavior or change in mental status and the physician was trying to appease the family member by ordering tests and antibiotics. When asked if the facility felt that the physician was ordering unnecessary antibiotics if this issue was referred to the Quality Improvement Committee or Medical Director, LN B stated it had not been discussed. Review of Resident 13's clinical record on 5/11/15, at 2 p.m., indicated that Resident 13 had been admitted to the facility in December of 2014 following a hospital stay for urinary tract infection.Resident 13 was readmitted to an acute care hospital on 2/8/15 for altered mental status, diarrhea and a fever of 104.4 degrees Fahrenheit (F), with a final diagnosis at discharge back to the facility of Norovirus (contagious virus affecting the stomach and intestines), acute diarrhea and urosepsis (bacterial infection in the blood caused by a urinary tract infection - with a culture positive for E coli). Resident 13 was readmitted to the facility on 2/21/15. Laboratory reports for Resident 13 included stool cultures which were positive for C diff on 3/8/15, 4/2/15 and 4/23/15.On 5/13/15 at 4 a.m., Resident 13 developed a fever of 102 degrees F and dropped oxygen levels in the blood to 66 % (normal range is 92 - 100%) and was transferred again to the acute care hospital. The emergency room report for this admission indicated recurrent C diff (positive culture on 5/13/15) with a positive culture for urinary tract infection. Review of Resident 15's clinical record on 5/14/15 at 9:30 a.m., revealed the following: On 12/5/14 the Nurse Practitioner ' s note included a small penile erosion (ulcer) and nursing staff were instructed to secure the catheter tubing to Resident 15 ' s leg and include a teaching plan directed to prevent further penile injury; On 2/5/15 the penile erosion had increased in size to 2.0 centimeters (cm) and the wife requested a suprapubic catheter (inserted through the abdominal wall into the bladder) so the penile erosion could heal; On 2/16/15 Urine culture: 100,000 colonies/ml E coli and 50,000 colonies Methicillin Resistant Staphylococcus Aureus (MRSA) which was treated with Ertarpenem (an antibiotic for severe infections) via intramuscular injection for 7 days and a second antibiotic, Doxycillin twice a day for 10 days;On 3/12/15 Resident 15 was transferred to a hospital for insertion of the suprapubic catheter and received 5 days of antibiotics following the insertion to prevent post-operative infection;On 4/2/15 Urine Culture: 100,000 colonies/ml Proteus Mirabilis, with a white blood cell count of 44.6 (normal 4.4 - 11.0, elevated levels are indicators of infection by bacteria) and the physician noted probable urosepsis; On 4/17/15 Stool culture: positive for C diff and treated with Vancomycin (an antibiotic) 250 mg four times a day for 14 days, with notation that the C diff was clinically resolved on 5/2/15; and On 5/11/15 Stool culture: positive for C diff and treated with Vancomycin 250 mg four times a day for 14 days. Review of Resident 14's clinical record on 5/15/15, at 10 a.m., indicated that Resident 14 was admitted to the facility on 7/8/14, revealed the following laboratory data: On 1/2/15 stool culture: positive for C diff and treated with the antibiotic Vancomycin; On 1/28/15 stool culture: positive for C diff and treated with the antibiotic Vancomycin; andOn 3/13/15 stool culture: positive for C diff and treated with the antibiotic Vancomycin.Review of Resident 11's clinical record on 5/13/14, at 11 a.m., indicated that Resident 11 had a stool culture on 2/11/15 that was positive for C diff.During an interview on 5/19/15, at 11:50 a.m., the facility Medical Director stated the facility staff provided infection control reports monthly to the Quality Improvement Committee. Staff had not provided information about recurrent infections; especially repeated C diff and UTI's and staff should have provided that data to the committee members. The Medical Director agreed that fluid intake and output and nutritional needs should be addressed in the care plans for residents with C diff and UTI's and that care planning should include the prevention of recurring infections. 3. During an interview on 5/12/15, at 9:15 a.m., Resident 14 recalled being sick and isolated for a long time. When asked if he knew what C diff was, Resident 14 became agitated, his voice went up an octave, and stated, "I sure don't want any of that again!" A review of Resident 14's admission record, dated 7/8/14, indicated that Resident 14 had been admitted from a hospital with C diff. A review of Resident 14's laboratory data on 5/18/15 at 11:50 a.m. indicated that Resident 14 had a recurrence of C-diff on 1/2/15, 1/28/15 and 3/16/15. During an interview on 5/12/15, at 10:14 a.m., Administrative Staff Q stated the facility trained housekeeping staff to use 1 part bleach to 9 parts water for cleaning isolation rooms contaminated by C diff. Administrative Staff Q stated they also used Microdot wipes that contained bleach and it was important to leave the bleach to air dry for 10 minutes. During an interview on 5/12/15, at 10:36 a.m., Unlicensed Staff P stated Clorox wipes could be used to clean surfaces had been infected by C-diff and then wiped off with a clean blue cloth. When asked if bleach required to be air dried in order to kill C diff spores, Unlicensed Staff P stated, "No." During a concurrent interview and demonstration on 5/14/15, at 6:04 a.m., Unlicensed Staff R demonstrated how she would clean a room infected with C diff by spraying a 1:9 bleach spray on a blue cloth and wipe surfaces, i.e. resident's bedside table, mattress, side rails, and then flip the cloth to a dry side and wipe the wet surface dry. Unlicensed Staff R did not allow the bleach spray to air dry. During an interview on 5/14/15 at 6:20 a.m., Unlicensed Staff S stated housekeeping were unavailable during nights to clean rooms and therefore it was the job of certified nursing assistants (CNAs) and nursing to clean up after residents with C diff. Unlicensed Staff S stated isolation carts, located outside isolation room doorways, had no bleach spray available or wipes available. Unlicensed Staff S stated there were wipes kept on the nursing carts that could be used for wiping surfaces, and paper towels and water for the floors. At 6:34 a.m., Unlicensed Staff T stated sometimes isolation carts had the bleach wipes, but not always. Unlicensed Staff T stated wipes could be found at the nursing carts.During an interview on 5/15/15, at 10:40 a.m. Unlicensed Staff W stated isolation carts did not have any cleaning supplies. Unlicensed Staff W stated they would wash up with soap and water and paper towels and then leave the room to get cleaning supplies. Unlicensed Staff W thought bleach was used for C-diff but usually it was the housekeepers ' job to clean resident rooms and CNAs job to clean the resident using soap and water and wash towels. During a concurrent observation and interview on 5/15/15, at 9:55 a.m. Licensed Nurse X opened a bottom drawer of the nursing cart and displayed 2 round containers of wipes. One had a red top and indicated Sani-Cloth Plus, and the other had a green top and indicated Clorox wipes but was bleach free. Licensed Nurse X stated that she did not know if the Sani-Cloth Plus killed C diff without reading the label first. A review of the label indicated that Sani-Cloth Plus killed Vancomycin Resistant Enterococcus (VRE), but not the Clostridium difficile (C diff) organism.During an interview on 5/15/15, at 2:30 p.m., Unlicensed Staff Y stated that there were no cleaning supplies kept on the isolation carts. Unlicensed Staff Y indicated that it was a housekeeping task to clean room surfaces and CNAs job to clean the resident. Therefore, the facility failed to maintain an effective infection prevention and control program designed to prevent the development and transmission of disease and infection for the residents in the facility, when: 1. Staff did not implement contact precautions correctly and did not follow infection control policy and procedures for 2 of 24 sampled residents (Residents 13 and 15) with Clostridium difficile (C diff, a bacteria in feces that causes watery diarrhea and is a frequent cause of antibiotic associated diarrhea), with the potential for widespread exposure of pathogenic organisms to all residents. (Contact precautions are rules and procedures that staff and visitors must follow when they are in the room of a resident who has been diagnosed with an infectious disease that can be spread from person to person by direct contact [touching the infected person] or by indirect contact [touching surfaces or objects that the infected person has touched].),2. Staff failed to care plan, analyze, trend or report the recurrent urinary tract and C diff infections and failed to notify the Quality Improvement Committee of the recurrent infections for 4 of 24 sampled residents (13, 14, 15, and 20).There were 23 positive cultures for Clostridium difficile (C diff) between 1/1/15 and 5/14/15 and 1 of 24 sampled residents (Resident 20) had been treated for 9 urinary tract infections between 1/1/14 and 5/15/15), and 3. Staff failed to disinfect rooms and surfaces contaminated by C diff with the appropriate bleach solution with the potential for widespread exposure of C diff to all residents. These failures had a direct relationship to the health, safety, or security of patients. |
| 110000046 |
Napa Valley Care Center |
110012047 |
A |
09-Mar-16 |
H4AB11 |
4251 |
T22 DIV5 CH3 ART3-72311(A)(2) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The facility failed to follow their care plan interventions for Resident 1 when CNA B (certified nursing assistant) massaged and repositioned the right knee of Resident 1 who had contracture of the right leg. Failure to follow their care plan of gentle and safe handling of Resident 1, with a diagnosis of osteoarthritis, could have potentially resulted in the fracture of Resident 1's right leg. Resident 1 was an 84 year old female admitted on 2/10/08, with diagnoses to include osteoarthrosis NOS (not otherwise specified), muscle weakness and polymyalgia rheumatica (inflammatory disorder causing pain and stiffness). The MDS (minimum data set, an assessment tool) dated 12/1/13, indicated that Resident 1's cognitive skill was moderately impaired and supervision was needed. MDS further indicated that Resident 1 needed extensive assistance for activities of daily living and she had impairment of range of motion on lower extremities because of contracture. During an observation on 12/26/13 at 1:30 p.m., Resident 1's right knee was markedly swollen and slightly twisted, and the right leg from the knee was twisted and bent backward. During an interview on 12/27/13 at 11:25 a.m., Licensed Staff A stated that CNA B told her that he cleaned Resident 1 really good and massaged her legs. Licensed Staff A did not notice any problem with Resident 1 until the following morning when the morning shift Licensed Staff discovered Resident 1's swollen right knee with a bruise. Licensed Staff A stated "the bruise looked weird, it was linear, fading like semicircle along the right knee area. The linear bruise was fading not continuous." During an interview on 12/27/13 at 11:40 a.m., Licensed Staff C stated that the CNA who was assigned to Resident 1 asked her to come with her and look at Resident 1. Licensed Staff C stated she saw Resident 1's right knee markedly swollen and bruised. During an interview on 12/27/13 at 3:40 p.m., CNA B stated he repositioned and massaged the right leg of Resident 1 for five to six minutes. CNA B stated while massaging Resident 1's right leg he did not notice Resident 1 to be in pain. CNA B stated he was doing the massage without Licensed Staff supervision. Record review of the Interdisciplinary Notes written on 12/16/13 at 5:13 p.m., indicated the CNA working with Resident 1 on Saturday evening (12/14/13) attempted to straighten and reposition Resident 1's right leg to better clean behind the knee, later noted the knee was in a different angle and it was reported to the nurse. The next day the morning nurse noted the right knee to be slightly red and swollen, with some discoloration. The MD (Medical Doctor) was notified and a right knee X-ray was ordered which showed supracondylar fracture. Review of the X-ray result of the right knee, dated 12/15/13, indicated "there is an incompletely characterized right supracondylar femur fracture, which appears recent." Review of the care plan of Resident 1 for pressure ulcer dated 11/21/13, indicated right foot redness and abrasion. Potential for pressure ulcer related to immobility and contracture and care plan indicated gentle and safe handling of patient, continue to encourage for repositioning. Use cushion and pillows to help with comfort. Care plan dated 2/25/13 was developed for the resident's risk for pain. One approach indicated "Needs gentle handling, turning-severe osteoahtritis [sic] (any handling, turning causes pt [patient] to feel she is being hurt." Therefore, although there was no care plan developed and implemented for Resident 1 requiring gentle handling of the resident due to the fragile osteoarthrosis diagnosis, the resident's clinical record included two care plans which indicated that the staff should handle the resident in a safe and gentle manner. The CNA B failed to follow these interventions. This presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 110000046 |
Napa Valley Care Center |
110012906 |
B |
7-Feb-17 |
FJ8X11 |
3587 |
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.
See tag A 065
Health & Safety Code 1418.91
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
The facility failed to report an incident of physical and verbal abuse to the Department of Public Health within 24 hours. This could decrease the protection of the resident when the Department's investigation to ensure resident safety was delayed.
Findings:
Review of a facility letter to the department, dated 8/12/16, indicated Resident 1's family member informed the Administrator on Monday (8/8/16) that Resident 1 had bruises on her arm, caused by a CNA (Certified Nursing Assistant) who pulled on Resident 1's arm, as the CNA moved Resident 1 from the bed to the wheelchair. The Administrator documented Resident 1 stated the CNA pulled Resident 1 straight from the lying down position to the wheelchair without Resident 1's feet touching the ground.
During an interview on 9/6/16 at 1:30 p.m., The Administrator stated a Family Member of Resident 1 called him to say Resident 1 had some discoloration on her forearm and Resident 1 stated a CNA grabbed Resident 1's arm, pulled her straight out of bed and called Resident 1 "Queenie" which Resident 1 did not like. The Administrator stated, as soon as he got a call from a family member, he suspended the CNA. The Administrator stated he "didn't send the report in a "timely fashion" to the Department of Public Health because he wanted to complete the investigation and make sure other residents were safe. The Administrator stated he found out on Monday 8/8/16 and sent the report in to the Department on 8/12/16. The Administrator stated he should have reported it on 8/8/16 when Resident 1's family member called him according to policy and procedures.
On 8/12/16 there was a note form the social worker who addressed the patient's complaint of a CNA grabbing her arm and moving her out of bed. The Social Worker also wrote the CNA hurt Resident 1's feelings by calling her "Queenie".
During an interview and observation on 9/30/16 at 10:20 a.m., Resident 1 stated she had a fistula (blood vessel access) for dialysis (mechanism to remove toxins from the blood due to kidney failure) in her right arm which was clotted (clogged vessel) and was no longer used. Resident 1 had dark discolored small markings on the distal right arm and stated she did not know how long the markings were there. Resident 1 stated as she pointed to her right lower arm, a CNA "jerked" her out of bed and hurt her right arm. Resident 1 stated the CNA called her "Queenie" and said to her "Queen, What do you want?" Resident 1 stated the CNA was rude to her.
Review of a facility provided policy tiled Reporting Abuse to State Agencies and Other Entities/Individuals dated 2011 indicated "Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse....be reported, the facility Administrator, or his/her designee," will promptly notify the State licensing/certification agency responsible for surveying/licensing the facility within 24 hours of the occurrence of the incidence.
Therefore, the facility failed to notify the Department within 24 hours of an alleged incident of abuse resulting in an automatic B violation. The violation had a direct relationship to the health, safety or security of patients. |
| 010000047 |
Northbrook Healthcare Center |
110013413 |
B |
28-Aug-17 |
NRPS11 |
23300 |
A State Class B Citation: #1100-3161-13413 is issued under F-314.
F314: ?483.25(b) (1) TREATMENT / SVCS TO PREVENT/HEAL PRESSURE SORES
(b) Skin Integrity -
(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition
demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
The facility failed to ensure Resident 6 received the necessary care, consistent with professional standards of practice, to prevent pressure ulcers when the facility did not implement a frequent turning and repositioning program to prevent pressure ulcers for Resident 6, whom it had assessed to be at a very high risk for developing pressure ulcers; failed to consistently accurately assess pressure ulcers; and failed to implement the Registered Dietician's initial recommendation for a multivitamin supplement for Resident 6, whom the facility had assessed to be in poor nutrition and at a very high risk for pressure ulcers. Resident 6 developed two pressure ulcers, including a Stage 4 pressure ulcer.
According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure injury/ulcer is "localized damage to the skin and underlying soft tissue usually over a bony prominence... the injury can present as intact skin or an open ulcer ... the injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear" (shear is stress/deformation of the skin from movement). Pressure injuries/ulcers are classified or "staged" according to the degree of injury to tissue, from Stage 1 (least injury) to Stage 4 (greatest injury). Stage 2 pressure injuries/ulcers involve the loss of the first skin layer (epidermis), thus exposing the second skin layer (dermis). The wound appears pink and moist. Stage 3 pressure injuries/ulcers involve a wound with total loss of the skin, revealing the layer of fat underneath. Stage 4 pressure injuries/ulcers involve the total loss of the skin and the underlying fat tissue, revealing muscle, bones and other tissues. A pressure injury/ulcer may also be classified as "unstageable", which occurs when the wound is covered by slough or eschar (dead tissue). "If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed." (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (2016) and www.npuap.org/wp-content/uploads/2012/02/Shear_slides.pdf).
Review of Resident 6's "Admission Record", dated 7/11/17, indicated Resident 6 was 81 years old and admitted to the facility on XXXXXXX16 with diagnoses that included Parkinson's disease (a progressive movement disorder), dementia (a brain disease that causes a long term and often gradual decrease in the ability to think and remember), aphasia (loss of ability to communicate using speech) and generalized weakness.
Resident 6's "Initial Admission Record," dated 9/27/16, indicated Resident 6 was admitted on hospice care (terminal prognosis), had no open skin injuries but had "very fragile skin."
During an interview on 7/12/17 at 4 p.m., Resident 6's family member and responsible party stated Resident 6 was immobile and needed complete assistance to turn and reposition but had no skin injuries at the time she was admitted to the facility. The family member stated Resident 6 lived with her prior to admission and family frequently turned and repositioned her at home to prevent skin injuries.
A nursing "Admission Note" for Resident 6, dated 9/27/16 at 2:15 p.m. stated: "The resident came from home. The resident has very fragile skin, though in very good shape r/t [related to] the families [sic] ongoing care for her ... No open areas noted."
The "Braden Scale for Predicting Pressure Sore Risk" assessment (a pressure ulcer assessment scale) dated 9/27/16, indicated Resident 6 was bedfast (confined to bed), completely immobile, did not make even slight position changes in body or extremity without assistance and had very poor nutrition. The assessment indicated a score of 9, corresponding to a "very high risk" of developing pressure ulcers.
Resident 6's record contained a care plan, dated 9/27/16, for Resident 6's potential for skin injuries related to her fragile skin and poor nutrition. The goal of the care plan was to keep Resident 6 free of skin injuries. The care plan contained interventions such as the use of an alternating pressure mattress and the application of barrier creams to at risk areas. The care plan did not contain interventions to turn and reposition Resident 6.
A second care plan for Resident 6, dated 9/28/16, focused on self-care performance of activities of daily living related to Resident 6's disease processes, limited mobility, pain and dementia. This care plan noted Resident 6 was "totally dependent on staff for repositioning and turning in bed." This care plan did not include any intervention for turning and repositioning Resident 6.
A review of Resident 6's physician orders, the "Order Summary Report," for September 2016 through April 2017, revealed no physician orders for turning and repositioning Resident 6.
Resident 6's Admission MDS (Minimum Data Set - an assessment tool), dated 10/3/16, indicated Resident 6 had no pressure ulcers but was at risk for developing them. In the Admission MDS the facility selected pressure reducing device for bed (pressure redistribution mattress) and application of ointments/medications as interventions for preventing/treating skin injuries. The facility did not select turning and repositioning Resident 6, an available intervention in the MDS.
On 10/4/16, at 8:22 a.m., the IDT (Interdisciplinary Team) convened to review Resident 6's conditions and care plans. The "IDT/Care Conference Note" dated 10/4/16, documented Resident 6 had poor food intake, ate 35-40% of meals, and needed extensive staff assistance with bed mobility. The IDT team made no recommendation to update Resident 6's care plans to include turning and repositioning Resident 6.
According to the Wound, Ostomy and Continence Nurses Society, avoidable pressure ulcers can occur when the provider does not "define and implement interventions consistent with individual needs, individual goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate." (Wound Ostomy and Continence Nurses Society, 2017. WOCN Society Position Paper: Avoidable vs. Unavoidable Pressure Ulcers/Injuries. Mt. Laurel, NJ: Author.)
According to the U.S. National Library of Medicine PubMed Health Service, frequent repositioning is a key intervention in preventing pressure ulcers: "Even if certain mattresses and overlays have been shown to lower the risk of pressure sores ... reducing pressure through movement and repositioning is still the most important way to prevent pressure ulcers." (https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0079409/).
The facility's policies and procedures recommended repositioning to prevent pressure ulcers. The policy titled "Pressure Ulcers - Care and Treatment", revised 05/2016, indicated, under "Prevention Measures": "B. Repositioning".
Licensed Nurse A documented in an "Incident Note", dated 10/4/16 at 11:48 p.m., Resident 6 had a skin injury to her right hip classified as a possible deep tissue injury (a form of pressure ulcer where the outer skin is intact but the underlying tissue is injured) measuring 3 centimeters (cm) length by 1 cm width.
A "Nursing Summary - Weekly", dated 10/5/16, contained documentation that Resident 6 had a pressure ulcer to the right hip area. There was no documentation of the stage or a measurement of the pressure ulcer.
On 10/11/16 Registered Dietician G completed Resident 6's admission nutrition assessment. In the "RD - Nutrition Risk Review - Admission" assessment, dated 10/11/16, Registered Dietician G documented Resident 6 ate 50% of her meals, had a pressure injury to the right hip and had "insufficient recorded [food] intake to support healing of wound and maintain weight." Registered Dietician G recommended Resident 6 receive a multiple vitamin with minerals supplement.
A review of physician orders for Resident 6, "Order Summary Report", for October, November, and December 2016, revealed no orders for a multiple vitamin with minerals supplement for Resident 6. Vitamin supplements for Resident 6 were ordered starting on 1/19/17.
During an interview on 7/13/17 at 9:45 a.m., Registered Dietician H stated the dietician's recommendations were usually communicated to the resident's physician the same day. Registered Dietician H also stated a multiple vitamin with minerals supplement would have assisted in the prevention and healing of pressure ulcers for Resident 6.
On 7/14/17 at 8:25 a.m., Resident 6's nutrition assessments, physician orders and other clinical records were reviewed with the Director of Nursing (DON). The DON verified the dietician's recommendation on 10/11/16 for a multiple vitamin with minerals supplement for Resident 6 was not followed. She stated she believed the reason was Resident 6 was on hospice care with a terminal prognosis. The DON verified Resident 6's clinical condition eventually improved and Resident 6 was subsequently taken out of hospice care in November 2016. The DON stated after Resident 6 was taken out of hospice care in November 2016 a multiple vitamin with mineral supplements would have helped improve Resident 6's nutrition and prevent skin wounds.
The National Pressure Ulcer Advisory Panel (NPUAP) recommends vitamin supplements to people at risk for or with pressure ulcers and nutritional deficiencies. According to the NPUAP providers should "provide/encourage an individual assessed to be at risk of a pressure ulcer to take vitamin and mineral supplements when dietary intake is poor or deficiencies are confirmed or suspected". The NPUAP has the same recommendation for individuals with confirmed or suspected pressure injuries. (National Pressure Ulcer Advisory Panel, Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, 2014, available at http://www.npuap.org/).
The facility's policies and procedures recommended improved nutrition for pressure ulcer prevention and treatment. Facility policy titled "Pressure Ulcers - Care and Treatment", revised 05/2016, indicated "Maintain or improve nutrition or hydration status" as a pressure ulcer preventing and treatment measure.
A Change of Condition MDS assessment for Resident 6, dated 11/11/16, indicated Resident 6 had no current pressure ulcers, but was at risk for developing them. In the MDS the facility selected several interventions for preventing/treating skin injuries. The facility did not select turning and repositioning the resident, an available intervention in the MDS.
The IDT documented in the "IDT/Care Conference Note" dated 11/16/16, Resident 6 needed extensive assistance with bed mobility. The IDT Team did not recommend or update Resident 6's care plans to include frequent turning and repositioning.
A "Braden Scale for Predicting Pressure Sore Risk" assessment, dated 11/25/16, noted Resident 6 had a score of 12 corresponding to a "high risk" for developing pressure ulcers.
A "Change of Condition" note, dated 1/10/17 at 6:33 a.m., contained documentation that Resident 6's right hip wound had reappeared. No staging or measurements of the wound were documented.
A "Nursing Summary - Weekly", dated 1/11/17, documented Resident 6's right hip wound was a pressure ulcer, but there was no documentation of the staging or measurement of the wound.
On 1/17/17, Physician C wrote treatment orders for Resident 6's right hip pressure ulcer. Resident 6's "Order Summary Report", dated 1/31/2017, contained the following order, dated 1/17/17: "Cleanse pressure injury to right hip with DWC [Dermagran Wound Cleanser], and pat dry. Apply Santyl [an ointment] to necrotic/slough [dead tissue] to wound bed (indicating at least a Stage 3 pressure ulcer per NPUAP). Cover with calcium alginate and foam dressing as needed for pressure injury if soiled or dislodged."
In a "Change of Condition" note, dated 1/21/17 at 9:53 p.m., Licensed Nurse J documented Resident 6 had a sheared (stress / deformation of the skin from movement) area to right buttock area.
In an "Incident Note", dated 1/24/17 at 10:29 p.m., Licensed Nurse A documented Resident 6 had a reddened "skin tear" to her right buttock measuring 3 cm x 2 cm.
A new skin care plan, dated 1/24/17, noted Resident 6 "Has actual impairment to skin integrity r/t [related to] Stage 4 pressure injury on right ischial tuberosity [the sit bone]." The new skin care plan did not include turning and repositioning interventions for Resident 6.
During an interview on 7/12/17 at 4:25 p.m., Licensed Nurse B stated Resident 6's right buttock pressure ulcer was first identified by the facility as a Stage 4 pressure ulcer in the last week of January 2017. She stated the wound evolved very quickly from a skin tear to a Stage 4 pressure ulcer. She stated the wound location had been referred by facility staff as either right buttock or right ischial tuberosity, with both names referring to the same pressure ulcer.
A review of Resident 6's nutrition assessments revealed no assessments of Resident 6's nutritional status by a Registered Dietician following the detection of her Stage 4 pressure ulcer on 1/24/17. During a review of Resident 6's records on 7/13/17, at 9:45 a.m., Registered Dietician H verified Resident 6 had been assessed by a Registered Dietician on 1/18/17 and again on 3/30/17. She stated, in her professional opinion, a new assessment of Resident 6's nutritional status should have been made by a registered dietician following the identification of Resident 6's Stage 4 pressure ulcer on 1/24/17.
The facility policy, "Nutrition", revised 1/2014, stated: "Each resident's nutritional status is assessed by the Registered Dietician or his/her designee on admission and at least quarterly thereafter, and following a change in condition."
A "Skin Pressure Ulcer Weekly" assessment, dated 2/3/17, noted Resident 6's right buttock wound as an unstageable pressure ulcer (unable to determine the stage due to the presence of dead tissue covering the wound) measuring 1.9 cm length x 2.9 cm width. The assessment documented bone was visible in the wound bed.
During an interview on 7/14/17, at 8:25 a.m., the Director of Nursing (DON), who stated she was a wound certified nurse, stated pressure ulcers in which it was possible to visualize bone in the wound bed were categorized as Stage 4 pressure ulcers.
The "Skin Pressure Ulcer Weekly" assessment, dated 2/3/17, documented Resident 6's right hip wound was a Stage 2 pressure ulcer measuring 0.7 cm x 0.9 cm.
A quarterly MDS assessment, dated 2/7/17, indicated Resident 6 had pressure ulcers and was at risk for developing them. In the MDS the facility selected several interventions for preventing/treating skin injuries. The facility did not select turning and repositioning the resident, an available intervention in the MDS.
The "IDT - Care Plan Review", dated 2/7/17, contained no documentation of recommendations to update Resident 6's care plans to include turning and repositioning Resident 6.
A Skin Pressure Ulcer Weekly assessment, dated 3/13/17, documented Resident 6's right buttock ulcer was an unstageable pressure injury and Resident 6's right hip pressure injury was closed.
"Skin Pressure Ulcer Weekly" assessments, dated 4/13/17 and 5/2/17, documented Resident 6's right buttock wound as a Stage 4 pressure ulcer.
A second quarterly MDS assessment, dated 5/2/17, indicated Resident 6 had pressure ulcers and was at risk for developing them. The MDS contained several interventions which were selected for Resident 6 for preventing/treating skin injuries. The facility did not select turning and repositioning the resident, an available intervention in the MDS.
A physician's order, dated 5/3/17, directed staff to "Turn and reposition resident a minimum of every 2 hours for pressure redistribution."
On 5/16/17, Resident 6's care plan for potential skin impairment related to fragile skin and poor nutrition was updated to include the following intervention: "Turn and reposition resident a minimum of every 2 hours for pressure redistribution."
During interview and concurrent record review, on 7/13/17 at 5:50 p.m., Resident 6's care plans were reviewed with the Director of Nursing (DON). The DON verified the turn and repositioning intervention for Resident 6 was not present in any of Resident 6's care plans until it was added on 5/16/17. The DON stated given Resident 6's high risk for developing pressure ulcers, identified by the facility on 9/27/16, Resident 6's care plans should have included turning and repositioning interventions starting on the day Resident 6 was admitted to the facility on 9/27/16.
Review of "Skin Pressure Ulcer Weekly" assessments, dated 6/13/17 and 7/11/17, noted Resident 6' right buttock injury were classified as a Stage 4 pressure ulcer.
During an observation, on 7/13/17 at 2:50 p.m., Licensed Nurse B completed a dressing change and wound measurement of Resident 6's Stage 4 right buttock pressure ulcer. The wound measured 2.1 cm length, 2.1 cm width, 2.1 cm depth, and 4.6 cm of tunneling.
During interview and concurrent record review, on 7/14/17 at 8:25 a.m., Resident 6's record was reviewed with the Director of Nursing (DON). The DON was asked which interventions the facility implemented to prevent pressures ulcers for Resident 6 after the facility determined Resident 6 to be "very high risk" for pressure ulcers on 9/27/16. The DON stated the facility implemented all the interventions listed in the care plans plus turning and repositioning Resident 6 every two hours. She stated the facility had continuously turned and repositioned Resident 6 every two hours starting from admission on 9/27/16 until the present day. The DON was asked to provide evidence that Resident 6 had been turned and repositioned every two hours. The DON provided copies of Resident 6's "Treatment Administration Record" for May, June and July 2017. The turning and repositioning documentation in these reports consisted of a check mark next to each shift - a.m., p.m., and night - confirming Resident 6 had been turned and repositioned every two hours during each shift. These reports did not specify the times Resident 6 had been turned and repositioned during each shift. The DON was asked for this information.
During interview and concurrent record review, on 7/14/17 at 12 p.m., the DON and Registered Nurse Consultant K provided facility reports titled, "Follow Up Question Report", dated September 27, 2016 to July 14, 2017, which contained documentation of Resident 6's turning and repositioning by the facility's Certified Nursing Assistants (CNAs). These reports contained the question "Did you turn and reposition?" followed by the response, "Yes" and the CNA's name, date and time. Registered Nurse Consultant K stated the date and time recorded on the reports was not necessarily the date and time Resident 6 was turned and repositioned, but the time the CNA recorded it on the computer system. She stated CNAs did not always record care immediately after providing care. Registered Nurse Consultant K was asked if, from the documentation provided, it was possible to determine the times Resident 6 had been turned and repositioned. Registered Nurse Consultant K replied it was not possible to know, stating it was only possible to know the turning and repositioning had been done sometime during the CNA's shift.
A review of the turning and repositioning documentation provided by the facility, the "Follow Up Question Reports", from 9/27/16 to 6/30/17, revealed documentation Resident 6 was turned and repositioned an average of once every 8 hours. On several days during the period, such as on 9/28/16, 10/2/16, 11/13/16, 12/11/16, 1/1/17, 2/6/17, 3/3/17, 4/28/17, 5/31/17 and 6/5/17, there were gaps of more than 12 hours without documentation of Resident 6 being turned and repositioned.
The "Follow Up Question Report" for July 2017 documented on 7/11/17 Resident 6 was turned and repositioned a total of three times: at 6:39 a.m., at 11:17 a.m. and at 9:47 p.m.
On 7/11/17 Resident 6 was observed in her room at 9:15 a.m., at 11:15 a.m., at 2 p.m. and at 4 p.m. In all four instances Resident 6 was observed asleep lying on her right side.
The "Follow Up Question Report" for July 2017 documented on 7/13/17 Resident 6 was turned and repositioned a total of three times: at 2:10 a.m., at 8:52 a.m., and at 9:51 p.m.
On 7/13/17 Resident 6 was observed in her room at 9:10 a.m., and at 11:10 a.m. In both instances Resident 6 was observed asleep lying on her left side.
According to the American Association of Family Physicians, "Pressure ulcers may develop in as little as four to six hours" and, "there is also no evidence to suggest an optimal interval at which to reposition patients, although every two hours is recommended based on expert opinion." (http://www.aafp.org/afp/2015/1115/p888.html.)
The National Database of Nursing Quality Indicators, a national nursing quality measurement program, indicates, as pressure injury prevention interventions, that "Many clinicians start by turning immobile patients every 2 hours while in bed as this is a common practice for patients unable to turn/reposition themselves" and "Patients who are at higher risk will likely need to be turned/repositioned more frequently than every 2 hours." (https://members.nursingquality.org/ndnqipressureulcertraining/Module3/PressureULcerSurveyGuide_16.aspx.)
The U.S. National Library of Medicine MedlinePlus Service recommends "changing a patient's position in bed every 2 hours" to prevent pressure ulcers. (https://medlineplus.gov/ency/patientinstructions/000426.htm.)
The facility therefore failed to ensure Resident 6 received the necessary care, consistent with professional standards of practice, to prevent pressure ulcers when the facility did not implement a frequent turning and repositioning program to prevent pressure ulcers for Resident 6, whom it had assessed to be at a very high risk for developing pressure ulcers; failed to consistently accurately assess pressure ulcers; and failed to implement the Registered Dietician's initial recommendation for a multivitamin supplement for Resident 6, whom the facility had assessed to be in poor nutrition and at a very risk for pressure ulcers. Resident 6 developed two pressure ulcers, including a Stage 4 pressure ulcer.
The violation of the regulation had a direct relationship to the health, safety or security of patients. |
| 120001511 |
NEW HORIZONS 'B' |
120007951 |
A |
07-Mar-12 |
GUVM11 |
4171 |
483.460(c)(5)(iii)Nursing services must include implementing with other members of the interdisciplinary team, appropriate protective and preventive health measures that include, but are not limited to training direct care staff in detecting signs and symptoms of illness or dysfunction, first aid for accidents or illness, and basic skills required to meet the health needs of the clients. On November 18, 2010 at 10:30 AM a visit was made to the facility to investigate an entity reported incident regarding Client A's fractured femur (thigh bone). Based on interview and record review, the facility failed to ensure staffs were adequately trained to correctly implement a facility policy/procedure while caring for the client. This failure to follow the correct procedure caused Client A's fracture. Client A is a 20-year-old male admitted to the facility May 25, 1995 with diagnoses including cerebral palsy. The client does not bear weight and weighs 118 lb. On November 3, 2010 the client sustained a complete mid-shaft femur fracture with angulation, and required surgery (internal fixation with a plate and screws). The facility report dated November 3, 2010 indicated that while transferring Client A to his wheelchair, there was a "pop" sound in his left leg, and the client immediately began to cry. During an interview with the Program Manager (PM) on November 18, 2010 at 10:50 AM, she stated Direct Care Staff (DCS) 1 "admitted she single-lifted (Client A), he's a two-person transfer." During an interview with DCS 1 on November 19, 2010 at 2:45 PM, she stated "I went to lift (Client A) and put him in his chair, and his leg got up on his chair, and I didn't see it, and when I put him in his chair I heard a cracking noise...He's supposed to be transferred with two people...It was a mistake...I didn't realize his leg was on the seat like that." During an interview with DCS 2 on November 23, 2010 at 10:40 AM, she stated that on the day of the incident she observed DCS 1 "swinging (Client A) into the chair. When she put him down, one of his legs was up and got stuck on the pommel. (DCS 1) didn't see the leg and set him down and his leg popped...So, (DCS 1) just grabbed his foot away from the pommel. I thought we should recline (Client A) to get the pressure off in a more comfortable way but (DCS 1) didn't listen to me. After she released his foot it swung odd... (DCS 1) had to put pressure on the leg to release it. The pommel was high and she had to raise the foot over the pommel to release it. I told her no, recline the chair to release the pressure and slide (Client A) back, but she didn't listen... (DCS 1) had pulled (Client A's) foot out with all the weight still on his leg. He had grimaced after the fracture, then he startled when she pulled his foot out." DCS 2 also stated when staff touched the leg, Client A started to cry. "As time passed his crying got harder and harder and the tears fell. We are supposed to use two people, one person grabs from behind and grasps under the armpits, and...we count 1, 2, 3 so (Client A) is prepared for it...The second person holds the legs. Because it was a one person transfer, it was an abrupt move. (DCS 1) had put her arm between (Client A's) legs, and her other arm was around his shoulder...It was a loud pop, his whole body went stiff." The facility policy titled "Lifting and Transfer Techniques" indicates in part "Clients over 100 lbs. require three person lift or mechanical lift...Assess the client's...weight...to determine the number of staff needed to perform the procedure safely...Do not operate lift alone. At least two people are needed to stabilize and guide the client being moved." During an interview with PM on November 23, 2010 at 8:14 AM, she stated "It hasn't been our practice to use three people or the lift (when transferring Client A)." Therefore, the facility failed to ensure staff was adequately trained to correctly implement a facility policy/procedure while caring for the client. 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. |
| 220000038 |
Nazareth Vista |
220011126 |
A |
14-Nov-14 |
CT0B11 |
6618 |
T22 DIV5 CH3 ART3-72311(a)(2) 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. This STATUTE is not met as evidenced by: Based on observation, interview and record review, the facility failed to implement the plan of care for one sampled patient (Patient 1) when the patient was not assisted to the bathroom every two to three hours. As a result, Patient 1 fell on 7/1/14 and broke her left hip when no one helped her to the bathroom. This failure caused the resident pain and decline in mobility resulting from her injury.Findings: Patient 1 was admitted to the facility on 8/3/12 with diagnoses including dementia, and anxiety.Review of Nurses Notes dated 7/1/14 at 1:15pm, indicated, " Found resident (Patient 1) lying on her left side calling for help. Able to move UE (upper extremities) and R (right) leg. Complained of left leg pain. 2pm, Paramedics came and transported resident to XYZ Hospital via ambulance. 4:03pm, Spoke with ER (emergency Room) doctor from XYZ Hospital and he stated that resident has left hip fracture..." Review of Patient 1's Fall Risk Assessment Total Score was 14 on 2/2014 and 14 on 5/2014. A total score of 10 or above represents High Risk for falls. Review of Patient 1's Anxiety Care Plan dated 3/13/14 indicated, "(Patient 1) has episodes of anxiety, restlessness and getting out of bed without assistance..." Review of Patient 1's Care Plan for ADL Maintenance (Activities of Daily Living) dated 5/3/14 indicated, "Decline in ADL's: dressing, bathing, toileting, ambulation, transfer (to bed/chair), eating... Related to Dementia... Intervention: ...Assist as needed...Assist with shower...Assist with toileting ...Assist with ambulation...Walker/Cane within reach...Provide support with bed/chair transfer...Complete all ADL's for resident..." Review of the facility's policy titled Falls and Fall Risk, revised 2007, indicated, "As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling... Risk factors include lightheadedness or dizziness, multiple medications... gait and balance disorders, cognitive impairment... weakness, confusion... (Falls)...They should also be identified as witnessed or unwitnessed... After more than one fall the physician should review the resident's gait, balance and current medications that may be associated with dizziness or falling... The staff will monitor and document each patients response to interventions intended to reduce falling or the risks of falling... Patients must be assessed in a timely manner for potential causes of falls..." Review of Patient 1's Care Plan for Unavoidable Fall Risk dated 5/3/14 indicated, "...High Score on Fall Risk assessment, history of frequent falls... Unable to maintain posture...Gets out of bed without assistance. Secondary to: dementia... unstable gait... poor safety awareness... Intervention 8/3/13: ...Toilet every 2-3 hours... Bed in low position... 11/3/13 Bed and chair pressure pad alarm... Call light within reach at all times... Remind to use when needs help." Review of Patients 1's Care Plan for Cognitive Loss dated 5/16/14 indicated, "...Decline in cognition due to Dementia... short term memory problem... problem making decisions... decline in functional ability... Confusion, Poor safety awareness..." Review of the CNA (Certified Nursing Assistant) Assignment sheet for July 1, 2014, indicated a score of 1 was a Light acuity patient (level of attention/service the patient will receive from staff), score of 2 was a Medium acuity patient, a score of 3 was a Heavy acuity patient. Patient 1 was given a score of 2 or Medium acuity. CNA 1 had 8 patients assigned to him including Patient 1, the other 3 CNA's had 6 or 7 patient's. There were four CNA's working on that day. Review of medical records showed no documentation of Patient 1's toileting schedule. During an observation and interview on 8/25/14 at 11:30 AM, Patient 1 was in a wheelchair, dressed and groomed. She was alert and confused. She stated, when asked about her fall, "I don't remember falling. I don't need help to walk to the bathroom. I didn't know about a call light. I don't know how to notify the nurses. Am I in a wheelchair?..." During an observation on 8/25/14 at 11:55 AM of Patient 1's room across the hall from the nurses station. Patient 1 was in a semi-private room. Her bed was next to the doorway. Patient 1's bed was not in low position and there was no bed pad on the floor as indicated in Unavoidable Fall Risk Care Plan. During an interview on 8/25/14 at 9:30 AM, Director of Nurses (DON) stated, "(Patient 1) was in her room watching TV on 7/1/14, she got up from her wheelchair, her alarm went off. She fell in the bathroom at 1:15 PM. She was trying to use the toilet. She usually yells, she's confused. She has to walk with (staff) assistance. We didn't get there in time..." During an interview on 8/25/14 at 12:05 PM, CNA 2 stated she was caring for Patient 1 today. She stated, "I have 9 patients... "During an interview with CNA 2 at 12:55pm, she stated, "I took her (Patient 1) to the bathroom at 8 AM. She limped with the walker. I haven't taken her again... She's usually in the hallway, calls out help, help..." During a telephone interview with the DON on 8/29/14 at 12:20 PM, she was asked if there was evidence that Patient 1 was monitored every two hours for toileting. She stated, "We don't have a set time. We do it after she eats or if she wants. We don't record it..." During a telephone interview on 9/2/14 at 3:10 PM, CNA 1 stated, "I was assigned to (Patient 1) on 7/1/14. When asked if he took Patient 1 to the bathroom that day, he said,"No I didn't help her to the bathroom after 8AM. When Patient 1 fell on 7/1/14, her chair alarm went off. I was in the other room. CNA 3 found her on the floor. When I got there, CNA 3, the DON and a therapist assisted her back to bed. She was crying..." Therefore, the facility failed to implement the plan of care for Patient 1 when the patient was not assisted to the bathroom every two to three hours. As a result, Patient 1 fell on 7/1/14 and broke her left hip when no one helped her to the bathroom. This failure caused the resident pain and decline in mobility resulting from her injury. 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. |
| 230000680 |
NVDS- Oak Mesa |
230009088 |
B |
21-May-12 |
PIM311 |
3798 |
A 008 W&I 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to ensure that Client 1 remained free from harm and injury when he was left unattended, in the shower, fell from a shower chair, hitting his head on the floor tile resulting in a laceration to the forehead, requiring six sutures, an emergency room visit, and x-rays to the head and neck. This had the potential for further injury due to head trauma and a decline in health status.Client 1, a 35 year old male, was admitted to the facility on 2/19/10 with diagnoses that included cerebral palsy (a disorder affecting body movement, balance, and posture). Client 1 was alert, non verbal, and confined to a wheel chair. In an interview on 2/23/12 at 3:10 pm, Program Staff (PS) A stated that on 2/21/12, she and PS B decided to give Client 1 a shower because he was soiled. PS A stated that they transferred Client 1 to a shower chair in the shower room. PS A stated that while PS B was taking Client 1's soiled clothing to the laundry, she stepped out of the shower room to obtain towels from the linen closet. She stated, " I went back into the shower and found him on the floor." She explained that the shower chair had a seat belt that snapped together. She stated, "I didn't realize the belt was not on him." She stated, "He flopped forward because of the way he was positioned in the shower chair." She stated that Client 1 was in a "curled position." PS A stated, "I was in a hurry and stepped out to get towels. He must have rocked forward and rolled out of the chair. I found him on the floor, his head was bleeding, and he was crying." In an interview on 3/1/12 at 9:55 am, PS B stated that she and PS A undressed Client 1 to give him a shower. PS B stated that she asked PS A if there was anything else that she needed and was told no. She stated that she did not recall a seat belt around Client 1. A review of a document titled, "Physical Therapy Evaluation," dated 1/11/12, contained a section describing Client 1's strength that read, "When awake, Client 1 frequently and vigorously moves his legs. During this evaluation, he was observed drawing his knees to his chest, and forcefully extending both legs." The Physical Therapy evaluation described Client 1's balance as, "No sitting or standing balance." A review of a document titled, "Nursing Care Plan," dated 2/13/12, identified Client 1 as a potential for injury, due to Cerebral Palsy. The implementation section of the nursing care plan directed the staff to monitor Client 1, due to uncontrolled movements.In an interview on 3/1/12 at 10:55 am, the Qualified Mental Retardation Professional (QMRP) confirmed that Client 1 had no balance and that Client 1 should not have been left alone in the shower room. Therefore the facility failed to ensure the safety of Client 1 by not protecting him from harm and injury resulting in a fall with an injury to the forehead, requiring six sutures, an emergency room visit, and x-rays to the head and neck. The violation of this regulation had a direct relationship to the health, safety, or security of clients. |
| 230000633 |
Nova Developmental Centers-Tom Polk House |
230009247 |
A |
16-May-12 |
8DYS11 |
13519 |
B 530 T22 DIV5 CH8.5 ART3-76905(b) Pharmaceutical Services--Staff (b) A pharmacist or registered nurse shall review the drug regimen of each client at least monthly and shall document the review in writing. If the drug regimen review is performed by the registered nurse, a pharmacist shall review the drug regimen at least quarterly. The review of the drug regimen of each client shall include all drugs currently ordered, information concerning the client's condition relating to drug therapy, medication administration records, and, where appropriate, physician's progress notes, nurse's notes and laboratory test results. Irregularities in drug dispensing, drug administration, potential adverse drug reactions, allergies, interactions or contraindications, as well as laboratory test results shall be reported to the prescriber. The facility's registered nurse (RN) and contracted pharmacist failed to identify the potential risks of Client 1's medication regimen, including known clinically significant drug interactions, potential adverse drug reactions, or sudden death associated with antipsychotic medications when reviewing Client 1's drug regime. These failures presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm to the client.On 5/25/10, the Department received a faxed report that Client 1 had exhibited unusual behaviors at his day program on 5/24/10, collapsed, and became unresponsive. The client was transferred to a local emergency room where he died on 5/24/10 at 1:55 pm.Client 1's autopsy report, dated 5/28/10, revealed the cause of Client 1's death as "Acute Clomipramine Poisoning." The toxicology report, dated 6/25/10, from blood samples obtained from Client 1 revealed that his clomipramine drug level, a medication he had been receiving, was 1.84 mg/L (milligrams/liter), approximately seven times above the effective therapeutic level of 0.02 to 0.25 mg/L.Tricyclic antidepressants, such as clomipramine, have a narrow therapeutic index (a ratio of the drug's toxic dose divided by the therapeutic dose). Therefore, they can become a potent cardiovascular and central nervous system toxin even in moderate doses. Complications include effects of prolonged hypotension, cardiac arrhythmias, seizures, and death.On 6/8/10, an unannounced visit was made to the facility to investigate Client 1's death. Client 1 was a 44 year old male, who was admitted to the facility on 6/9/09 with diagnoses that included mental retardation, psychosis (a condition characterized by delusions and hallucinations), anxiety, bipolar disorder (a condition characterized by extreme opposite mood swings) and schizophrenia (a disorder characterized by hallucinations, disorganized thinking and anti-social behavior). Upon admission, Client 1 was under the medical supervision of an attending physician, Physician E. Prior to and during his admission, the client had been under the care of a psychiatrist, Psychiatrist F, to manage his behaviors and medications.Client 1's most recent physician orders, dated 4/22/10, included the following prescribed medications: 1. Clomipramine 200 milligrams (mg) daily for "psychosis" (a tricyclic antidepressant); 2. Depakote ER (extended release) 500 mg three times daily for "bipolar" (a mood stabilizer); 3. Cogentin 1 mg orally twice a day for "EPS" [extrapyramidal symptoms-a type of movement disorder associated with antipsychotic use] (an anticholinergic medication) 4. Haldol Decanoate 100 mg IM (intramuscularly) every three weeks for "schizophrenia," (a typical antipsychotic), which had been increased from 50 mg to 100 mg on 4/21/10; 5. Symbyax 6/25 mg daily for "mental health" (a selective serotonin reuptake inhibitor [SSRI] antidepressant and atypical antipsychotic combination [fluoxetine and olanzapine]); 6. Aripiprazole 30 mg daily for "psychosis" (an atypical antipsychotic); and 7. Seroquel 200 mg every morning and 400 mg every evening for "depression and sleep" (an atypical antipsychotic), which had been increased on 10/20/09 from 200 mg twice daily. 8. Nexium 40 mg twice a day (prescribed to decrease stomach acid). The maximum daily recommended dosage is 40 mg (manufacturer's product information).Review of Client 1's Medication Administration Records (MARs), from 6/09 through the morning of 5/25/10, revealed that the above mentioned medications had been ordered and administered as prescribed for the past year.On 9/2/10 at 10:35 am, a review of the facility's untitled and undated policy for pharmaceutical record reviews, provided by Administrative (Admin) Staff A, indicated that an RN would review each client's drug regimen at least once each month. She stated that Admin RN reviewed drugs for all the clients and would sign their monthly MARs as verification of her audit.During an interview on 10/4/10 at 9:20 am, Admin RN stated she conducted drug reviews for each client every fourteen days. Admin RN's signature was observed on Client 1's MARs for her administration of the drug, Haldol. However, Client 1's MARs and nurses notes failed to reveal documentation verifying that she had reviewed his drugs for potential adverse reactions, interactions, or contraindications identified with the multiple behavioral controlling medications Client 1 had been receiving. On 10/4/10 at 9:45 pm, Admin RN confirmed she could not substantiate that she had reviewed Client 1's drugs for this type of information.From 6/09 to 5/10, a year's review prior to his death, Client 1's MARs showed documentation that his drugs were reviewed by an RN for only three of the twelve months reviewed. On 7/09, 8/09, and 11/09's MAR sheets, there was an RN signature and a check mark indicating that the nurse reviewed Client's drugs. Prior to the Client 1's death, the 3/10, 4/10, and 5/10 MARs showed the staff, who administered these medications, documented almost daily (exception dates of 3/12 through 3/21/10; on 4/23 and 4/29/10; and on 5/4 and 5/17/10) that Client 1 had shown at least one "possible side effect" of aggressiveness, agitation, anxiety, confusion, depression, headache or pain, hostility, insomnia, manic behavior, or nervousness.The facility's two most recent quarterly "Medication Regimen Reviews," conducted by Pharmacist G, revealed the following: 1. The 2/25/10 entry disclosed that lab results were pending and that a "note to" the registered nurse (RN) of the facility was left with a box checked, "See report for any noted irregularities." On 8/26/10 at 8:30 am, Administrative (Admin) RN B stated that any notes from the pharmacist's review would be addressed in the pharmacy section or in her nurses notes located in the client's record. However, no communication notes from the facility's pharmacist were found in the pharmacy section or the nurses notes in Client 1's record.2. The 5/21/10 "Medication Regimen Review" showed that the Haldol medication was increased to 100 mgs every three weeks and that all psychotropic medications (medications to manage behavior) had been reviewed, and that Client 1's psychiatrist was now prescribing and reviewing these medications. The entry instructed "watch side effects EPS" (extrapyramidal symptoms, which include tremors, nervous twitching, and irregular twisting movements). During the 5/21/10 Medication Regimen Review, the pharmacist failed to address Client 1's history of constipation, bowel obstruction (a blockage of the bowel), and that the physician had been notified on 3/24/10 that Client 1 had experienced a "...distended abdomen, chronic bowel issues, a protruding area on abdomen."Continued record reviews revealed that Pharmacist G had not identified the following medication related irregularities for Client 1: 1. Concurrent use or need for four antipsychotic medications (one typical and three atypical): Haldol Decanoate (haloperidol decanoate), Seroquel (quetiapine), Abilify (aripiprazole), and Zyprexa (olanzapine) as contained in Symbyax; 2. The known potential for altered cardiac conduction (cardiac arrhythmias) with three of these antipsychotics (Abilify, Haldol and Seroquel); 3. Use and need for the tricyclic antidepressant Anafranil (clomipramine) and known potential for altered cardiac conduction; 4. Use and need for the selective serotonin reuptake inhibitor (SSRI) antidepressant/atypical antipsychotic combination Symbyax (fluoxetine/olanzapine), a second antidepressant and one of four antipsychotic medications; 5. Use of the anti-Parkinson's/anticholinergic agent Cogentin (benztropine) and, 6. Use of the anticonvulsant/mood stabilizer Depakote ER (divalproex acid) and the potential interaction with clomipramine (decreased metabolism of the latter); 7. The excessive Nexium dose and the potential interaction with clomipramine (decreased metabolism of the latter resulting in elevated drug levels). Clinically significant drug interactions among Client 1's drug regimen included: 1. The use of clomipramine with Haldol Decanoate: concurrent use may result in life-threatening cardiac arrhythmias; 2. Clomipramine plus Seroquel: concurrent use may result in life-threatening cardiac arrhythmias; 3. Clomipramine plus Symbyax (fluoxetine and olanzapine): concurrent use may result in elevated serum clomipramine levels. 4. Clomipramine plus Depakote: concurrent use may result in elevated serum clomipramine levels. 5. Clomipramine plus Nexium: concurrent use may result in elevated serum clomipramine levels. 6. Clomipramine plus Depakote: concurrent use may result in increased serum concentration levels of clomipramine. The "Consultation Report," dated 2/1 through 2/14/09, from the consultant pharmacist, Pharmacist G, to Physician E regarding Client 1's use of "several antipsychotics" included Haldol Decanoate, Symbyax, and Abilify. This document indicated that, "If the physician wants these medications to continue at current dosage, this document will serve as a RISK vs. BENEFITS STATEMENT." The consultant pharmacist recommended, "If therapy is to continue at the current dose, please provide rationale describing a dose reduction as clinically contraindicated." At the bottom of the consultation report, Physician E indicated by a checked mark next to a pre-printed entry, "I decline the recommendation(s) above as GDR (gradual dosage reduction) is CLINICALLY CONTRAINDICATED for this individual, because the resident's target symptoms returned or worsened after the most recent GDR attempt in the facility." The facility was unable to provide any documented evidence that it had attempted any prior gradual dosage reductions and/or that Client 1's target symptoms returned or worsened after attempting same.In response to "Please document patient specific rationale for GDR contraindications," Physician E wrote an entry of, "Needs more medications not less secondary to behaviors. Will refer to psych [Psychiatrist F]."Physician E ' s documentation was dated 15 months prior to the resident's death, and he failed to identify the potential risks or benefits of continued use of these medications for Client 1. Subsequent to this date, the facility was unable to provide any evidence of attempted gradual dosage reductions or risk benefit documentation of this combination of medication for Client 1. Client 1 received the medications above for fifteen months with no documented evidence of clinical justification for continued use of such combination.On 2/16/10, a signed order by Physician E read, "[Psychiatrist F] has accepted responsibility for all psychotropic medications and their adjustments." On 10/19/10 at 11:50 am in an interview, Physician E thought the reason for the clomipramine poisoning and Client 1's death "must have been a drug interaction." He denied that Client 1 had any history of heart problems. Physician E stated that he was "glad" that Psychiatrist F took over Client 1's psychotropic medications, because he felt Client 1 "was out of my [Physician E's] league." Concurrently at 12 pm, Physician E stated he had never met with Psychiatrist F or Pharmacist G, and neither had apprised him of any potential drug interactions.On 8/5/11 at 1:55 pm, Pharmacist G was interviewed. He confirmed that when he worked as a consultant pharmacist for the facility, he would conduct drug regimen reviews on all clients every three months. He stated after his reviews, he would type up his findings and give them to Admin RN. He stated that, in his professional opinion, he could not identify any problems with the combination of drugs prescribed to Client 1. He stated he thought all the medications were in therapeutic range and were not the maximum doses that could have been prescribed.The facility's registered nurse and contracted pharmacist failed to conduct and record meaningful and timely drug regimen reviews, encourage drug reductions, and note potential adverse drug reactions, interactions and contraindications. In so doing, they placed Client 1 at severe risk that death or serious harm would result from the combination of these medications. They failed to identify the potential risks of his medication regimen, including known clinically significant drug interactions, potential adverse drug reactions, relative contraindications or potential sudden death associated with antipsychotic medications and to notify the attending physician.These failures presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm to the client. |
| 230000468 |
NVDS, Inc - Valentine House |
230009307 |
B |
24-May-12 |
FFM211 |
3281 |
A 008 W&I 4502(h)Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. Based on interview and record review, the facility failed to ensure that all clients were free from harm, when a client sustained an injury after falling out of a shower chair causing her right hip to be fractured. On 1/19/12, Client 1's record was reviewed. Client 1 was admitted to the facility on 4/6/92 with diagnoses that included severe mental retardation, history of hip fracture, and osteoporosis (thin bones). The facility's "Nursing Care Plan" for Client 1, dated 7/12/11, read that the client was dependent for transfers using a mechanical lift.On 1/19/12 at 3:30 pm, House Manager (HM) recalled that on 1/9/12 after direct care staff (DCS B) had transferred Client 1 using a mechanical lift from her bed to a shower chair, Client 1 was not properly seated on the shower chair. HM stated that DCS B moved Client 1 before she secured the seat belt on the shower chair, and Client 1 fell to the floor.A facility protocol, dated 3/06, instructed staff to fasten the shower chair seatbelt before moving a client that is seated in a shower chair. The acute care hospital's emergency room (ER) documentation, dated 1/9/12, revealed Client 1 had been transported to the hospital for a painful right hip. The ER report, dated 1/9/12, read Client 1 had slipped out of her shower chair and experienced right hip pain. The right hip x-ray showed an acute intertrochanteric hip fracture that was angulated (bones are not straight) and an old hip fracture. Client 1 underwent surgery to repair her fractured hip.On 3/14/12 at 2 pm in an interview, DCS B recalled that she had transferred Client 1 from the bed to a shower chair using a mechanical lift on 1/9/12. She stated Client 1 fell forward out of the shower chair before she could fasten the shower chair seat belt.On 1/19/12 at 10:30 am in an interview, the Administrator (Admin) stated that an investigation of Client 1's fall was conducted on 1/9/12. Admin stated that it was determined that DCS B did not follow the proper procedure for transfers (seat belt client in the shower chair before moving the shower chair) and had not ensured the safety of Client 1. She confirmed that Client 1's was injured, because DCS B had not ensured that Client 1 was secured in the shower chair. Therefore, the facility failed to ensure that all clients were free from harm, when a client sustained an injury after falling out of a shower chair causing her right hip to be fractured. This violation has a direct or immediate relationship to the health, safety, or security of clients. |
| 230000760 |
NVDS- Cirrus House |
230010420 |
B |
20-Feb-14 |
1R6611 |
8227 |
A 004 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. Based on interview and record review, Client 1's right to receive prompt medical care and treatment was violated after she fell twice. During these falls Client 1 hit her head and sustained injuries that included a broken neck. The delay in treatment resulted in or had the potential to result in a longer hospitalization and recovery period than if Client 1 had received treatment immediately. A review of Client 1's record disclosed she was admitted to the facility on 7/23/03 with diagnoses that included severe intellectual disabilities, seizure disorder, schizophrenia (abnormal thoughts), mood disorder and depression. The facility's "Individual Service Plan" (ISP) for Client 1, dated 11/6/12, indicated that the client was able to "express herself verbally to make her wants and needs known," was a fall risk and "needed encouragement to slow down and take her time when walking."During an interview on 4/24/13 at 5 pm, the House Manager (HM) recalled that on 4/17/13 at 5:30 pm, Client 1 had rolled off her bed, hit her face on equipment that was on the nightstand next to her bed, and sustained a cut by her right eye. This was witnessed by Direct Care Staff (DCS). HM stated that Client 1 was given first aid (cleaned with soap and water and the cut was taped closed with steri-strips) for the 1/2 inch cut next to her right eye. HM stated that she did not call the nurse about the fall and injury. (Fall 1) HM recalled that on 4/18/13 at 2 am, DCS B had called her and reported that Client 1 had thrown herself several feet onto the floor face down on the rug, and sustained the following injuries: a cut on her nose, forehead, and rug burns on her face. HM stated she instructed DCS B to help Client 1 back to bed. HM stated she arrived at the facility at 6 am on 4/18/13, and that Client 1 complained that her "neck hurt" during her shower at 8 am. HM stated that she called the facility Registered Nurse (RN) and told her that Client 1 complained of neck pain after a fall. HM stated that Client 1 was given Tylenol for her "sore neck." (Fall 2) HM stated that she took Client 1 to her day program (DP, a program outside the facility where clients participate in activities to help maintain or improve their level of functioning) and later, received a call from the facility's Registered Nurse (RN). RN told her that Client 1 was able to move her neck, had some neck stiffness, but was "OK," and to continue with the Tylenol for pain.HM recalled the next morning, on 4/19/13 at 6:40 am, Client 1 was at the table eating her breakfast, when her lips and around her mouth became "dusky" (a dark color), and she was "not breathing." HM instructed staff to call "911" while she attempted to dislodge any food in case Client 1 was choking. HM stated she did an Heimlich maneuver (a thrust to the upper stomach), then a finger sweep in Client 1's mouth, stood Client 1 up and hit her on her back between her shoulder blades, and then sat Client 1 on the floor. HM stated that Client 1 did not have visible food in her mouth and that Client 1 started to make noises, took a deep breath, and then became alert once again, and "acted like herself." HM stated that she canceled the 911 call. HM also stated that she did not notify the RN about the above "choking, not breathing" incident.HM stated that Client 1 went to the DP at 9 am, and that the DP was informed about the "choking incident" earlier that morning. Client 1 returned from the DP at 2 pm, and told DCS that her neck hurt. HM stated the DP had written a note to the facility that Client 1 "did not eat lunch." HM stated that she became concerned when Client 1 did not want to eat after she returned home so contacted the RN. The RN called back, and instructed her to take Client 1 to the emergency room to be evaluated.HM acknowledged that the RN had not been immediately called after the incidents on: 4/17/13 at 5:30 pm, 4/18/12 at 2 am, or after the "not breathing" incident on 4/19/13 at 6:40 am. During an interview on 4/25/13 at 4:45 pm, the RN stated that HM called on 4/18/13 at 8 am, and reported Client 1's fall during the night at 2 am, six hours earlier. HM reported that Client 1 had complained of neck pain, was able to move her arms and legs, and had no other symptoms. RN stated that HM had asked her if Client 1 should go to the emergency room (ER) for an evaluation. RN stated that she instructed HM to watch Client 1, give her medications, and let Client 1 go to the DP. RN stated that later that day, she received a call from the DP staff, and was informed that Client 1 was "acting weird," complained that her neck hurt, and had been given Tylenol for pain.RN recalled that she first saw Client 1 on 4/18/13 at 7 pm, at the facility and that her neck and upper shoulders were "very tight." RN stated that she gave Client 1 a "light massage" and that her tight muscles had "relaxed a little," and she had limited movement in her neck. Client 1 informed RN that it hurt to move her head, her neck was painful and she did not want to move her neck. RN stated that Client 1's hand and muscle tone in her arms and legs seemed "OK." RN stated that she told facility staff to monitor Client 1 that night.On 4/19/13 at 1:30 pm, RN recalled that the DP staff had told her that Client 1 would not eat, and was making a "weird noise" from her throat. RN also stated that HM had called at 3 pm, and reported that Client 1 would not eat, which was unusual for Client 1. RN stated she called Client 1's physician and urgent care offices, and when they could not see Client 1, it was recommended to have Client 1 be seen at the ER. RN stated that at the ER, an x-ray revealed that Client 1 had severe fractures of her neck (cervical - C 1, the first neck vertebrae) and needed immediate attention. RN stated that Client 1 was transferred to a different hospital and later required intubation (a breathing tube inserted into the lungs) because she could not breathe because of her neck fractures and required surgery.RN recalled that she had debated what to do about Client 1's symptoms and complaints of neck pain after her fall, and that it was on 4/19/13 at 3 pm, when she realized that Client 1 needed to be seen by a physician. RN acknowledged that Client 1 needed immediate medical care, and that care was delayed.The facility's undated policy, titled, Client Safety Policy 1.8, "If the fall involves the client landing on or hitting their head ... if there are complaints, or unusual behavior that might be related to the fall, notify the RN immediately."On 9/18/13 at 5 pm, the facility Administrator stated that the RN was not made aware of all the events that had occurred to Client 1, which further delayed Client 1's care and medical intervention for her severe injuries. Admin stated that the facility did not follow the policy to notify the RN immediately after each of the falls on 4/17 and 4/18, and when Client 1 was "not breathing" on 4/19/13.Client 1 fell and sustained injuries on 4/17/13 at 5:30 pm and again on 4/18/13 at 2 am, then had an incident where she turned dusky and was not breathing on 4/19/13 at 6:40 am. It was not until 4/19/13 at 3 pm before Client 1 was taken to the hospital for treatment. This was 37 hours after the second fall and more than eight hours after the choking incident.Therefore, the facility failed to ensure that all clients received prompt medical care and treatment, after Client 1 had fallen and suffered a broken neck. This violation had a direct or immediate relationship to the health, safety, or security of clients. |
| 250000592 |
NEW IDEALS/OTIS HOUSE |
250010298 |
B |
09-Dec-13 |
GQWX11 |
4035 |
W&I 15610.07 "Abuse of an elder or dependent adult" means either of the following: (a) Physical abuse, neglect, financial abuse, abandonment, isolation, abduction or other treatment with resulting physical harm or pain or mental suffering. The facility failed to protect Client A from the Facility Manager's (FM) physical abuse on 5/23/13. On 5/31/13, an unannounced visit was made at the facility to investigate a report that "an employee came into the office and reported that she had seen another employee hit client on the forehead as client was standing by the med cabinet" on 5/23/13. Client A, a 56-year-old male, was admitted to the facility on 6/21/12, with diagnoses that included: 1. Moderate intellectual disability 2. Down syndrome (genetic condition that can have physical problems as well as intellectual disabilities) On 5/31/13, at 2:50 p.m., Direct Care Staff (DCS) 1 was interviewed. She stated Client 1 was non-verbal and the facility staff communicated with the client by means of physical redirection and hand gestures.At that same date and time, the surveyor greeted Client A but he did not respond. Client A appeared not aware of his surroundings. DCS 1 held Client A's hand and physically redirected him to use the bathroom.At 3 p.m., the Assistant Qualified Intellectual Disabilities Professional (AQIDP) was interviewed. The AQIDP stated that DCS 2 came to her office on 5/23/13, and stated that she had seen the Facility Manager (FM) hit Client A on his forehead. The AQIDP stated that she asked DCS 2 to write a statement of her account of the incident.The AQIDP stated on the same date at 9 a.m., that she, the Executive Director, and the Registered Nurse (RN) conducted an interview with the FM. The AQIDP stated that the FM admitted physical contact with Client A's forehead happened, but the FM denied the physical contact was hard and intentional. The AQIDP stated that during the interview, the FM stated, "It (contact) was only rubbing the client's (Client A) forehead that the client likes. There was contact but not bad." The AQIDP stated that after the investigation was done, she believed that the incident happened. She further stated that the FM was suspended. The AQIDP asked the surveyor, "What do we do now?" The surveyor informed the AQIDP to look at the facility's policy and procedure for abuse for further guidance. A review of DCS 1's written statement dated 5/23/13, at 7:45 a.m., was completed. A review of the statement indicated "...as I was walking into the dining room area I seen (FM's name) hit (Client A's name) on the forehead because he was screaming...his forehead was slightly red...When (FM's name) noticed I (DCS 1) was there he tried to play it off as if the hit was soft and he always played with (Client A's name) that way." DCS 3's written statement dated 5/28/13, no time, was reviewed. The statement indicated "I was in the living room...on 5/23/13 time around 7:35 a.m., I heard both staff in dining room hitting each other yelling at themselves...(FM's name) walk (Client A's name) to the living room and sat him next to me." The FM's written statement was reviewed. His statement, no date and time, indicated "I" (FM's name) was touching and feeling on (Client A's name) forehead I always do that cause he like the way it feel I was not don (sic) so such thing as abuse I will never hit a client..." On 5/31/13, the facility's policy and procedure for prevention of abuse, neglect, and mistreatment was reviewed. Under "PROCEDURES...on page 4...If upon investigation, an employee's intentional action or inaction resulted in abuse, neglect or mistreatment, appropriate action will be taken up to and including termination of employment..."On 7/24/13 at 10:15 a.m., a follow up call with the AQIDP was conducted. She stated that the FM was terminated on 6/26/13.Therefore, the facility failed to protect Client A from the FM's physical abuse on 5/23/13. The above violation had a direct or immediate relationship to the health, safety or security of the patient. |
| 250000835 |
NEW IDEALS/NOGAL HOUSE |
250010592 |
B |
04-Apr-14 |
KRMG11 |
5842 |
W&I Code: 15610.07 (a) Abuse of an elder or a dependent adult includes physical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering. The facility failed to ensure clients were free from physical and verbal abuse. The facility failed to ensure Client 1 was free from physical abuse by Direct Care Staff 1 (DCS 1) on April 30, 2012. The facility failed to ensure Client 2 was free from physical and verbal abuse by Direct Care Staff 1 (DCS 1) on April 30, 2012. On March 20, 2014, an unannounced visit was made to the facility to investigate an entity reported incident. Clients 1 and 2's records were reviewed. Client 1 was admitted to the facility on May 21, 1990, with diagnoses that included profound mental retardation and spastic quadriplegia (a nonprogressive but not unchanging disorder of posture or movement, caused by an abnormality of the brain). Client 1 was non-ambulatory and used a wheelchair with seat belt for safety and postural support.Client 2 was admitted to the facility on January 11, 2008, with diagnoses that included mild mental retardation and cerebral palsy (a disorder that affects one's ability to move and to maintain balance and posture).On March 26, 2014, a statement written by DCS 2, on May 1, 2012, was reviewed. The statement indicated that when DCS 2 made a comment to DCS 1's abusive behavior towards Client 1, DCS 1 "gave a bad attitude causing me to just walk away". In addition, DCS 1 "began talking really hard and mean to (name of Client 2). He in return began to have small behavior problems (unspecified) at that time." The facility's "Observation/Information Report", dated May 1, 2012, at 5:30 p.m., was reviewed. The report indicated, as follows: a. For Client 1, Direct Care Staff 1 (DCS 1) "... committed an abusive act against the client", while the client sat in the living room in her wheelchair with her legs folded and crossed. DCS 1 pulled and tugged on Client 1's legs, yelling, "Put your legs down (name)", and that Client 1 would cross her legs again and began to cry as DCS 1 repeatedly "yanked and tugged" at client's legs. b. For Client 2, Direct Care Staff 1 (DCS 1) "... committed an abusive act against the client", while he sat on the floor to retrieve items from his organizational shelf. DCS 1 kicked Client 2 and yelled, "Get up (name of Client 2)".The "Observation/Information Report" did not include DCS 2 as the witness of DCS 1's abusive acts against Clients 1 and 2. The report indicated DCS 3 reported the allegations of abuse to the RN on May 1, 2012. There was no indication that DCS 1 was immediately removed out of the facility after she had committed physical and verbal abuse against Clients 1 and 2. There was no documentation found in the records indicating that the alleged physical and verbal abuse on Clients 1 and 2 were immediately reported to facility administration or other officials, until 35 hours after the incidents, when DCS 3 informed the Registered Nurse (RN) on May 1, 2012, at 5:30 p.m.DCS 2 told DCS 3 on April 30, 2012, at 6 p.m. 11 hours 30 minutes after the two incidents of possible abuse between DCS 1 and Clients 1 and 2.DCS 3 reported the incidents to the Registered Nurse (RN) on May 1, 2012 at 5:30 p.m., 23 hours 30 minutes after being informed by DCS 2. The Registered Nurse (RN) reported the incidents to the Executive Director on May 1, 2012 immediately. The facility reported the allegations of abuse by DCS 1 to Clients 1 and 2 to the Department on May 2, 2012 at 2:24 p.m. A review of the facility's P&P, dated January 1, 2006, titled "Prevention of abuse, neglect, and mistreatment", included the following guidelines: "... The purpose of these procedures is to ensure prompt detection of abuse ... TRAIN: All Direct Care Staff (DCS) are instructed on procedures for reporting ... during their initial orientation ... PROTECT: The Administrator AND one additional management personnel are to be informed immediately by the individual witnessing and/or receiving the accusation ... The accused employee is suspended from working directly with individuals receiving services, pending completed investigations ..." During an interview with the Operations Manager (OM), on March 20, 2014, at 9 a.m., she verified the facility's abuse prevention policy was to report to two administrative staff immediately. The OM verified "immediately" meant: "Right then, and can't let it drag on". The OM verified that DCS 2 witnessed the incidents by the start of her work shift. DCS 2's work shift on April 30, 2012, was from 6:30 a.m. to 9:30 a.m., while DCS 1's work shift was from 12 midnight to 8 a.m. DCS 1 continued to work directly with the facility clients until completion of her work shift at 8 a.m. on April 30, 2012. DCS 2 failed to immediately report DCS 1's physical and verbal abuse to Client 1, occurring on April 30, 2012, at 6:30 a.m., to any management staff. DCS 2 failed to immediately report a second incident of physical abuse by DCS 1 to another client (Client 2), occurring on April 30, 2012, at approximately 6:35 a.m., to any management staff. DCS 1 was not immediately removed and was allowed to work directly with facility clients including Clients 1 and 2. These failures had the potential to result in further abusive acts by DCS 1 to other clients living in the facility. The facility failed to ensure clients were free from physical and verbal abuse. The facility failed to ensure Client 1 was free from physical and verbal abuse by Direct Care Staff (DCS) on April 30, 2012. The facility failed to ensure Client 2 was free from physical and verbal abuse by Direct Care Staff 1 (DCS 1) on April 30, 2012. These violations presented a direct or immediate relationship to the health, safety, and security of patients. |
| 250000835 |
NEW IDEALS/NOGAL HOUSE |
250010594 |
B |
04-Apr-14 |
KRMG11 |
5865 |
Health and Safety Code: 1418.91 (a) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. Health and Safety Code: 1418.91 (b) (b) Failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to ensure that a Direct Care Staff (DCS) immediately reported a witnessed physical and verbal abuse to clients.The facility failed to ensure DCS 2 immediately reported an incident of physical and verbal abuse to Client 1 on April 30, 2012, at approximately 6:30 a.m., to the administrative staff. The facility failed to ensure DCS 2 immediately reported an incident of physical and verbal abuse to Client 2 on April 30, 2012, at approximately 6:35 a.m., to the administrative staff. On March 20, 2014, an unannounced visit was made to the facility to investigate an entity reported incident. Clients 1 and 2's records were reviewed. Client 1 was admitted to the facility on May 21, 1990, with diagnoses that included profound mental retardation and spastic quadriplegia (a nonprogressive but not unchanging disorder of posture or movement, caused by an abnormality of the brain). Client 1 was non-ambulatory and used a wheelchair with seat belt for safety and postural support. Client 1 had died on February 6, 2013, not related to this event. Client 2 was admitted to the facility on January 11, 2008, with diagnoses that included mild mental retardation and cerebral palsy (a disorder that affects one's ability to move and to maintain balance and posture).On March 26, 2014, a statement written by DCS 2, on May 1, 2012, was reviewed. The statement indicated that when DCS 2 made a comment to DCS 1's abusive behavior towards Client 1, DCS 1 "gave a bad attitude causing me to just walk away". In addition, DCS 1 "began talking really hard and mean to (name of Client 2). He in return began to have small behavior problems (unspecified) at that time." The facility's "Observation/Information Report", dated May 1, 2012, at 5:30 p.m., was reviewed. The report indicated, as follows: a. For Client 1, on April 30, 2012, Direct Care Staff 1 (DCS 1) "committed an abusive act against the client", while the client sat in the living room in her wheelchair, with her legs folded and crossed. DCS 1 pulled and tugged on Client 1's legs, yelling, "Put your legs down (name of Client 1)", and that Client 1 would cross her legs again and began to cry as DCS 1 repeatedly "yanked and tugged" at client's legs. b. For Client 2, on April 30, 2012, Direct Care Staff 1 (DCS 1) "committed an abusive act against the client", while he sat on the floor to retrieve items from his organizational shelf. DCS 1 kicked the client and yelled at Client 1,"Get up (name of Client 2)".The "Observation/Information Report" did not include the abusive acts against Clients 1 and 2 were witnessed by DCS 2. The report indicated DCS 3 reported the allegations of abuse to the RN on May 1, 2012. There was no documentation found in the records indicating that the alleged physical and verbal abuse on Clients 1 and 2 were immediately reported to facility administration or other officials, until 35 hours after the incidents, on May 1, 2013, at 5:30 p.m. when DCS 3 informed the Registered Nurse (RN). DCS 2 told DCS 3 on April 30, 2012, at 6 p.m., 11 hours 30 minutes after the two incidents of possible abuse between DCS 1 and Clients 1 and 2. DCS 3 reported the incidents to Registered Nurse (RN) on May 1, 2012, at 5:30 p.m., 23 hours 30 minutes after being informed by DCS 2. The Registered Nurse (RN) reported the incidents to the Executive Director on May 1, 2012 immediately. The facility reported the allegations of abuse by DCS 1 to Clients 1 and 2 to the Department on May 2, 2012 at 2:24 p.m. A review of the facility's P&P, dated January 1, 2006, titled "Prevention of abuse, neglect, and mistreatment", included the following guidelines: "... The purpose of these procedures is to ensure prompt detection of abuse ... TRAIN: All Direct Care Staff (DCS) are instructed on procedures for reporting ... during their initial orientation ... the Administrator AND one additional management personnel are to be informed immediately by the individual witnessing and/or receiving the accusation ..." During an interview with the Operations Manager (OM on March 20, 2014, at 9 a.m., she verified the facility's abuse prevention policy was to report to two administrative staff immediately. The OM verified "immediately" meant: "Right then, and can't let it drag on". The OM verified that DCS 2 witnessed the incidents by the start of her work shift. DCS 2's work shift on April 30, 2012, was from 6:30 a.m. to 9:30 a.m., while DCS 1's work shift was from 12 midnight to 8 a.m. DCS 2 failed to immediately report DCS 1's physical and verbal abuse to Client 1, occurring on April 30, 2012, at 6:30 a.m., to any management staff. DCS 2 failed to immediately report a second incident of physical abuse by DCS 1 to Client 2, occurring on April 30, 2012, at approximately 6:35 a.m., to any management staff. This failure had the potential to result in further abusive acts to other clients living in the facility. The facility failed to ensure that a Direct Care Staff (DCS) immediately reported a witnessed physical and verbal abuse to clients.The facility failed to ensure DCS 2 immediately reported an incident of physical and verbal abuse to Client 1 on April 30, 2012, at approximately 6:30 a.m., to the administrative staff. The facility failed to ensure DCS 2 immediately reported an incident of physical and verbal abuse to Client 2 on April 30, 2012, at approximately 6:35 a.m., to the administrative staff. These violations presented a direct or immediate relationship to the health, safety, and security of patients. |
| 250000592 |
NEW IDEALS/OTIS HOUSE |
250010752 |
B |
12-Jun-14 |
1WKQ11 |
4078 |
483.420 (d) (1) (i) W150 - Staff of the facility must not use physical, verbal, sexual or psychological abuse or punishment. The facility failed to ensure Client 1 was free from physical abuse by Facility Manager 1 (FM1) on October 8, 2013. On October 10, 2013, an unannounced visit was made to the facility to investigate one entity reported incident and one complaint, for same incident, regarding an alleged abuse.On October 10, 2013, Client 1's record was reviewed. Client 1 was admitted to the facility on November 21, 1990, with diagnoses that included profound mental retardation, seizure disorder, left hemiplegia (paralysis of the left side of the body), and schizo- affective disorder (a mental illness that interferes with correct perception of daily life). The comprehensive functional assessment dated July 29, 2013, indicated Client 1 was able to follow two step instructions and respond to simple directions. Facility Manager (FM) 1's written statement, dated October 8, 2013, (time not indicated) " ... (Name withheld - FM 2) was off and on her phone ... spent at least 15 min (minutes) to find someone to pick up her daughter ... (family matter) ... And that is why I felt I had no choice to remove (Client 1) from the meds myself cuz (because) I had no one to help me redirect her (Client 1) from the med cabinet ..." The facility form, titled "Observation/Information Report (incident report)", was reviewed on October 10, 2013. The report indicated the alleged incident happened on October 8, 2013, at approximately 7:15 a.m., while FM 2 watched FM 1 (in training) pass the morning medication, when FM 1 grabbed Client 1's right arm and pushed the client out of the dining area. During the facility's investigation, the facility determined that possible cause of Client 1's redness on right arm was caused by FM 1 grabbing Client 1's arm. During an observation of the facility dining area, there was a notice posted on the top of the cupboard, on top of the kitchen counter, clearly marked, "No Cell Phones". A concurrent interview was conducted with FM 2. FM 2 stated FM 1 was in training, which included medication administration. FM 2 stated she was present when the incident happened. FM 2 further stated, Client 1 walked by and leaned on FM 1's back. FM 1 told Client 1 not to lean her head on her back, but the client did not comply. FM 1 then grabbed Client 1's right arm and pushed the client in front of Direct Care Staff1 (DCS 1), then Client 1 stumbled but did not fall. FM 2 stated she immediately counselled FM 1, and then placed a call to the facility administrator. FM 2 stated she had assumed FM 1 was frustrated because Client 1 was not following her instructions.During an interview with the facility Registered Nurse (RN) on October 10, 2013, at 9:30 a.m., she acknowledged the facility's failure to recognize FM 1's frustration which was the potential cause of her abusive behavior. FM 1 could not be interviewed due to the fact that her employment at the facility had already been terminated on October 11, 2013, as a result of the investigation of the allegation of abuse of Client 1 on October 10, 2013. The facility's Policy and Procedure (P&P), dated January 1, 2006, was reviewed. The P&P indicated, "The purpose of the procedures is to ensure prompt detection of abuse ...The following policies outline practices for the prevention of abuse ... Train ... all Direct Care Staff receive information regarding abuse/neglect/mistreatment during their initial orientation ... includes a thorough review of the agency System to Prevent Abuse, Neglect, and Mistreatment, the agency Zero Tolerance Program and the video and written curriculum entitled "Your Legal Duty ... Reporting Elder and dependent Adult Abuse". Direct Care Staff also receive intermittent review (at least annually) ..." The facility failed to ensure Client 1 was free from physical abuse as evidenced by rough handling by FM1 on October 8, 2013. This violation presented a direct or immediate relationship to the health, safety, and security of all facility clients. |
| 920000024 |
NORTH VALLEY NURSING CENTER |
920008940 |
B |
01-Feb-12 |
GRWP11 |
3888 |
Title 22, Section 72527(a) (9)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: (9) To be free from mental and physical abuse.Based on interview and record review, the facility failed to ensure Patient 1 was free from verbal and physical abuse. Employee A told Patient 1 to shut up, covered Patient 1?s mouth and squeezed it with her hand, then slapped Patient 1 on the back of his shoulder. On May 26, 2011, at 5:10 p.m., an unannounced visit was made to the facility to investigate an entity reported incident of an alleged patient abuse. According to the admission record, Patient 1 was a 55 year-old male admitted to the facility on October 15, 2009, with diagnoses that included quadriplegia (paralysis of both arms and legs), depression, and history of cervical root injury (neck injury). The Minimum Data Set (MDS ? standardized comprehensive of the patient?s problems and conditions) assessment dated April 9, 2011, indicated Patient 1 was independent in his cognitive skills for daily decision making and totally dependent on staff with all activities of daily living. On July 5, 2011, at 12 p.m., during an interview with Patient 1 regarding the May 14, 2011 abuse incident, he stated Employee A came to his room to provide his morning care on May 14, 2011, around 10 a.m. Patient 1 stated that during the care, he and Employee A were talking when suddenly Employee A told him to shut up, then covered his mouth and squeezed it. Patient 1 stated that Employee A turned him on his back and slapped him on the back of his shoulder. Then, Employee A left the room without finishing providing Patient 1 with his morning care. Patient 1 stated that Employee A was his caregiver prior to the incident and was ?very moody,? but never hurt him. On July 5, 2011, at 12:40 p.m., an interview was conducted with Patient 1?s roommate (Patient 2) regarding the May 14, 2011 abuse incident. Patient 2 stated he was lying in his bed waiting for Employee A to help him get ready, because he was going home. He stated that he noticed Employee A was not in a good mood when she went to provide Patient 1?s morning care. Patient 2 stated that he overheard Patient 1 telling Employee A what needed to be done with his care. Then, Employee A told Patient 1 not to tell her what to do. Patient 2 stated that he heard a slap and a splash of water and saw Employee A come away from the privacy curtain, appearing mad and was talking to herself. A review of Patient 2?s Initial History and Physical dated January 27, 2011, indicated he had the capacity to understand and make decisions. A review of Employee A?s personnel file, from April 2005 to December 2010, revealed that she had verbal warnings and had been counseled regarding patient care issues on six separate occasions, including one suspension for her ?attitude and ?failure to perform work? as required.The facility?s investigation concluded on May 20, 2011, and revealed the patients? statements were consistent with their information about the incident. Employee A was suspended during the facility?s investigation and was eventually terminated as a result of the incident with Patient 1. The facility failed to ensure Patient 1 was free from verbal and physical abuse. Employee A told Patient 1 to shut up, covered Patient 1?s mouth and squeezed it with her hand, then slapped Patient 1 on the back of his shoulder. The above violation had a direct relationship to the health, safety, or security of Patient 1. |
| 920000025 |
NEW VISTA NURSING AND REHABILITATION CENTER |
920012446 |
A |
3-Aug-16 |
8L4D11 |
13724 |
F223 42 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 facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. "Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (42 CFR 488.301) "Sexual abuse" includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. The facility failed to ensure Resident 1, who did not have the capacity to make decisions, was free from sexual harassment, coercion, and mental abuse by Employee 1. Employee 1 was found sucking Resident 1?s left breast, placing her at risk of injury, and unable to protect herself from Employee 1?s ongoing sexual abuse. On May 26, 2015, the Department received an Entity Report Incident (CA00444312) indicating on May 26, 2015, at about 6:00 a.m., a certified nursing assistant (CNA) overheard a noise coming from a resident room. The CNA went to the room and opened the closed privacy curtain and saw Employee 1 kneeling and holding and sucking the left breast of Resident 1. A review of the clinical record revealed Resident 1 was originally admitted to the facility on January 30, 2015, and readmitted on May 9, 2015, with diagnoses that included cardiac dysrhythmia (abnormal rhythms of the heart), atrial fibrillation (irregular and rapid heartbeat), cardiac pacemaker (an electric device inserted into the chest wall that controls the heart beat), difficulty swallowing, high blood pressure, diabetes (high blood sugar), and dementia (loss of memory). The Initial History and Physical reports dated January 30, 2015, and May 10, 2015, indicated Resident 1 did not have the capacity to understand and make decisions due to advanced dementia. The Nursing Assessment and History dated May 9, 2015, indicated Resident 1's short term memory was not intact, with difficulty with decision-making. The Minimum Data Set (MDS - a standardized comprehensive assessment tool) dated May 16, 2015, indicated Resident 1 usually makes self understood, and was able to understand others. Resident 1 needed extensive assist with one person physical assist for her daily needs, except set up help for eating. A Care Plan dated May 9, 2015, identified the problem of cognitive loss/dementia with impaired decision making and behavioral problems. The behavior Resident 1 was exhibiting was not identified on the plan. A Care Plan dated May 20, 2015, identified the problem of Resident 1's behavioral symptoms of being "Overly friendly with the opposite sex and had the tendency to call men babe or baby." The intervention indicated to provide reality orientation, set limits to behavior and explain to the resident that her behavior is not acceptable, and to provide psychiatric consult and follow up as indicated. A review of the progress notes indicated the psychiatric consult was not ordered until May 26, 2015, and Resident 1 was not seen until May 29, 2015. A review of the Nurses Notes from May 10, 2015, until May 26, 2015, indicated there was no documentation of Resident 1's inappropriate behavior until May 27, 2015, the day after the sexual abuse occurred. The Social Progress Notes dated May 21, 2015, indicated Resident 1 was observed referring to an employee as "Babe." The resident was redirected and asked not to address any employee or residents that way. There was no other documentation regarding the resident's behavior until after the incident on May 26, 2015. A review of the SBAR (Situation, Background, Appearance, Review) Communication Form dated May 26, 2015, indicated Resident 1 was observed and evaluated with left nipple redness/soreness. A psychiatric Examination occurred with Resident 1 on May 29, 2015. The examination indicated Resident 1 was possibly hypersexual and had difficulty controlling her desires. A review of the Nurses Notes revealed the following: On May 27, 2015 at 2 p.m., Resident 1 tried to remove her clothes and exposing her breast to the nurse. Staff reminded Resident 1 not to expose herself. Resident 1 responded "No, I'm upset because they fired my boyfriend." At 2:35 p.m., a CNA reported that Resident 1 took off all her clothes and when the resident was asked why she removed her clothes she said she's ?waiting for her boyfriend to suck her boobs and private part." On May 27, 2015, at 10:30 p.m., Resident 1 had 2 episodes of taking her clothes and underwear off. When the resident was told that it was not appropriate to do so, the resident started crying and stated, "I miss my boyfriend." On May 28, 2015, Resident 1 continued exposing herself. On May 29, 2015 at 11 a.m., notified by activity staff of Resident 1 removing her clothes in the dining room. The Social Progress Notes dated May 27, 2015, indicated Resident 1 stated she was sad because her boyfriend was fired. When asked for her boyfriend's name, she stated she did not remember. When asked how long she was with her boyfriend, Resident 1 stated she did not remember stating, ?I love him I miss him." On May 29, 2015 at 11:00 a.m., it was documented in the Social Progress Notes that the Social Services Director (SSD) and the Activities Director (AD) spoke with Resident 1 regarding the incident of removing her clothes during the coffee social. The resident stated she did not know she was doing anything wrong. On June 1, 2015, the Social Progress Notes indicated that during the SSD's visit, Resident 1 mentioned that she missed her boyfriend. The SSD explained to Resident 1, what happened was not appropriate. The resident stated, "She did not care and that she loved him." A late entry for June 1, 2015, indicated the SSD referred the resident to a psychologist for psychotherapy. During an interview with CNA 1 on May 28, 2015, at 11:05 a.m., she stated on the morning of the incident, she was working with the residents in the room and came out to place soiled linen in a hamper. CNA 1 completed her tasks with her residents and came out again to put more soiled linen in the hamper. At this time, CNA 1 heard Resident 1 saying "You can suck it but don't hurt me." CNA 1 quietly walked into the room, where the privacy curtain was partly closed and observed Employee 1 kneeling down beside Resident 1 holding her breast in his hands and had his mouth on her breast. Employee 1 looked at her then turned to Resident 1 and said, "She saw me now she is going to tell." CNA 1 also stated Resident 1 had her gown up above her breasts and her diaper open. Employee 1 was fully clothed but had an erection. CNA 1 left the room and Employee 1 followed her asking to not report him. CNA 1 reported the incident. CNA 1 also stated that over two weeks ago, Resident 1 called Employee 1 her boyfriend and Employee 1 responded by saying, "Oh no don't pay attention to what she is saying." On May 22, 2015, at 12:05 p.m., Housekeeper 2 was interviewed and stated that when she first started to work at the facility in 2006, Employee 1 tried to touch her inappropriately and made inappropriate comments about her skin color. Housekeeper 2 reported Employee 1 to the supervisor and to Administrator 2. Employee 1 touched her arms and shoulder and she felt this behavior was "repulsive" and made her feel uncomfortable. Employee 1 was suspended for a few days and did not do it to her again. Housekeeper 2 also stated that Resident 2, who was no longer in the facility, confided with her that Employee 1 was inappropriate with her and touched her breasts and private parts. At that time, Housekeeper 2 was new, had never worked at a skilled nursing facility before, and did not report the incident to anyone because the resident stated she was not forced by Employee 1, and it was consensual. She now knows to report. Housekeeper 2 stated she saw Employee 1 go to Resident 1's room once last week and once the week before. Housekeeper 2 thought that Employee 1 may be fixing a bed but never thought that he may be doing something wrong. On May 28, 2015 at 6:30 p.m., in an interview with the Registered Nurse Supervisor (RNS), she stated that Resident 1 was "uneasy" and denied anything happened, but at the end of each statement, Resident 1 would say, "But he is my boyfriend." The RNS stated Resident 1's body check revealed her left nipple was red compared with the right nipple. The RNS interviewed Employee 1, who became uneasy, kept answering in Spanish, and kept blaming Resident 1 that she wanted him to go near her. A review of Employee 1's file revealed a Memorandum from the Executive Director dated March 9, 2012, indicating on March 3, 2012, CNA 3 observed Employee 1 hugging a female resident and pushing her in her wheelchair to her room, the privacy curtain was closed, and then he left the room. Also, CNA 3 had seen Employee 1 in other female residents' rooms, and that was why she was reporting it. Employee 1 was placed on suspension. On March 3, 2012, an e-mail sent to the Executive Director indicated two CNAs reported that they observed Employee 1 in the dining room hugging a female resident in an inappropriate way and kissed her on the cheek. When Employee 1 was the CNA saw this, Employee 1 wheeled the resident to her room. The CNA followed Employee 1 and saw that he closed the curtain. The CNA walked into the room and Employee 1 left. The CNA also stated Employee 1 always goes to other female resident's rooms, a lot, especially those that are not alert. A review of the investigation dated March 6, 2012, revealed the following: At 12:15 p.m., during an interview, CNA 4 stated she saw Employee 1 hug Resident 2 and did not like the way he hugged and touched her. Employee 1 then pushed the resident to her room, and CNA 4 asked another CNA to follow Employee 1. CNA 4 stated CNA 6 had informed her that Employee 1 had gone to Resident 2's room many times. At 12:30 p.m., during an interview, CNA 7 stated CNA 4 told her to check on Employee 1. CNA 7 went to the room and the curtain was closed. Employee 1 was inside the curtain with Resident 2, standing beside her. At 12:35 p.m., during an interview, CNA 8 stated she saw Resident 2 in the hallway, and saw Employee 1 fixing the resident's shirt. At 12:43 p.m., during an interview, CNA 7 stated she saw Employee 1 go to Resident 2's room to talk to her, and he sits on the chair inside the room. At 12:50 p.m., CNA 6 stated she had seen Employee 1 in Resident 2's room a "lot", whenever the resident is alone. A review of an email dated May 26, 2015, sent to Administrator 1 from the director of staff development, indicated that CNA 8 was interviewed in regards to her recollection of an incident where she was part of the investigation as a witness to Employee 1 and Resident 2, which occurred in 2012. According to CNA 8, she observed inappropriate behavior by Employee 1 like fixing Resident 2's clothing and witnessed on multiple occasions that Employee 1 would sit next to Resident 2 after activities or meal times. She stated the behavior was "weird" and uncomfortable at times. CNA 8 stated that she had recently observed Employee 1 with similar behaviors towards Resident 1, spending time in the dining room after activities and meal time. CNA 8 stated that this made her uncomfortable and she felt weird about it. A review of the Correction Action Notice dated December 7, 2012, indicated Employee 1 received verbal counseling for verbal harassment. The issue was complaints from female workers indicating Employee 1 was telling inappropriate jokes and stories. On May 27, 2015, at approximately 3:35 p.m., an interview was conducted with CNA 1 by ?VPHR?. CNA 1 stated that on May 26, 2015, around 6 a.m., she was in a resident's room and noticed that a dirty linen cart was next to Room "Z" for approximately 30 minutes. She heard a female voice coming from Room "Z" saying, "Suck it but don't hurt me." CNA 1 walked into the room and noticed the curtain was a little closed and found a Hispanic dark skinned man with a mustache bending next to the resident's bed, on the left side, with both of his hands on her left breast with his mouth on her breast. The resident had a low bed and both rails were up. CNA 1 asked what was going on, and Employee 1 responded in English saying, "You see the lady saw us now I am in trouble." Employee 1 told CNA 1 that Resident 1 asked me for it. Resident 1 always talks about her boyfriend, and that he works at the facility. CNA 1 stated that in the past, she had told Employee 1 not to go into her residents' rooms because she cleans everything inside. Resident 1 calls Employee 1 her boyfriend and told her, "I love him dearly, but I am not sure if he is using me." The facility's investigation conclusion to the Department indicated Employee 1 was suspended on May 26, 2015, and would be terminated effective June 2, 2015. On June 2, 2015, as indicated, a letter of termination was hand delivered to Employee 1. On June 9, 2016, the Department of Justice informed the facility that Employee 1 was arrested on June 8, 2016. Therefore, the facility failed to ensure Resident 1, who did not have the capacity to make decisions, was free from sexual harassment, coercion, and mental abuse by Employee 1. This violation presented a substantial probability of serious physical harm to residents, and produced a situation likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident 1. |
| 940000048 |
NORTH WALK VILLA CONVALESCENT HOSPITAL |
940010714 |
A |
02-Jun-14 |
S1Z811 |
11657 |
483.25(l) Unnecessary Drugs Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:(i) In excessive dose (including duplicate therapy); or (ii) For excessive duration; or (iii) Without adequate monitoring; or (iv) Without adequate indications for its use; or (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (vi) Any combinations of the reasons above. The Department received a faxed complaint allegation on February 19, 2014, alleging a resident (Resident 1) was not given pain medications as needed, and the resident wanted a one person assist to transfer, but have been provided two, staff was verbally abusive, staff ruined the resident?s eye shadow and seven bottles of lotion were missing.On March 3, 2014, an unannounced visit to the facility to investigate the complaint was conducted.Based on interview, observation and record review, the facility failed to ensure Resident 1 was free from unnecessary drugs by:1. Continuing to administer narcotics and other pain medication in excessive amounts. 2. Administering pain medication in the presences of adverse consequences. 3. Administering large amounts of Morphine (narcotic pain relievers and a respiratory depressant) without monitoring the resident?s respiratory rate. These failures resulted in the resident sleeping all day until the afternoon, not participating in the activities of daily living, exhibiting adverse consequences of the medication such as body tremors with slurred speech, and the excessive amounts of Morphine which had the potential to lead to respiratory arrest and death. On March 3, 2014, at 8:20 a.m., during an initial tour of the facility, Resident 1's room door was observed closed with a "Do Not Disturb" sign on the door. Upon knocking and entering after given permission, Resident 1 was observed in bed in a dark room, barely able to hold her head up with a slurred speech. A review of Resident 1's record indicated the resident was initially admitted to the facility on November 25, 2013. The resident's diagnoses included chronic pain syndrome, anxiety, multiple sclerosis (body's immune system eats away at the protective sheath (myelin) that covers the nerves), neuropathy (nerve pain), seizure (symptoms of a brain problem that happen because of sudden, abnormal electrical activity in the brain), chronic obstruction pulmonary disease (lung disease that makes it hard to breath [COPD]), gastroesophageal reflux disease (return of the stomach's contents back up into the esophagus[GERD])and tobacco.A review of an admission Minimum Data Set (MDS), a standardized assessment and care screening tool, with an assessment reference date of December 19, 2013, indicated the resident had clear speech, able to express ideas and wants and understood verbal content. The MDS functional content (activities of daily living), under Section G, indicated Resident 1 required extensive assistance in bed mobility, transferring, dressing, and required a one-person assist with toilet use. A review of the resident's Medication Administration Record (MAR) from December 2013- March 2014 (4 months), indicated the resident was receiving Soma 350 milligrams (mg) tablet PO TID for pain management; Valium 10 mg tab PO TID for seizure disorder; Klonopin 3 mg PO TID for seizure disorder; Neurontin 1200 mg PO every 8 hours for pain management; Reglan 5 mg tab PO before breakfast for GERD; Nexium 40 mg PO before breakfast for GERD and Keppra 1000 mg tab PO TID for seizure; morphine sulfate IR (narcotic pain relievers with an instant release [I/R]) 45 mg PO every 6 hours for pain management , which was increased February 25, 2014 to morphine sulfate IR 60 mg every 4 hours around the clock for pain; MS Contin ER (morphine sulfate extended release [ER]) 120 mg PO every 6 hours for pain management; Roxanol (oral morphine to be placed under the tongue) 20 mg per milliliter (ml) SL (to be placed under the tongue) every hour as needed (PRN) was administered to Resident 1, between February 6-14, 2014. According to the Controlled Drug Records, Resident 1 received Morphine (The Drug Abuse Prevention and Control Act 1970 classifies Morphine as a schedule II opioid analgesics, which means that any such drug has a high potential for abuse, and that such abuse may lead to severe psychological and/or physical dependence) in the form of IR, ER, and Sublingual Concentration, from December 1, 2013 through March 5, 2014. The Controlled Drug Record indicated: in December 2013, Resident 1 received 107 doses totaling 9,090 mg of Morphine; in January 2014, Resident 1 received 267 doses totaling 19,940 mg of Morphine; in February 2014, Resident 1 received 163 doses totaling 13,800 mg of Morphine; in the first five days of March 2014, Resident 1 received 23 doses totaling 2,220 mg of Morphine. Resident 1 also received Morphine administered via a patient-controlled analgesia (PCA) pump (method of allowing a person in pain to administer their own pain relief) from February 6-14, 2014, however the facility failed to produce the administration records for the PCA.The manufacturing label for the morphine atindicated, "Proper dosing and titration are essential and [morphine] should only be prescribed by healthcare professionals who are knowledgeable in the use of potent opioids for the management of chronic pain ...Respiratory depression is the chief hazard of opioid agonists, including MS Contin. Respiratory depression if not immediately recognized and treated, may lead to respiratory arrest and death." According to "Lexi-Comp ONLINE," a nationally recognized drug information source, indicates that potential drug related concerns associated with the use of morphine include an increased risk for central nervous system (CNS) depression, anxiety, coma, insomnia, lethargy (abnormal drowsiness), seizure, slurred speech, drowsiness; and for patients with pre-exiting respiratory disease, such as COPD, should be used with caution as critical respiratory depression may occur, even at therapeutic dosages. Use with caution in patients with seizure disorders; (morphine) may cause or exacerbate per-existing seizures. Some dosage forms may be contraindicated in patients with seizure disorder.On March 3, 2014, at 9:56 a.m., during an interview with a certified nursing assistant (CNA 1), and a review of CNA 1's declaration she stated, "The resident does not want to get up in the mornings, does not eat breakfast or lunch, tells the staff to do not disrupt, and usually gets up around 1 p.m." CNA 1 stated, ?She is always so drowsy, she can barely open her eyes, with slurred speech and it is always dark in her room. She always wants four cups of coffee when she gets up and stays in the patio to smoke all day, sometimes till 5 a.m."During interview and review of another declaration, CNA 2 stated, "The resident sleeps most of the day, does not eat breakfast or lunch, doesn't get up till around 2 p.m., and she likes to smoke. She also puts her cell phone alarm on to wake her up for her medication, so she doesn't forget it. She is always shaking and drowsy." On March 3, 2014 at 10:20 a.m., during an interview, licensed vocational nurse (LVN 1), stated she administered Resident 1's 8 a.m., medication that morning. She stated, ?The resident uses her cell phone alarm to wake up for her medication and I still give her medications on time even if she is drowsy, but as a nurse I know I shouldn't." On March 3, 2014 at 10:39 a.m., during an interview, the director of nurses (DON) stated, "She (Resident 1) came to our facility with all those medications on admission. We tried to taper, but she is always refusing. She requested to be on hospice, probably for more medication. I knew it was going to come to this. She is manipulative. She refuses everything. The physician is aware of her refusing her labs, but she is still getting her medication." When asked should the licensed staff administer medications while the resident was drowsy and unable to talk, the DON stated, "If the resident is drowsy and slurring I would not give the medication." On March 3, 2014 at 11:05 a.m., during an interview, the administrator stated, ?She wants to be on hospice. We got the hospice to make her feel better and because she requested it. We just give her whatever she wants to make her happy."On March 3, 2014, at 2:29 p.m., during an interview and observation, Resident 1 was observed in the room with CNA 2 sitting in a reclining chair crying with hands trembling. Resident 1 stated, ?I don't sleep. I wake up every 10, 15, 20 minutes, I have anxiety and I didn't have that before." During a speaker telephone interview in the presence of the survey team, on March 3, 2014 at 1:21 p.m., Physician 2 (medical director) stated, "The resident is difficult to handle, she is noncompliant, needs to be detox and have psychiatric support. She also needs a conservator." When asked about Resident 1's maximum doses and duplication of narcotic medications, he stated, "She's still alive isn't she?" During a record review, Nursing Progress Notes, through the months of December 2013- March 2014, indicated Resident 1 repeatedly refused to be weighed, have laboratory draws, x-rays, and vital signs to be taken, although the pharmacist consultant requested respiratory rates due to the resident receiving large amounts of narcotics. There was only one vital sign taken and documented in December 2013 since the resident was admitted, in which was the resident's temperature.On March 4, 2014, during an review of a physician's order, dated February 7, 2014, indicated the resident was started on a patient-controlled analgesia (PCA) pump of morphine 9 mg/ hour and 3 mg every 15 minutes bolus (dose of a drug given rapidly at one time) for generalized pain and then the order was changed on February 8, 2014 to morphine 10 mg/hr and 4 mg every 15 minutes bolus. Another physician order, dated February 7, 2014, indicated an order for Roxanol (used to ease pain) 20 mg sublingual (under tongue [SL]) every 2 hours as needed (PRN) for pain, while on hospice care.According to "Lexi-Comp ONLINE," a maintenance PCA dose (when self-administered intermittently) of 0.5- 2 mg, usually not more frequently than every 6 to 12 minutes (totaling 10 mg per hours). However, Resident 1 was receiving through the PCA a total of 26 mg of morphine every hour, which is over two and half times the maximum recommended maintenance dose of morphine.On March 4, 2014, during a review of the MAR for February 2014, indicated that while the resident was under hospice care from February 6-14, 2014, the resident received 46 doses of Roxanol 20 mg SL PRN for a total of 920 mg of Morphine being administered in addition to receiving morphine PCA pump, until the medical director at the hospice indicated the resident did not meet the criteria for hospice care and was not " at the end of life" and was discharged from the hospice service (February 14, 2014). 1. Continuing to administer narcotics and other pain medication in excessive amounts. 2. Administering pain medication in the presences of adverse consequences. 3. Administering large amounts of Morphine (narcotic pain relievers and a respiratory depressant) without monitoring the resident?s respiratory rate. The above violation 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 harm would result. |
| 940000048 |
NORTH WALK VILLA CONVALESCENT HOSPITAL |
940010742 |
B |
02-Jun-14 |
None |
9471 |
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. Based on observation, interview, and record review, the facility`s physicians and director of nurses failed to: Act upon the pharmacist consultant`s last three month recommendations regarding clinically significant risks and adverse medication consequences for Resident 1. Resident 1 received large doses of morphine (narcotic pain reliever and respiratory depressant) for pain management without monitoring of the resident's respiratory rate. These failures resulted in Resident 1 receiving high doses of morphine in the presence of adverse consequences and duplication of medication doses without adequate monitoring, which put the resident at risk for respiratory depression and possibly death. On March 3, 2014, at 8:20 a.m., during an initial tour of the facility, the closed door to Resident 1's room displayed a "Do Not Disturb" sign. Upon knocking, obtaining permission, and entering, Resident 1 lay in bed, in the dark, struggling to hold her head up. The resident slurred her speech during conversation. A review of Resident 1's Admission Face Sheet indicated the facility admitted the resident, a 51 year-old female, on November 25, 2013. The resident's diagnoses included chronic pain syndrome, anxiety, multiple sclerosis (disease of the nervous system), neuropathy (nerve pain), seizures (a brain condition that can cause convulsions), chronic obstructive pulmonary disease (COPD/lung disease that blocks airflow and makes breathing difficult), and tobacco use. A review of a Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated December 19, 2013, indicated the resident had clear speech, was able to express ideas and wants, and understood verbal content. The MDS functional content (activities of daily living), Section G, indicated the resident required extensive assistance with bed mobility, transferring, dressing, and required one-person physical assist with toileting.During an interview on March 3, 2014, at 11:05 a.m., when asked regarding the physician (physician 1) response to the pharmacist consultant's recommendations, the administrator stated, "The doctor got off the case because of too much medication." Regarding the pain medications the resident received, the administrator stated, ?The medications are not good for her.? A review of the Medication Administration Record (MAR) for the months of December 2013 through March 2014, indicated Resident 1 received the following medications: Morphine Sulfate IR (narcotic pain reliever with an instant release [I/R]) 30 milligram (mg) by mouth (PO) every 6 hours for pain management; Soma (powerful, rapid pain relief) 350 mg tablet PO TID (three times a day) for pain management; MS Contin ER (morphine sulfate, time-release pill) 120 mg PO every 6 hours for pain management; Neurontin (treatment of seizures and nerve pain) 1200 mg PO every 8 hours for pain management; Valium (a drug that is well known for its sedative abilities) 10 mg tab PO TID for seizure disorder; Reglan (treats nausea and vomiting) 5 mg tab PO before breakfast for GERD, Nexium 40 mg PO before breakfast for GERD; Keppra 1000 mg tab PO TID for seizures; Klonopin (control of seizures in epilepsy and treatment of panic disorder) 3 mg PO TID. According to the pharmacist consultant's Medication Regimen Review (MRR), dated December 11, 2013, the resident received both morphine sulfate 45 mg and MS Contin 120 mg every 6 hours. The pharmacist recommended monitoring for adverse consequences of long-acting opiate therapy. The medical record did not have documentation that the resident's physician saw or was informed of the recommendation. The nurse documented on the MRR report, "Resident refuses vital signs.? There was no further documentation in the clinical record that the resident's respiratory rate was assessed or monitored. On March 3, 2014, at 9:56 a.m., during an interview and review of a declaration, a certified nursing assistant (CNA) 1 stated, "The resident does not want to get up in the mornings, does not eat breakfast or lunch, tells them to do not disrupt, and usually gets up around 1 p.m.? CNA 1 also stated, ?She is always so drowsy, she can barely open her eyes, with slurred speech and it is always dark in her room. She always wants four cups of coffee when she gets up and stays in the patio to smoke all day, sometimes till 5 a.m." The pharmacist's MRR report for the month of December 2013 indicated the resident was receiving duplication therapy for seizure disorder with klonopin and diazepam. The pharmacist recommended re-evaluating the need for both agents. A check in the box to ?decline? the recommendation was present without any additional explanation or justification and documented as a telephone order dated February 2, 2014. No physician signature was present to indicate the physician read the report. According to the MRR report for December 2013, the resident received Reglan. The pharmacist recommended for a re-evaluation of the continued use of Reglan and consideration of discontinuation. Under the physician's response section of the MRR, the box for "decline" was checked and indicated, ?Per resident request to continue with Reglan", without a physician's signature. A review of the Medication Regimen Review (MRR), for January 2014, the pharmacist recommended monitoring for involuntary movements (tardive dyskinesia/TD) due to the ongoing use of Reglan. The MRR indicated the physician declined the recommendation due to the resident's refusal. According to the MRR, the pharmacist indicated the rationale for the recommendation was for early detection of TD-like symptoms as one of the best opportunities to avoid irreversible TD. The pharmacist indicated there was no assessment documented in the resident's record for the previous three months. A review of the resident's, History and Physical Examination (H/P), dated December 5, 2013, indicated Resident 1 was confused and combative, and did not have the capacity to understand and make decisions. However, the facility continued to honor the resident?s medical requests. According to a Monthly Prescribing Reference (MPR), dated January 2014, the adverse reaction of Reglan included restlessness, drowsiness, fatigue, dizziness, and extrapyramidal effects (serious side effects of antipsychotic and other drugs/ disorders of movement). On March 3, 2014, at 9:47 a.m., during an interview, the director of nurses stated nurses call the physician (Physician 1) and relay pharmacist's recommendations then document for the doctor. She stated the physician never saw the MRRs personally. The DON also stated the resident would refuse vital signs and monitoring despite receiving large doses of morphine. During a telephone interview, on March 3, 2014, at 11:31 a.m., the pharmacist consultant stated she was aware the resident received duplicate medications. She stated, she recommended to the physician to evaluate and monitor for respiratory depression, but the physician declined. Despite multiple attempts to contact Physician 1, on March 3, 2014 at 12:30 p.m., March 4, 2014 at 10:03 a.m., and at 1:15 p.m., the physician did not respond to calls or messages. A review of the facility's policy with an effective date of December 1, 2012, titled, "Medication Regimen Review," indicated the facility should independently review each resident's medication regimen directly from the resident's medical chart and with the Interdisciplinary Care Team and resident; the facility should encourage the physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR, for those issues that require a physician/prescriber intervention, the facility should encourage them to either (a) accept and act upon the recommendations contained in the MRR, or (b) reject all or some of the recommendations and provide an explanation as to why the recommendation was rejected. The policy also indicated the facility is to provide the medical director with a copy of the MRRs and he or she would follow-up. However, neither Physician 1 nor the medical director (Physician 2) acted upon the pharmacist consultant?s recommendations. During a speaker telephone interview on March 3, 2014, at 1:23 p.m. in the presence of the survey team, Physician 2 stated he took over Resident 1's care on February 2, 2014. Physician 2 stated, "I thought she has been on hospice care for years [sic], which is why she's on all that medication.? Physician 2 stated he was not aware the pharmacy consultant reviews did not contain physician signatures. Physician 2 asked, "She's still alive isn't she?" The facility failed to act upon the pharmacist consultant`s monthly documented recommendations for three months, regarding clinically significant risks and existing medication adverse consequences for Resident 1. Resident 1 was receiving large doses of morphine (narcotic pain reliever) for pain management, which is a respiratory depressant without monitoring of the resident's respiratory rate. This violation presented, jointly, either separately, or in any combination had a direct or immediate relationship to patient health, safety, or security. |
| 630013603 |
Napoli in the Desert |
980012054 |
A |
07-Apr-16 |
DYUL11 |
11076 |
Title 22, 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. (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.(3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of:(A) The admission of a patient. (B) Any sudden and / or marked adverse change in signs, symptoms or behavior exhibited by a patient.(C) An unusual occurrence, as provided in Section 72541, involving a patient.(E) Any untoward response or reaction by a patient to a medication or treatment.(F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient.(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.72515 The licensee shall: (b) Accept and retain only those patients for whom it can provide adequate care.On August 6, 2015, at 8:45 a.m., an unannounced visit was made to the facility to investigate a complaint alleging Patient 1 was subjected to negligence by the facility staff and died within four hours of arrival to the facility.Based on interview and record review, the facility failed to ensure Patient 1 received nursing services based upon identification of care needs and assessment by failing to:1. Ensure Patient 1's change of condition, a decreased oxygen saturation level of 69% (a percentage that reflects the level of oxygen available in the blood, values less than 90% are considered low) was reported to the physician.2. Ensure Patient 1?s blood sugar level, was checked due to her diabetes and insulin was administered per physician's orders. 3. Ensure Patient 1?s complaint of pain was relieved with administration of the physician ordered Dilaudid. 4. Ensure the policy and procedure on care of patients in emergency situations and emergency procedures was implemented.A review of the closed clinical record indicated Patient 1 was a 56 year old female, admitted to the facility, on 6/3/15, with diagnoses which included insulin-dependent diabetes (a chronic condition in which the body produces little or no insulin, a hormone needed to allow sugar (glucose) to enter cells to produce energy), chronic kidney disease (a serious complication caused by diabetes), high blood pressure, and obesity. Patient 1 was alert, oriented, and able to verbalize her needs.A review of the Daily Narrative Nurses Notes, dated 6/3/15, indicated Patient 1 arrived to the facility, on 6/3/15, at 6 p.m., via ambulance (gurney van). It was documented the van attendant stated, "Patient extremely agitated." It was also documented Patient 1 stated she had not received any medications prior to coming to the facility.A review of the Physician Orders, dated 6/3/15, at 2:30 p.m., indicated Patient 1 was to receive regular insulin (fast acting insulin, regulates blood sugar levels) per sliding scale, check before meals and at bedtime. The physician provided the number of units of insulin Patient 1 was to receive for each range of glucose level. There was no documentation to indicate Patient 1's glucose level was checked or the patient received any insulin.A review of the Physician's Orders, dated 6/3/15, at 2 p.m., Patient 1 was to receive Dilaudid (narcotic pain reliever) 2 milligrams (mg) every four hours on an as needed basis, for severe pain. Patient 1 was also to receive Albuterol 2.5 mg and Ipratropium Bromide 2.5 milliliters (ml) (breathing treatment inhalants), every six hours, for shortness of breath and wheezing. The Daily Narrative Nurses Notes indicated at 6 p.m., Patient 1's oxygen saturation was documented as 69% room air (normal range is above 90%).The Daily Narrative Nurses Notes also indicated at 6 p.m., Patient 1's vital signs included blood pressure of 105/60 mmHg (millimeters hemoglobin, normal range 120/80), heart rate 56 (normal range 60-100), respirations 23 (normal range 12-16). There was no documentation in the clinical record to indicate any action was taken regarding the low oxygen saturation and abnormal vital signs. There was no documentation that the primary care physician was notified regarding these concerns.A review of the Daily Narrative Nurses Notes indicated at 8:30 p.m., Patient 1 complained of pain rated 10 out of 10 (most severe). The physician was texted at 8:33 p.m., regarding the severe pain, but no further action regarding the patient's complaint of severe pain was documented. There was no documentation regarding administration of a pain medication or the location of Patient 1?s pain, i.e. chest pain / abdominal pain, given the patient?s history. The Daily Narrative Nurses Notes indicated that at 9 p.m., Patient 1 became short of breath. There was no documentation regarding administration of breathing treatment medication and/or oxygen for shortness of breath.A review of the Daily Narrative Nurses Notes, dated 6/3/15, at 9:17 p.m., the certified nurse aide (CNA) reported Patient 1 was unresponsive. The licensed vocational nurse (LVN 1) checked the patient's pulse (result not documented) and the patient was unresponsive to voice and agitation. The Daily Narrative Nurses Note indicated LVN 1 began cardiopulmonary resuscitation (CPR) immediately. The CNA was directed to call the emergency response team. A review of the Daily Narrative Nurses Note, dated 6/3/15, at 9:23 p.m., indicated paramedics arrived on scene. The paramedics performed five rounds of CPR. The Daily Narrative Nurses Note dated 6/3/15, indicated Patient 1 was unresponsive and pronounced dead at 9:53 p.m.During a phone interview with LVN 1, on 8/6/15, at 1:10 p.m., she stated when a new admission arrived to the facility; she would take a report from the transporter and obtain the patient?s vital signs. During the phone interview, LVN 1 became uncooperative and would not comment on Patient 1?s admission to the facility, stating she needed to have the patient's clinical record in front of her.According to facility management, LVN 1 resigned from the facility, on 8/21/15 (approximately two weeks after the initial phone interview). LVN 1 failed to respond to numerous voice mail messages left on 10/21, 10/22, and 10/23/15. During a phone interview, on 11/17/15, LVN 1 was nervous, and uncooperative, and did not want to answer any questions. A meeting was suggested and she stated she would call back the following day to confirm, but she failed to call back to confirm. A final voicemail was left for LVN 1, on 11/18/15, but she did not return the call.During an interview with Patient 1's primary care physician (Physician 1), on 11/23/15, at 11:15 a.m., he stated he was never notified of Patient 1's 69% oxygen saturation level. Physician 1 stated he was not informed of Patient 1's condition and death until 1:34 a.m., on 6/4/15.The City of Palmdale information line was called to get information regarding paramedic response in the city. The Sheriff?s Department provided a list of three ambulance companies that respond to 911 calls in the city of Palmdale. The company which handles emergency medical response in the facility's area of the city was contacted. The company representative stated he did not have any record of his company being at the facility address on 6/3/15. He stated they are the company that covers the area where the facility is located and would have been the ones to respond to any 911 call. He stated "If we performed CPR on a patient, we would have documentation of it." However, he stated his company did not go to that address on that date.The two other companies that provide service in the area were contacted. One company representative said his company did not respond to emergency response calls. The other company representative stated his company was the back-up for that area, but he had no documentation of having been at that address on that date. This indicated a discrepancy in the information provided from the facility regarding the circumstances surrounding Patient 1's death.The facility had no documentation, run sheet, or invoice to indicate who responded to the 911 call, performed CPR on Patient 1, and pronounced her dead.The facility's policy and procedure titled, "Emergency Situations???Emergency Situations, Care of Residents," revised 12/2012, Section 6 indicated in an instance of shortness of breath to elevate head to thirty (30) degree angle, loosen constrictive clothing, try to keep resident calm and decrease anxiety, assess need for oxygen (if cyanotic) and apply at three liters, and contact physician.The facility's policy and procedure titled, "Emergency Situations???Emergency Situations, Care of Residents," revised 12/2012, indicated that when providing immediate medical care to a patient whose condition indicates a need: check airway, breathing, and circulation; take vital signs; contact the patient's attending physician immediately. Documentation in the nurse's notes should include the following: vital signs, what was done for the resident, and time the physician was notified. The facility failed to ensure Patient 1 received nursing services based upon identification of care needs and assessment at time of intake and shortly thereafter by failing to:1. Ensure Patient 1's change of condition, a decreased oxygen saturation level of 69% (a percentage that reflects the level of oxygen available in the blood, values less than 90% are considered low) was reported to the physician.2. Ensure Patient 1?s blood sugar level was checked due to her diabetes and insulin was administered per physician's orders. 3. Ensure Patient 1?s complaint of pain was relieved with administration of the physician ordered Dilaudid.4. Ensure the policy and procedure on care of patients in emergency situations and emergency procedures was implemented.These violations, jointly, separately or in any combination, presented either (1) imminent danger that death or serious harm to the patient of the congregate living health facility would result therefrom, or (2) substantial probability that death or serious physical harm to the patient of the congregate living health facility would result therefrom. |
| 630013603 |
Napoli in the Desert |
980013128 |
A |
18-Apr-17 |
UURE11 |
11584 |
Title 22, 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.
Title 22, 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.
(b) All policies and procedures required of these regulations shall be in writing made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee.
On 1/19/17, at 11 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1 who was found unresponsive, 911 was called and the patient died.
Based on interview and record review, the facility failed to ensure Patient 1 received nursing services based upon identification of care needs and failed to implement patient care policies and procedures including:
1. Failure to identify and continuously assess Patient 1?s respiratory care needs to prevent respiratory distress.
2. Failure to implement the facility?s policy dated 12/2012, titled, ?Ventilators, Security for Residents on Mechanical," to ensure all patients on mechanical ventilators are checked by staff every half hour.
3. Failure to implement the facility?s policy revised 12/2012, titled, "Ventilations Function Checks," to ensure ventilator checks are done every four hours or as indicated per respiratory therapy, and are recorded on appropriate flow sheets.
As a result, on XXXXXXX17, at 6:10 a.m., Patient 1 was found unresponsive; paramedics were called due to emergency and pronounced the patient dead at the facility.
According to the Admission and Discharge Summary form, Patient 1 was admitted to the facility, on XXXXXXX16, with diagnoses including respiratory failure, Guillain-Barr‚ Syndrome (GBS - a rare, rapid-onset disorder in which the immune system attacks the body's own nerves and in its most severe form, paralyzes the entire body), and aspiration pneumonia (lung infection from inhaling food or liquid into the lungs). The form also indicated Patient 1 was Full Code (all appropriate resuscitative measures, including cardio-pulmonary resuscitation [CPR], are applied).
A review of the History and Physical form from the general acute care hospital (GACH 1), prior to admission to the facility, dated 7/9/16, indicated Patient 1 was ventilator dependent (requiring a machine to breath) and because of the failure to wean from the ventilator was given a tracheostomy (surgical opening in the neck in order to place a tube into the windpipe to allow air to enter the lungs). Patient 1 had difficulty communicating his needs and was unable to move upper lower extremities (flaccid extremities).
A review of a plan of care dated 10/8/16, developed for Patient 1?s risk of respiratory distress due to the above diagnoses, did not include interventions regarding ventilator settings and alarm function checks. A plan of care developed on 12/13/16 for the patient?s use of Oxygen, included in the interventions to maintain patent airway.
A review of the Certified Nursing Aide (CNA) Activities of Daily Living (ADL) form, dated 1/17/17 indicated around 4:30 a.m., Licensed Vocational Nurse 1 (LVN 1) and CNA 1 entered Patient 1?s room and noticed the tracheal tube (tracheostomy tube) was out of place and LVN 1 placed it back (into the windpipe opening). Patient 1 was fine and was repositioned. CNA 1 and LVN 1 left the room at 5 a.m. CNA 1 also documented LVN 1 went to check Patient 1 around 5:25 a.m., and the patient was unresponsive. CPR was started, but there was no response. CNA 1 called 911, the paramedics continued CPR for 7 to 8 minutes, and Patient 1 was pronounced dead at 6:10 a.m.
A review of the Daily Skilled Nurse?s Notes documented by LVN 1, dated 1/17/17, indicated Patient 1 was checked at 3 a.m. and 4 a.m. with no signs of distress. At 5 a.m., LVN 1 documented she assisted the CNA to reposition the patient, cleaned him, and performed a dressing change. This indicated Patient 1 was checked every hour.
According to the Daily Skilled Nurse?s Notes documented by LVN 1, dated 1/17/17, timed at 5:35 a.m., indicated she walked into Patient 1?s room and found the tracheal tube disconnected but the ventilator was not alarming and she immediately reconnected it back to the patient. Patient 1 was unresponsive with no pulse, LVN 1 called CNA 1 and they initiated CPR, and called 911. The skilled nurse?s notes indicated they continued CPR until the paramedics arrived and took over.
During an interview, on 1/24/17, at 7 a.m., LVN 1 stated she checked on Patient 1 every hour or so and confirmed what she documented in the nursing notes.
A review of the facility's policy and procedure titled, "Ventilators, Security for Residents on Mechanical," revised 12/2012, indicated all patients on mechanical ventilators must be checked by staff every half hour and a staff member must always be within hearing range for ventilator alarms.
On 1/24/17, at 7 a.m., LVN 1 stated she "bagged" (performed respirations via an ambu bag - a resuscitator bag used to assist ventilation) while CNA 1 did compressions for about two minutes, then told the CNA to call 911. LVN 1 stated the CNA called 911 then returned and resumed compressions while the LVN continued bagging the patient. LVN 1 stated paramedics arrived within 4-5 minutes. They placed Patient 1 on the floor and continued CPR. LVN 1 stated Patient 1's alarm sounds very loud and she was amazed that it did not go off. She stated she was ventilator certified and that the ventilator alarms were not routinely checked.
A review of the facility's policy and procedure titled, "Ventilations Function Checks," revised 12/2012, indicated ventilation function checks would be done every four hours or as indicated per respiratory therapy, and recorded on appropriate flow sheets.
According to the Respiratory Flowsheet, documented by four different respiratory therapists, dated from 1/10/17 ? 1/16/17, indicated Patient 1?s ventilator functions were checked approximately every six hours. The respiratory flowsheet indicated the last ventilator function checks were on 1/16/17, at 6:50 p.m., and 1/17/17 at 1 a.m.
A review of the Respiratory Progress Notes, dated 1/16/17 at 1 p.m., and 1/16/17 at 7 p.m., indicated Patient 1 received treatment with no signs of distress. The next respiratory progress note, dated 1/17/17, at 7 a.m., indicated Patient 1 was deceased, ventilator and parameters were checked, all were in order, and all alarms were audible.
During an interview with CNA 1, on 1/24/17, at 9:20 a.m., she stated when she entered Patient 1's room with LVN 1, the patient?s circuit was disconnected from his tracheostomy, but the ventilator alarm was not ringing. The CNA stated she did not notice any change in the patient and he responded that he was OK by nodding his head. CNA 1 stated she left the patient?s room at about 5 a.m., and went to the television room while LVN 1 finished her care for Patient 1 unassisted. CNA 1 stated LVN 1 then came and got her from the television room and they went and started CPR on Patient 1. The CNA stated they did not use a backboard and she had no idea how long the patient?s circuit was disconnected because the alarm did not go off.
During an interview with Respiratory Therapist 1 (RT 1), on 1/24/17, at 10:10 a.m., he stated Patient 1 had no cough reflex, was very responsive, was stable and improving, and could be off the ventilator for 2-3 minutes. RT 1 stated the ventilator had a maximum 10 second delay before the alarm sounded, if it became disconnected. He stated he checked the ventilator after 6:30 a.m. the morning of the incident and found the alarms working and the circuit intact. Only one alarm registered in the history on the ventilator at 5:35 a.m. RT 1 stated whenever parameters were changed on the ventilator, it registered in the history, however, the ventilator company indicated the history was wiped out when the ventilator was unplugged.
A review of the Pre-hospital Care Report Summary (paramedic run sheet) dated 1/17/17, indicated the 911 call was received at 5:36 a.m., and Patient 1 was dead prior to the arrival of the team at 5:49 a.m. The report summary indicated the dispatch reason was the patient was unconscious as of 5:30 a.m. The report summary indicated Patient 1 was "last seen normal two hours ago and no CPR prior to EMS arrival."
During an interview, on 3/3/17, at 9:30 a.m., access to the security video recording for the time of the incident was requested. The Operational Nurse Manager stated she contacted the security company and a copy of the requested video recording would be provided within 4-5 days. However, the requested evidence was not provided.
During a phone interview with Emergency Medical Technician 1 (EMT 1), on 4/14/17, at 1:30 p.m., he stated he was told by staff at the facility that Patient 1 was last seen normal two hours prior to the EMTs arrival. EMT 1 stated there was no staff performing CPR when the EMTs arrived at the patient?s bedside.
A review of the facility's policy and procedure titled, "Ventilators, Security for Residents on Mechanical," revised 12/2012, indicated it was the policy of this facility to ensure adequate staff contact for resident safety against mechanical malfunction and inability to call for help. The policy indicated all residents on mechanical ventilators must be checked by staff every half hour and a staff member must always be within hearing range for ventilator alarms.
The facility failed to ensure Patient 1 received nursing services based upon identification of care needs and failed to implement patient care policies and procedures including:
1. Failure to identify and continuously assess Patient 1?s respiratory care needs to prevent respiratory distress.
2. Failure to implement the facility?s policy dated 12/2012, titled, ?Ventilators, Security for Residents on Mechanical," to ensure all patients on mechanical ventilators are checked by staff every half hour.
3. Failure to implement the facility?s policy revised 12/2012, titled, "Ventilations Function Checks," to ensure ventilator checks are done every four hours or as indicated per respiratory therapy, and are recorded on appropriate flow sheets.
As a result, on 1/17/17, at 6:10 a.m., Patient 1 was found unresponsive; paramedics were called due to emergency and pronounced the patient dead at the facility.
These violations, jointly, separately or in any combination, presented either (1) imminent danger that death or serious harm to the patient of the congregate living health facility would result therefrom, or (2) substantial probability that death or serious physical harm to the patient of the congregate living health facility would result therefrom. |
| 940000063 |
NORWALK MEADOWS NURSING CENTER |
940013694 |
B |
15-Dec-17 |
3RRD11 |
7159 |
F206 ?483.15 (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.
?483.15 (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 Department received an anonymous complaint on 8/28/17 regarding the facility?s refusal to readmit Resident 1.
Based on interview and record review the facility failed to:
1. Adhere and follow its policy regarding transfer and discharges.
2. To readmit Resident 1, as per the State?s Hearing Officer.
This deficient practice violated Resident 1?s rights for returning to the facility and had the potential to affect other resident?s re-admission rights.
On 8/29/17, an unannounced complaint investigation was conducted.
A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on 2/28/17. Resident 1's diagnoses included cognitive communicative disorder (difficulty with attention, memory, organization, problem solving/reasoning functions), schizophrenia (a mental disorder that affects the ability to think, feel, and behave clearly), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).
A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 4/27/17, indicated Resident 1's cognition (ability to think and reason) was intact and was able to make himself understood and understood others. The MDS indicated Resident 1 required limited assistance from staff for activities of daily living (ADLs).
During an interview, on 8/29/27, at 8 a.m., the Acting Director of Nurses (ADON) stated the Admissions Coordinator (AC) was responsible for residents? readmissions.
During an interview, on 8/29/17, at 9:50 a.m., the AC stated the facility always re-admitted a resident that was discharged or transferred, even when the resident's seven-day bed hold policy was completed during that specified timeframe. The AC stated the facility had agreed to readmit Resident 1 to the first available bed, but Resident 1's Family Member (FM 1) refused to transfer him back to the facility. The AC stated FM 1 wanted Resident 1 in a semi-private room, but they did not have one available. The AC stated FM 1 stated she wanted Resident 1 transferred back to the facility as soon a semi-private room became available.
During an interview, on 10/18/17, at 10:30 a.m., FM 1 stated she knew Resident 1 was transferred to the hospital but did not receive a copy of the resident's Bed Hold Notification Form or Discharge Summary indicating the date and time of the transfer.
During an interview, on 10/18/17, at 11:45 a.m., the GACH's Social Worker (SW 1) stated the facility was informed by the State Hearing Appeals Officer to readmit Resident 1 on 8/9/17 and the facility's Administrator agreed. SW 1 stated she tried multiple times to have Resident 1 readmitted to the facility after the hearing, but the facility would always state they were full and had no available beds.
A review of Resident 1's Admission Bed Hold Notification form, dated 5/25/17, indicated there was no signature, time, or date to indicate that Resident 1 or his responsible party was given notification of the bed hold policy upon admission. The "Confirmation of Transfer and Bed Hold Provision" section, indicating the location Resident 1 was transferred was left blank in the following sections:
1. The name of the person notified
2. Date
3. Time
4. Facility Representative Who Witnessed.
A review of the same form, in the "24-Hour Notification" section, indicated a signature from the Facility Representative and FM 1, however there was no date and time indicated.
A review of Resident 1's Transfer Record, dated 5/25/17, did not indicate Resident 1?s reason for transfer to the GACH.
A review of Resident 1's Physician Discharge Summary form, dated 5/25/17, indicated there were no indication of the necessity for Resident 1's transfer/discharge. The form indicated under "medical reason," there was a physician (MD 1) note indicated Resident 1 had "complaints of intermittent pain to the right (R) shoulder, right rib, and right hamstrings. Under the "final diagnosis during stay" section, MD 1 wrote "Please see attached 'Face Sheet.'"
A review of Resident 1's Nurses Note, dated 5/25/17, indicated the resident complained of right shoulder pain, pain to the right rib, and right hamstring (thigh muscle between the hip and knee). The note indicated Resident 1's Nurse Practitioner (NP) ordered a transfer to the GACH, on 5/25/17 at 3:35 p.m. The note indicated emergency medical personal arrived to the facility at 5:45 p.m. and transported Resident 1 to the GACH.
A record review of the facility's "Admit/Discharge Report," dated from 5/1/17 to 8/31/17, indicated the facility had several semi-private beds available on the following days:
1. 8/4/17 - Room 2 Bed A
2. 8/8/17 - Room Bed 5 A
3. 8/10/17 - Room Bed 46 A
4. 8/11/17 - Room Bed 31 B
5. 8/25/17 - Room Bed 5 B
A review of the facility's policy and procedure titled, "Transfer or Discharge Notice," dated December 2016, indicated the resident and/or representative would be notified in writing for the reason for transfer or discharge.
A review of the facility's undated policy and procedure titled, "Bed Hold," indicated the facility would provide notice of the bed hold to the resident and/or family member with papers accompanying the resident to the hospital.
Based on interview and record review the facility failed to:
1. Adhere and follow its policy regarding transfer and discharges.
2. To readmit Resident 1, as per the State?s Hearing Officer.
The above violation had a direct relationship to the health, safety, or security of the residents in the facility. |