| 020000094 |
Park Central Care and Rehabilitation Center |
020010021 |
B |
22-Jul-13 |
55LZ11 |
7998 |
Code of Federal Regulations CFR483.25 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility violated the aforementioned regulation by failing to assess and respond to changes in condition for one of six sampled residents (Resident 1). The facility did not recognize, address symptoms of, or properly document, Resident 1's recurrent Clostridium difficile infection (contagious bacterium that infects the digestive system). This failure resulted in a delay in diagnosis and treatment for Resident 1's infection and she suffered a leukemoid reaction (severe reaction to infection), a life-threatening condition. The body increases production of white blood cells in response to bacterial or viral infection. Normally there are 4,500-10,000 white blood cells per microliter (mcL) of blood. [Reference: http://www.nlm.nih.gov/medlineplus/ency/article/003643.htm] Clostridium difficile (C. diff) is a contagious bacterium that infects the digestive system. It is characterized by diarrhea, though other symptoms include fever and nausea. It can lead to perforation (tears) of the large intestine, sepsis (infection in the blood), and death. C. diff is diagnosed by testing a sample of the diarrhea for signs of the bacteria. The Centers for Disease Control (CDC) recommends that when a person who has had C. diff in the recent past develops diarrhea again, then the first episode of diarrhea should be tested for the infection. [Reference: CDC Healthcare Associated Infections (HAI) Clostridium difficile (CDI) Infections Toolkit] A leukemoid reaction is a life-threatening reaction of the body to an infection. When a person has an infection, the body's normal response is to fight back using its white blood cells, which tend to increase in number while the infection is present in the body. In a leukemoid reaction, the white blood cell count increases far beyond what is typical. Studies have shown that when a person with C. diff has a leukemoid reaction to the infection, with a white blood cell count greater than 50,000, he or she is much more likely to die of the infection. [Reference: Markert, Ronald J. 2004 "Leukemoid reactions complicating colitis due to clostridium difficile."]Resident 1 was a 76 year old woman admitted to the facility on 1/3/13 following an acute care hospital stay for kidney failure and pneumonia (a lung infection). While in the acute care hospital, she developed and was successfully treated for a C. diff infection. The hospital transferred Resident 1 to the facility for physical therapy and Resident 1 was expected to return home to her family. Resident 1 developed diarrhea on 1/15/13, was transferred back to the hospital on 1/24/13, and died of leukemoid reaction and C. diff on 1/31/13. Review of Resident 1's clinical record showed that she had an episode of diarrhea in the evening of 1/18/13, which was documented on the Certified Nursing Assistant (CNA) Activities of Daily Living record. The medical record showed no evidence of a facility assessment for reoccurrence of a C. diff infection and the physician was not notified. A note signed by Occupational Therapist (OT) 1 showed that Resident 1 had another episode of "Loose stool" on 1/21/13. The medical record showed no evidence of a facility assessment for reoccurrence of a C. diff infection and the physician was not notified.Further review of the facility's nurses' notes, from 1/3/13 to 1/24/13, showed no documentation of diarrhea or loose stool at any point during Resident 1's stay at the facility.In an interview with a family member (FM) 1 on 5/17/13 at 12:30 p.m., she stated that she was concerned because of Resident 1's decline in condition. FM 1 took Resident 1 to see her primary care physician (MD 1) on 1/23/13 for an examination. MD 1 ordered a C. diff test. The facility collected a stool sample for C. diff testing on 1/24/13 at 10:00 a.m. The laboratory reported positive test results for C. diff toxin on 1/24/13 at 8:22p.m.According to the facility nurses' notes, dated 1/24/13, Resident 1 was "Sluggish" and "Lethargic" (unusually sleepy), had a temperature of 99.4ø Fahrenheit, and began having more difficulty breathing than usual. The facility transferred Resident 1 to the acute care hospital for an evaluation via ambulance on 1/24/13 at 2:45 p.m.. Review of hospital records showed that after an evaluation in the hospital emergency department, the hospital admitted Resident 1 to the intensive care unit. The hospital emergency room nurses' notes indicate that facility staff reported that Resident 1 had an altered level of consciousness at 8:00 a.m. that day. Resident 1's white blood cell count on 1/24/13 at 5:03 p.m. was 62,400, or more than six times the upper limit of normal. Resident 1 was unable to recover from the infection and leukemoid reaction and died on 1/31/13. A document titled, "Death Summary", dated 2/18/13 and signed by MD 1, showed final diagnoses of leukemoid reaction and Clostridium difficile. In an interview on 5/17/13 at 12:20 p.m., a family member (FM 2) of Resident 1 stated that he had visited Resident 1 every weekday and frequently on weekends. He stated that he witnessed an episode of diarrhea on 1/21/13.In an interview on 5/17/13 at 12:30 p.m., FM 1 stated that LVN 5 had reported to her on 1/15/13 that Resident 1 had had diarrhea. FM 1 stated that she witnessed an episode of diarrhea herself on 1/17/13. In an interview on 5/17/13 at 2:30 p.m., a companion hired by the family (CG 3) stated that she had spent 2-3 hours per day, 5-7 days per week with Resident 1. CG 3 stated that she witnessed Resident 1 have episodes of diarrhea on 1/19/13, 1/20/13, and 1/21/13.In an interview on 5/15/13 at 12:10 p.m., CNA 1 stated that if a resident had diarrhea, she would tell the charge nurse and record it in the Activities of Daily Living book.In an interview on 5/15/13 at 12:15 p.m., LVN 1 stated that if a resident developed diarrhea, she would call the physician as soon as possible to ask for a C. diff test. She further stated that if a resident had a fever, changes in mental status, or changes in breathing, blood pressure, or pulse, she would call the physician and check on the resident every 30 minutes. In an interview on 5/15/13 at 12:15 p.m., LVN 2 stated that diarrhea with a foul odor would be a "Red flag" but that if it did not have an odor he would wait before calling the physician. He stated that signs of infection included fever, chills, decreased blood pressure, confusion, and changes in mental status.In an interview on 5/15/13 at 12:33 p.m., CNA 2 stated that "Having fever or diarrhea are things that I would report to the nurse."In an interview on 5/15/13 at 12:45 p.m., CNA 3 stated that "Changes in condition" are reported to the charge nurse. She stated that a one-time episode of diarrhea is not reported; there would have to be three or four episodes before she would notify the charge nurse. In interviews on 5/15/13 at 2:28 p.m. and 2:57 p.m., the Director of Nursing (DON) stated that a resident who was admitted with risk for recurrent infection (of the same disease) would receive "Intensive monitoring" for 72 hours, and that the monitoring would focus on the specific body system that the disease would impact. The DON was given an example of a resident who had a history of treated C. diff infection who again developed diarrhea. She stated, "It would take two to three loose smelly stools for the staff to alert me." In an interview on 5/15/13 at 2:25 p.m., LVN 4 stated that if a resident who had had C. diff in the past developed new diarrhea, she would call the physician after the second episode of diarrhea.Therefore, the facility failed to assess and respond to changes in Resident 1's condition. This failure had a direct and immediate relationship to patient 1's health. |
| 140000086 |
Pleasanton Nursing and Rehabilitation Center |
020010852 |
B |
09-Jul-14 |
LF0Q11 |
9211 |
F309 483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEINGEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.The facility violated this regulation by its failure to:1. Consult with the physician promptly when Resident 1's condition changed from not needing oxygen on admission, to oxygen desaturation at 89%, nausea and weakness on 4/21/13 at 3:30 p.m. 2. Call for emergency transport to take Resident 1 to the emergency room immediately on 4/21/14 at 8:10 p.m., when she was weaker, with pale cold skin. 3. Prevent Resident 1's deterioration to the point of acute respiratory failure, requiring mechanical ventilation for breathing, treatment for very low blood pressure and a 2 1/2 week hospitalization. The facility admitted Resident 1 on 4/16/13 with a diagnosis of heart failure and pneumonia. Record review of the physician admission orders dated 4/16/13, showed that oxygen was to be provided to Resident 1 as needed to maintain oxygen saturation levels above 90. (oxygen saturation: concentration of oxygen in the blood) Record review of the nursing notes showed the following: 4/16/13 - Resident 1 was alert, responsive, with an oxygen saturation of 98% on room air. (room air: no oxygen provided) 4/17/13 - Resident 1 was alert and in no distress. Oxygen saturation was 93% on room air. 4/18/13 - Resident 1 had no shortness of breath and was verbally responsive with oxygen saturation at 94% on room air. 4/19/13 - Resident 1's oxygen saturation was 94% on room air. 4/20/13 - 2:00 p.m. - Resident 1's oxygen saturation was 92% on room air. 10:00 p.m. - Resident 1 appeared tired and weak. Oxygen saturation was 94% on 2 Liters of oxygen. There was no documented assessment of lung sounds. Record review of the nursing notes dated 4/21/13, showed the following: 5:00 a.m. - Resident 1 was placed on 2 Liters/minute of oxygen with saturations at 92% 2:30 p.m. - Resident 1 was nauseated. Oxygen saturation was 92% on 2 Liters of oxygen. 3:30 p.m. - Resident 1 appeared weak. Oxygen saturation was 89% on room air. Two liters of oxygen was administered. Oxygen saturation was rechecked at 92%. There were no documented vital signs, lung sounds, or calls made to the physician. In an interview on 4/3/14 at 2:17 p.m., the physician, (MD 1) was asked if the on-call physician should have been contacted regarding Resident 1's desaturation, (drop in oxygen level). MD 1 stated that, "Yes. The staff should have called when the oxygen saturation dropped to 89% at 3:30 p.m." On 4/21/13 between the times of 3:30 p.m. and 6:30 p.m., nursing notes showed no documentation of oxygen saturation level checks, vital signs, or lung sound assessments. Record review of the nursing notes dated 4/21/13 at 6:30 p.m., showed that Resident 1's oxygen saturations were between 86 and 89% on 2 Liters of oxygen. At 6:45 p.m., the nursing notes showed that a call was placed to the physician. Record review of the nursing notes dated 4/21/13 at 8:05 p.m., showed that the physician called back and directed staff to send Resident 1 to the Hospital Emergency Room for further evaluation. The ambulance was called and would arrive at the facility in 30 to 35 minutes. (Ambulance transport, not 911) In an interview on 4/3/14 at 2:17 p.m., MD 1 was asked about the timing of the call, (6:45 p.m.), to the physician. MD 1 stated that it was, "Not okay to wait 3 hours to call the physician. The physician should have been called earlier so that a Chest X-Ray and possible diuretics could have been given for heart failure." (Diuretics: medication which helps rid the body of excess fluid and salts which then improves circulation and breathing) In an interview on 3/14/14 at 9:45 a.m., the Charge Nurse, (CRN), was asked to describe the steps she took in caring for Resident 1 on 4/21/13. The CRN stated that she, "Could not remember the patient or what was going on at the time. " CRN stated that she therefore, "Could not answer," any questions regarding Resident 1's care. In an interview on 4/3/14 at 10:30 a.m., the Director of Nursing, (DON), was asked if staff responded appropriately to Resident 1's declining oxygen levels. The DON stated that she, "Would have had to have been there," in order to answer the question. The DON was then asked if, based on the nursing documentation regarding a decreasing level of oxygen, did the staff respond appropriately. The DON stated that she, "Would not answer the question." In an interview on 3/14/14 at 11 a.m., Resident 1's family member, (Family 1), stated that he had arrived at the facility at 5:30 p.m. on 4/21/13. Family 1 stated that Resident 1, "Could hardly breath. No one was paying attention. She was aspirating, (choking), on her own saliva. I talked to the charge nurse. She did not know what to do. They, (the staff), did not want to call 911. They said it was their protocol to call for an ambulance transport to the hospital. They were not realizing the seriousness of the situation. The charge nurse was working on the paperwork and said that the transport ambulance would be there in 30 minutes. I insisted that they call 911." Record review of the nursing notes dated 4/21/13 at 8:10 p.m., showed that Resident 1 appeared weaker with pale, cold skin. Hand grasps were equal but weak. Oxygen saturation was 82 to 85% on 4 Liters of oxygen. At 8:27 p.m., 911 was called and Resident 1 was transported emergently to the hospital. Record review of the emergency room record dated 4/21/13, showed that Resident 1 was diagnosed with the following: Respiratory Failure with Congestive Heart Failure, Pneumonia and Kidney Injury. Resident 1 was pale and cold in the emergency room and placed on 100% oxygen. Resident 1 was placed on a Dopamine Intravenous drip. (Intravenous: directly into the veins) (Dopamine: medication used to raise dangerously low blood pressure up to a safe level.) In an interview on 4/3/14 at 2:17 p.m., MD 1 was asked about the timing of the 911 call. MD 1 stated that, "911 should have been called at 8:10 p.m. Staff should not have waited another 17 minutes to call." MD 1 was asked if he thought that Resident 1's status and medical interventions in the emergency room would have had a different outcome if the physician had been called earlier. MD 1 stated that, due to Resident 1's baseline heart problems, she would have still needed to go to the hospital. She had, "Heart failure and sepsis which caused her kidneys to fail. If it had been caught earlier, she would not have crashed. Studies show that, if you treat sepsis quickly, there is a better outcome. She had a delay from her oxygen desaturations and weakness at 3:30 p.m. until the 911 call at 8:27 p.m. There was time for intervention. For example, we could have spared her the damage to her kidneys." (Sepsis: generalized infection throughout the body) Record review of the facility's policy and procedure entitled, Guidelines for Notifying Practitioners of Clinical Problems, and dated 2001, showed that immediate notification problems include sudden onset or a marked change. (For example, much more severe), compared to usual, (baseline status), and are unrelieved by measures which have already been prescribed. Record review of the facility's policy and procedure entitled, Making an Emergency Transfer - 911, and dated 2007, showed that the facility should make an emergency transfer or discharge when it is in the best interest of the resident. Record review of the care plan dated 4/16/13, identified Resident 1 as being at risk for cardiac and respiratory distress. Interventions included monitoring of lung sounds, cardiac-respiratory distress and to notify the doctor. One of the first signs of heart failure is fatigue and an inability to adequately oxygenate. The heart is failing and is unable to do its work; it has lost its' pumping efficiency. Failure of the heart can lead to congestion in the bodies' circulation. The pulmonary, (lung), circulation becomes congested. Symptoms include crackling lung sounds and dyspnea (shortness of breath). Excess fluid in the circulation can be relieved by the use of diuretics, which help rid the body of excess fluid and salts, thus improving systemic circulation and increasing urinary output. Acute renal failure occurs when the cardiovascular system fails to perfuse the kidneys adequately with blood. [Textbook of Basic Nursing: Wolters/Kluwer, 2008] Therefore the facility failed to: 1. Consult with the physician promptly when Resident 1's condition changed from not needing oxygen on admission, to oxygen desaturation at 89%, nausea and weakness on 4/21/13 at 3:30 p.m. 2. Call for emergency transport to take Resident 1 to the emergency room immediately on 4/21/14 at 8:10 p.m. when she was weaker, with pale cold skin. 3. Prevent Resident 1's deterioration to the point of acute respiratory failure, requiring mechanical ventilation, treatment for very low blood pressure and a 2 1/2 week hospitalization. This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 020000070 |
Providence All Saint's Subacute |
020010964 |
B |
24-Sep-14 |
NF2H11 |
3898 |
F 206 483.12(b)(3) POLICY TO PERMIT READMISSION BEYOND BED-HOLD A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services.The facility violated the aforementioned regulation, by failing to re-admit one (Resident 1) of three sampled residents after he was sent to the hospital for evaluation of coffee ground (indication of bleeding) vomiting. Resident 1, who was on a ventilator (a breathing device), was sent to the hospital on 7/18/14, after having episodes of vomiting, and was ready to return to the facility on 7/19/14. The facility did not do any discharge planning for the resident and refused to readmit him due to an unpaid bill. This failure resulted in Resident 1 having a prolonged stay in a hospital instead of returning to an appropriate level of care.On 7/22/14, review of the medical record, showed Resident 1 was admitted to the facility on 2/11/14, with diagnoses that included anoxic brain injury (brain damage due to lack of oxygen), permanent vegetative state (absence of responsiveness and awareness), chronic respiratory failure, tracheostomy (tube into the neck to enable oxygen to be infused into the lungs by a ventilator), gastrostomy, (a tube surgically placed into the stomach for the infusion of liquids and nutrition), heart failure, and quadriplegia (paralysis of all four extremities).The complete resident assessment, dated 6/27/14, showed Resident 1 was totally dependent in all activities of daily living and required the extensive assistance of two or more staff for all care. Resident 1 was on a ventilator to assist with breathing.Review of the medical record showed nursing notes, dated 7/18/14, "Patient noted to have ...emesis twice." The physician was notified and an ambulance transported Resident 1 to the hospital emergency room. During an interview on 7/22/14 at 9:05 a.m., the facility Admissions Director (AD) stated, "He (Resident 1) went to the hospital on Friday 7/18/14. He was ready to return on Sat., 7/19/14, but we lacked staff to admit over the weekend. On Monday, 7/21/14, the Administrator (ADM) told me to refuse to readmit." During a phone interview on 7/22/14 at 9:45 a.m., the Administer (ADM) stated, "He's (Resident 1) a private pay patient and they owe us money. We're not taking him back."During an interview on 7/22/14 at 9:50 a.m., the Assistant Director of Nurses (ADON) stated, "He (Resident 1) was admitted here 2/14. This was not a planned discharge." During an interview on 7/22/14 at 10:15 a.m., the Social Service Designee (SSD) stated, "There was no plan for him to leave. He was long term. I don't know about a notice to discharge. In May, I spoke to Resident 1's wife and informed her of the last covered day. He would be moved to another building or pay privately. She said she had a lawyer helping her." During a phone interview on 7/24/14 at 9:25 a.m., the hospital case manager (HCM) stated, "He's (Resident 1) still at the hospital." During an interview on 7/24 at 3:40 p.m., the case manager stated, "A letter was sent to inform the (Resident 1's) wife that the insurance ended and directions for appealing the decision. Prior to the exhaustion of benefits, we discussed payer source and she said Medicaid was pending. I spoke to her lawyer who told me the application was pending. The wife believes that Medicaid will pay the bill." Therefore the facility refused to readmit Resident 1 when he was stabilized and ready to be readmitted. This failure caused circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 020000091 |
Piedmont Gardens Health Facility |
020011347 |
B |
23-Mar-15 |
15UI11 |
3775 |
483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.The facility violated the aforementioned regulation by failing to ensure that one of one sampled residents (Resident 1) was not abused during care. CNA 1 was witnessed by another staff covering Resident 1's mouth, slapping her on the tops of both hands and punching her on the mid chest during care, telling her to be quiet, causing Resident 1, who was restless, to become more agitated and make sounds like "Aw, Aw, Aw."Later, CNA 1 left Resident 1 naked in the wheelchair in her room while she went to get supplies, leaving Resident 1 exposed to anyone entering the room. On 1/8/15, record review showed Resident 1 was a 94 year old woman who was admitted to the facility on 10/29/08 with the diagnoses of Dementia (decline in mental ability severe enough to interfere with daily life.).According to the most recent minimum data set (assessment tool), dated 11/4/14, Resident 1 needed extensive assistance, requiring two persons to assist transferring from the bed to wheelchair, and one person assist for dressing, eating, toileting and personal hygiene. On 1/8/15 at 12:45 p.m., Resident 1 was observed sitting up in a wheelchair. She did not have any visible injuries; did not appear distressed and did not respond to questions. Review of the nurses note dated 1/1/15 at 8:41 a.m., revealed that at 11 p.m., on 12/31/14, Resident 1 had her legs on the edge of the bed as she was trying to get up and was disrobing. An hour and half later on 1/1/15 at 12:30 a.m., the bed alarm was beeping and CNA 1 and CNA 2 got the resident up into a wheelchair because of her restlessness. Around 12:35 a.m., CNA 2 told the charge nurse (RN 1) that CNA 1 slapped the resident on both of her cheeks, the tops of both hands and punched the resident on the mid chest. RN 1 went to the room and heard Resident 1 saying, "Aw, Aw, Aw," repeatedly. The resident was naked, sitting in the wheelchair and CNA 1 went out of the room to get a gown and 'other stuff' for the resident. As RN 1 was speaking with the resident, CNA 1 came back into the room and, "...Was complaining about how the resident (1) was giving her a hard time because she was disrobing...trying to get up..." RN 1 assessed the resident and there were no skin discolorations. RN 1 reported the incident to the Director of Staff Development (DSD). In a telephone interview on 1/9/15 at 9:36 a.m., CNA 1 stated that when she arrived on her shift on 1/1/15,RN 1 told her to get Resident 1 up in the wheelchair. She asked CNA 2 to help her. The resident was full of feces and she went to get warm water to clean her. The Resident was not cooperative because, "She doesn't like to be washed." CNA 1 bent down to clean the resident and Resident 1 reached out and grabbed CNA 1's uniform top with her hand and was hanging on. CNA 1 stopped her and tried to remove her hand. CNA 1 then put her hand over Resident 1's mouth and told her, "Be quiet, it's the middle of the night, people are sleeping." During a telephone interview on 1/9/15 at 12:30 p.m. the Administrator stated that CNA 1 had told him during the investigation that she put her hand over Resident 1's mouth to quiet her and that was the basis for CNA 1's termination because he considered that abuse.Therefore the facility failed to protect Resident 1 from the initial and repeat abuse from CNA 1. This failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients.1 |
| 020000091 |
Piedmont Gardens Health Facility |
020011348 |
B |
23-Mar-15 |
15UI11 |
5144 |
483.13(c) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.The facility violated the aforementioned regulation by failing to ensure that CNA (certified nurses aide) 2 and RN (Registered Nurse) 1 implemented their written policy regarding abuse, for one of one sampled residents (1). CNA 2 failed to intervene immediately when she witnessed CNA 1 hitting Resident 1 and charge nurse (RN 1) failed reassign CNA 1 to non-resident duties immediately, and allowed CNA 1 to finish providing care, unsupervised, to Resident 1 and other residents, while she telephoned the Director of Staff Development (DSD). This left Resident 1 and other residents unprotected from the potential for further abuse.On 1/8/15, record review showed Resident 1 was a 94 year old woman who was admitted to the facility on 10/29/08 with the diagnoses of Dementia (decline in mental ability severe enough to interfere with daily life.). According to the most recent Minimum Data Set (assessment tool) dated 11/4/14, Resident 1 needed extensive assistance two persons assisting for transferring from the bed to wheelchair, and one person assisting for dressing, eating, toileting and personal hygiene. A record review of the nurses note dated 1/1/15 at 8:41 a.m., revealed that at 11 p.m. on 12/31/14 the resident's legs were on the edge of the bed and she was trying to get up and disrobing. At 12:30 a.m., on 1/1/15 the bed alarm was beeping and the assigned certified nursing assistant (CNA 1) and an extra CNA (CNA 2) got the resident up into a wheelchair because of her restlessness. Around 12:35 a.m., CNA 2 told the charge nurse (RN 1) that CNA 1 slapped the resident on both of her cheeks, the tops of both hands and punched the resident on the mid chest. RN 1 went to the room and she heard the resident saying "Aw, Aw, AW," repeatedly. The resident was naked, sitting in the wheelchair and CNA 1 went out of the room to get a gown and 'other stuff' for the resident. RN 1 was speaking with the resident who only said, "Aw, Aw...," when CNA 1 came back into the room and, "...Was complaining about how the resident was giving her a hard time because she was disrobing...trying to get up..." RN 1 assessed the resident and there were no skin discolorations. RN 1 reported the incident to the Director of Staff Development (DSD). During a telephone interview with CNA 2 on 1/9/15 at 9:30 a.m., he stated that while helping CNA 1 transfer Resident 1 from her bed to the wheelchair, he went to get the wheelchair, which was in front of the bed next to Resident 1's bed, and out of the corner of his eye he saw CNA 1, "Slap both hands and both cheeks," of Resident 1. He could hear the slaps. When he helped CNA 1 transfer Resident 1 to the wheelchair he saw CNA 1, "Punch," Resident 1 in the chest with her fist, and the Resident kept saying "Ow, Ow, Ow." He didn't say anything to CNA 1 and went out of the room to report what he saw to the charge nurse (RN 1). In a telephone interview with RN 1 on 1/9/15 at 10:30 a.m., she stated that sometime after midnight, CNA 2 came to her and said that CNA 1 was slapping Resident 1 on the face and hands and punched her on her chest. RN 1 went in to check the resident who was unclothed in her room sitting on the wheelchair. She stated that CNA 1 went to get a gown and pads for the resident. RN 1 left CNA 1 in the room to continue caring for Resident 1 while she went to telephone the Director of Staff Development (DSD) to report the incident. RN 1 was not sure if CNA 1 went on to work with other residents while she was speaking with the DSD on the phone.In a telephone interview with CNA 1 on 1/9/15 at 9:36 a.m., she stated that after providing care to Resident 1 she placed her in the T.V. room and she went on to finish her rounds and took care of three or four other residents before RN 1 told her to talk with the DSD on the telephone. She stated that the DSD told her "You have abused somebody and leave the building." She didn't know why or what she had done. In an interview with DSD on 1/8/15 at 1 p.m., he stated that he received a phone call from RN 1 on 1/1/15 around 12:45 p.m., to report that CNA 2 told her that CNA 1 slapped Resident 1. He stated that when he was talking to RN 1, CNA 1 and CNA 2 had already transferred Resident 1 and they were taking care of other residents. DSD then spoke with CNA 1 on the phone and told her there was an allegation of abuse and she had to go home. According to the facility's Resident Rights and Abuse Prevention Policy and Procedure Manual dated August 2011, "Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact..." Therefore the facility failed to: Intervene to protect Resident 1 from further abuse from CNA 1 and also failed to follow their policy and procedure to immediately remove CNA 1 from all resident care. The above violation had a direct relationship to the health, safety or security of patients. |
| 020000070 |
Providence All Saint's Subacute |
020011376 |
B |
17-Apr-15 |
K62F11 |
4293 |
483.13(c) PROHIBIT MISTREATMENT/NEGLECT/MISAPPROPRIATIONThe facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.The facility violated the aforementioned regulation by failing to implement their written abuse policy and procedure that prohibited abuse for one of three sampled residents (1). Resident 1 was found in bed screaming in pain by CNA (Certified Nursing Assistant) 4 with an oral use lemon swab protruding from her anus. This failure resulted in Resident 1 suffering physical and emotional pain.A confidential complainant reported to the Department of Public Health that on 1/24/15, Resident 1 was found with an oral use lemon swab sticking out of her anus during an incontinence change by CNA 4.Resident 1's record was reviewed on 1/28/15 at 12:00 noon during an unannounced onsite visit to the facility. According to the face sheet Resident 1 was a 58 year old individual admitted to the facility on 10/28/08 with diagnoses including dementia (a decline of reasoning, memory and other mental abilities), psychotic disorders (severe mental disorders that cause abnormal thinking and perceptions) and depression.The annual Minimum Data Set (MDS- an assessment tool) dated 9/9/14, showed Resident 1 lacked the ability to recall events; required total assistance of two people for personal hygiene needs and for turning side to side and repositioning her body while in bed. She had limited range of motion of her upper and lower extremities.The nurses notes for Resident 1, dated 1/24/15 at 1:30 p.m., showed, "Pt (patient) noted with a (oral lemon) swab stick, sticking out of pt's anus area." The facility's abuse policy and procedure last revised 1/2012 reflected, ''Abuse, neglect will not be tolerated in this facility at any time. The facility will take every proactive measure to prevent the occurrences of alleged abuse of any resident. The Administrator has overall responsibility for implementation and oversight of the Abuse Prevention Program. All suspected abuse will be investigated and reported. Neglect means the negligent failure of any person having the care or custody of an elder or dependent adult to exercise that degree of care that a reasonable person in a like position would exercise. Failure to protect from health and safety hazards. Failure to provide services necessary to avoid physical harm, mental anguish or mental illness." An interview was attempted with Resident 1 on 1/28/15 at 12:15 p.m., but she did not respond to questions. During an interview on 1/28/15 at 1:45 p.m., charge nurse 5 stated, "The CNA (4) was cleaning the Resident (1) and felt resistance and called me. I looked at the Resident (1) and told the CNA (4) to take the swab out. I did a digital exam. The swab was one half way into her rectum. I faxed the report to the doctor."During a telephone interview with CNA 4, on 2/4/15 at 12:30 p.m., she stated, "I usually work with that Resident (1). I was going to do another Resident, but she (Resident 1) was screaming. It's normal for her to scream. But she was screaming, "Ouch." So I decided to do her first. When I cleaned her front she was fine. But when I turned her to clean her buttocks, I noticed a little bowel movement. While I was wiping the bowel movement with a wet wipe, I felt something on my finger tip. I got another wipe and wiped again. I saw a plastic stick coming out of her anus. I was cleaning her by myself. I usually get help to get her up in the chair, but not for bed bath and turning her in bed. I stopped and called my charge nurse. The charge nurse watched me while I cleaned the plastic stick. The charge nurse told me to remove it. When I removed it, the cotton was still on (attached to) the tip of the lemon swab. She (Resident 1) would not have been able to put the swab up (inside her anus) herself; she can't reach that far in back of her." During a telephone interview with the Director of Nurses on 2/19/15 at 10:11 a.m., she re-reviewed the facility's Abuse Policy and Procedure for date and content and stated the policy was current. Therefore the facility's failure to protect Resident 1 from abuse had a direct relationship to the health, safety, or security of patients. |
| 020000090 |
Parkview Healthcare Center |
020012677 |
B |
26-Oct-16 |
FMK911 |
7309 |
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 aforementioned regulation by failing to ensure a safe environment when it failed to keep liquid soap off Resident 1's bedside. As a result, Resident 1 ingested liquid soap and experienced vomiting, respiratory distress with low oxygen saturation levels (low amounts of oxygen in the blood). Resident 1 required emergent medical treatment and hospitalization at a general acute care hospital. On 1/14/16, the manufacturer's label for the Apple Strawberry Shampoo/Body Wash showed: "For external use only". The manufacturer's website showed, "Classification: ACUTE TOXICITY-ORAL-Category 5...may be harmful if swallowed...Call poison center/doctor..." Medical record review for Resident 1 showed he was in his 60's with diagnoses including, glaucoma (a disease that damages the optic nerve resulting in decreased vision), dementia (a disorder which causes a decline in mental ability marked by impaired reasoning), chronic pulmonary edema (fluids back up into the lungs due to inadequate pumping action of the heart). Resident 1's MDS (Minimum Data Set for assessment which guides care), dated 11/7/15, showed he had cognitive difficulties and required extensive staff assistance for activities of daily living. Resident 1 was on a special diet of nectar thick liquids (for easier swallowing) to prevent aspiration (inhalation of food or liquids into the lungs). On 1/21/16 review of a nursing note titled, SBAR Note, dated 12/16/15 at 7:30 a.m., Licensed Vocational Nurse (LVN 1) wrote the following prior to transferring Resident 1 to the hospital: "CNA [CNA 1 certified nursing assistant] noticed resident [1] was vomiting...noticed some bubbles in the vomitus...she [CNA 1] proceeded to check each container on the resident's bedside table...CNA discovered that one unlabeled container had a soapy liquid in it which the resident could have ingested inadvertently...first aid was provided and the resident was transferred to the emergency department for further evaluation...Resident 1 confirmed that he drank some of the contents of that cup...Oxygen saturation at 82% [normal range is 95-100%]...oxygen at 3 liters per minute was started.". Also "Suction of oral secretions...crackles [abnormal breath sounds usually caused by fluids within the airways] noted all over lung field." The Hospital Transfer Summary, dated 12/24/15, when Resident 1 was transferred back to facility (eight days after the vomiting incident) showed, "...Discharge Diagnoses: Aspiration Pneumonia, Detergent Aspiration...man with known history of dementia with underlying psychosis [an abnormal condition of the mind when one loses contact with reality], who was found to have drunk the detergent, which was put in front of his table and then, the exact amount is unknown, approximately 300 ml [10 ounces] and soon after the patient has discomfort and vomiting, and then decreased oxygen saturation, and the patient was rushed to the hospital for evaluation. Presumed aspiration of the detergent. The patient's respiratory failure continued in the hospital with oxygen supplement, nebulizer treatment [liquid medication becomes a mist which can be inhaled into the lungs], and needed BiPAP [face mask and tubing connected to a device that delivers pressurized air and oxygen at two alternating levels to a person's airway], then was brought to the ICU [intensive care unit]... Subsequently, the patient has had leukocytosis [increase in white blood cells signaling infection] with fever, aspiration pneumonia and antibiotic was started." During an interview on 1/14/16 at 9:30 a.m., Administrator (Admin) said the facility completed its investigation and concluded Resident 1 ingested a pink (colored) liquid soap that was left at his bedside, and was sent to the hospital where he was treated for "aspiration pneumonia" (lung infection caused by inhaling food or liquids into the lungs) related to vomiting. Admin added that the morning shift CNA 1 found Resident 1 vomiting with bubbles and discovered an unlabeled cup with liquid soap on Resident 1's bedside table. Admin stated the facility staff did not know soap was in the Styrofoam cup until after Resident 1 drank it and began vomiting. During an interview on 1/14/16 at 9:59 a.m., CNA 1 stated, "I saw [Resident 1] vomiting...I went to get the Charge Nurse...[CNA 2] was assigned to care for Resident 1..." CNA 1 stated around breakfast at 7:30 a.m. she was feeding another resident in the same room. CNA 1 stated that Resident 1 was eating breakfast when the vomiting began. During an interview on 1/14/16 at 10:35 a.m. LVN 1 stated she was notified by CNA 1 that Resident 1 vomited. LVN 1 stated she saw vomit on Resident 1's clothing and that CNA 1 reported to her, "looks like he drank soap..." LVN 1 confirmed that on 12/16/15, Resident 1 drank from an unlabeled Styrofoam cup of soap. During an interview on 1/14/16 at 10:57 a.m., CNA 2 confirmed that Resident 1 vomited after eating breakfast. CNA 2 said Resident 1 feeds himself and loved to drink liquids/fluids. CNA 2 said monitoring contents of drinking cups was not usually done. LVN 1 confirmed statements from ADMIN, CNA 1 and CNA 2 that they were unaware of the presence of the cup of soap on Resident 1's bedside table until after he drank from it and started vomiting. During a telephone interview, on 1/20/16 at 2:30 p.m., CNA 3 stated that Resident 1 was on a nectar thick diet and she did not place a hydration cup at his bedside. CNA 3 stated that she checked Resident 1's bedside area between 6-6:45 a.m., before ending her shift and there was no cup of soap. During observation and concurrent interview on 1/14/16 at 11:47 a.m., the Acting Director of Nurses (ADON) stated she was not on duty on 12/16/15. ADON described the facility's practice of using white 16 oz Styrofoam cups for hydration passes. ADON stated the cup with soap, on Resident 1's bedside table, was the same as the ones used for hydration. During an interview and concurrent record review, on 1/14/16 at 1 p.m., Admin stated there was no facility policy and procedure that reflected the facility's practice of liquid soap dispensing for bed bath use and monitoring for unlabeled containers. Admin presented a facility memo, dated 12/18/15, which was distributed to all staff with the following instructions: "In order to prevent any and all possibilities of accidental ingestion of inappropriate materials by residents ...Charge Nurses will verify that CNA's conduct a thorough inventory of all items at the bedside of each resident, especially liquid containers...the inventory shall be conducted at the end of each shift ...CNA's will verify that all liquid containers at the bedside of the resident are correctly labeled, dated, and appropriate for that resident ." Therefore the facility failed to ensure a safe environment for Resident 1 resulting in him ingesting a toxic substance (liquid soap) which was left in a hydration cup on his bedside table. The violation had a direct relationship to the health, safety or security of Resident 1. |
| 100000084 |
Pioneer House |
030009086 |
B |
08-Mar-12 |
YXUK11 |
11270 |
F-309 483.25 Provide Care/Services for Highest Well Being Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.An unannounced visit was made to the facility on 7/24/09 to investigate complaint #CA00195664. The Department determined the facility failed to: 1) Ensure Resident A's neurological assessments were done per the facility's policy. 2) Ensure an immediate transfer to the acute care hospital for intervention in an emergency situation. Patient A fell sustaining an injury to the back of her head. The facility failures resulted in delay of emergency care to reverse bleeding risks and stabilize the head injury with a potential for development of life threatening pressure to the brain.Resident A had a PT of 48.0 (Reference 11.5-14.5 sec) and an INR was 5.0 (Reference 0.9-1.1) at the General Acute Care Hospital and sustaining a large 3.7 cm (centimeter - 1 inch = 2.5 cm) hematoma (collection of blood) in the brain and blood was also found in the spinal fluid.Prothrombin Time (PT) is used to evaluate the ability of blood to clot. International Normalized Ratio (INR) is used to monitor the effectiveness of blood thinning drugs such as Coumadin (Warfarin). Coumadin is a high risk medication that interacts with many other medications such as Acetominophen, (Tylenol). This additional medication with possible interactions with Coumadin could significantly increase the resident's potential for bleeding. Review of Resident A's clinical record was done on 7/24/09 and documented she was 84 year old female originally admitted to the facility on 5/7/09. Her diagnoses included a recent right hip fracture with surgical repair. She was admitted for rehabilitation therapy.Her admitting medical orders documented that her rehabilitation potential was "good". Her MDS documented an anticipated discharge within 31- 90 days.Resident A's Admission Minimum Data Set (MDS, a standardized assessment tool), dated 5/20/09, documented Resident A as having short-term memory problems, as having independent cognitive skills for daily decision making, as having clear speech, able to make herself understood and able to understand others. The MDS also documented Resident A as needing limited assistance with bed mobility and transfers and as needing extensive assistance with walking in the room, walking in the corridor, locomotion on and off the unit, dressing, toilet use and personal hygiene.Review of Resident A's clinical record revealed that on 03/06/09 her PT was 32.6 and INR was 3.07. A physician's order was obtained, on 6/8/09, for Warfarin 5.5 mg 1 tablet every day for prevention of DVT (Deep Vein Thrombosis - blood clots). On 6/11/09 Resident A's PT was 38.6 and INR was 3.78. A physician's order was received on 6/11/09 to hold the Coumadin 5.5 mg on 6/11/09 and then restart the Coumadin at 5mg every day on 6/12/09 for DVT. The Federal Drug Administration has issued a Black Box Warning for Coumadin noting additional concerns identified for elderly patients and their increased risk for bleeding. The warning is published in the American Hospital Formulary Service published by the American Society of Health System Pharmacists. The warning states (in part): "Boxed Warning: Bleeding: May cause major or fatal bleeding. Risk factors for bleeding include high intensity anticoagulation (INR 4), over age 65 years, variable INRs, history of GI (Gastro-intestinal bleeding), high blood pressure, cerebrovascular disease, serious heart disease, anemia, etc...Special populations: Elderly: The elderly may be more sensitive to anticoagulant therapy Geriatric Considerations - Before committing an elderly patient to long-term anticoagulation therapy, the risk for bleeding complications secondary to falls, drug interactions, living situation, and cognitive status should be considered. A risk of bleeding complications has been associated with increased age. Adverse Reactions (in part): Bleeding is the major adverse effect of Coumadin (warfarin). Hemorrhage may occur at virtually any site. Risk is dependent on multiple variables, including the intensity of anticoagulation and patient susceptibility...Central nervous system: Coma, dizziness, fatigue, fever, headache, lethargy, malaise, pain, and stroke."Review of a Daily Skilled Nurse's Note, undated at 11:00 a.m., documented Resident A had taken off her tab to an alarm system to alert staff she was getting out of bed, had not used her call light and attempted to get up. Resident A fell hitting the back of her head. The LN (Licensed Nurse) documented Resident A was given Tylenol 650 mg for complaint of mild headache. The facility's policy titled, "Neurological Nursing Assessment," was provided by Administrative Staff (AS) 1 on 7/24/09 and confirmed it was the facility's most current policy on neurological assessment. The policy documented under the section "Nursing Alert" that "a change in the level of responsiveness is the most sensitive indication of improvement or deterioration. The level of responsiveness may change from minute to minute. As intracranial pressure increases, the brain substance is compressed. A sudden increase may produce an emergency situation, in a few minutes this condition may lead rapidly to death or result in a vegetative existence for the resident." The policy also documented (in part) under the section "Clinical Manifestations" "The following are clinical manifestations of head injuries: ....2. Headache 3. Confusion or delirium..." Under the section "Procedure" "When a resident is suspected of a head injury the following procedure is required: 1. Vital signs must be taken every 15 minutes for the first hour beginning at the time of the incident. 2. Take vital signs every hour following the initial first hour. After the initial hour, vital signs must be taken every hour for 8 hours then every 4 hours for 16 hours, then every shift for 48 hours. 3. Observe and document the following along with the vital signs: spontaneous behavior and level of consciousness." Review of Resident A's "Neurological Assessment Flowsheet" documented on 6/11/09 that neurological assessment checks were started at 11:05 a.m. including vital signs (VS) and Resident A complained of a headache with pain rated as a 6 out of 10 (0 being no pain and 10 being the worst pain). Documentation revealed Resident A's vital signs were then taken at 11:50 a.m., 1:05 p.m. and then at 5:05 p.m. The facility failed to ensure their policy was implemented when Resident A's vital signs and neurological assessment checks were not completed every hour between 1:05 p.m. and 5:05 p.m.Review of a Nurse's Note, dated 6/11/09 at 11:00 p.m., documented Resident A as "alert with neurological change of condition." The Nurse's Note further documented that Resident A "had dinner then started vomiting, could not talk to family members" and was "shaking." The LN documented she paged the physician but did not receive a telephone call back from the physician so an ambulance was called at 8:45 p.m. The onset of vomiting is recognized as a possible sign of increased intracranial pressure after head trauma.LN 1 was interviewed on 7/24/09 at 10:32 a.m. She stated she had received report from the day shift nurse that Resident A had fallen earlier during the day. LN 1 stated she went to see check on Resident A and observed a lump on the eating dinner between 6:30-7:00 p.m. when she started vomiting. She stated she called the physician and when she didn't receive a telephone back from the physician she called for an ambulance. LN 1 was asked, according to the facility's policy, how often neurological checks are to be done. She stated at first that it "depended upon the resident" but then stated "every shift."According Resident A's "Neurological Assessment Flowsheet" at 5:05 p.m. documentation revealed Resident A was described as vomiting but an ambulance was not called until 8:45 p.m., 3 hours and 40 minutes later. The family indicated that the ambulance was called at their insistence.The facility failed to expedite immediate transfer to the GACH 0n 06/11/09 resulting in delayed medical assessment, intervention and treatment.Review of Resident A's General Acute Care Hospital (GACH) medical record revealed Resident A's PT, drawn on 6/11/09 at 9:30 p.m., was 48.0 and her INR was 5.0. Review of Resident A's "Emergency Department Report" from the GACH, dated 6/11/09, documented Resident A "was brought to the emergency department because of altered level of consciousness. Apparently, the patient (Resident A) had a fall earlier today and struck her head. On examination, the patient does appear to be awake but obtunded. She responds to her name and occasionally to commands but is nonverbal. The patient immediately had a CT scan of the brain done which showed intracranial hemorrhage (bleeding into the brain). It was also noted that the patient was on warfarin (Coumadin) therapy and had an elevated prothrombin time and partial thromboplastin times. Because of the critical nature of the patient's bleed, she was administered fresh-frozen plasma and Vitamin K in order to reverse her coagulopathy (bleeding potential)."Resident A's "Consultation Report" from the GACH, dated 6/12/09, documented "This is a previously healthy 84 year old female who was placed in a nursing home for rehab after sustaining a fractured hip that was treated with conservative therapy. She is placed on Coumadin for prophylaxis of possible DVT. Early today she had fallen at the nursing home. Her family came to evaluate her and found that she was "slightly aphasic" (unable to speak or understand verbal communication) and insisted that EMS be called....Once here, the family stated she was not herself. She was not talking as much any more; normally she was quite active and talking."She required acute hospital care for 8 days and was then transferred to another skilled nursing facility.According to Resident A's family member she stated she arrived at the facility on 6/11/09 at around 7:30 p.m. The family member stated Resident A was "slumped forward" in her wheelchair at a table in the dining room. The family member stated an attendant (Certified Nursing Assistant) was with Resident A and informed the family member that Resident A had fallen earlier that day. The family member further described Resident A as "unable to talk" and "looked drugged." The family member stated when admitted to the facility Resident A was "very verbal" and "highly functional" and was now "drastically different than the day before" when the family member visited Resident A. The family member also stated when the LN was informed and called Resident A's physician, the LN "did not appear to be particularly alarmed".The Department determined the facility failed to: 1) Ensure Resident A received neurological assessments per the facility's policy. 2) Ensure an immediate transfer to the acute care hospital for intervention in an emergency situation. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000560 |
Pine Creek Care Center |
030010122 |
B |
17-Sep-13 |
SB9Q11 |
5666 |
72527. Patient 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 to the facility on 11/9/10 to investigate complaint numbers CA00247096 and entity reported incident CA00246591.The Department determined the facility failed to prevent abuse when Certified Nursing Assistant (CNA) 1 verbally abused and handled Patient 1 in a rough manner on 10/13/10. Patient 1's record was reviewed on 11/9/10. Patient 1 was an 81 year old readmitted to the facility on 10/8/10 with a diagnosis that included a history of a stroke. Patient 1 did not ambulate. The Minimum Data Set (an assessment tool) dated 11/4/10,revealed Patient 1 required extensive 2 person assistance in bed mobility, transfer, toileting, and bathing; extensive 1 person assistance with locomotion in a wheelchair; and limited 1 person assistance with dressing and personal hygiene. In a document titled "Social Service Readmission Note" dated 10/13/10, the Director of Social Services (DSS) revealed, "Patient is more confused compared to the first time he was first admitted. Patient is alert but only oriented to person. Unable to communicate needs at this time." In a document titled "Formal Investigative Report" (undated), the Director of Nursing (DON) described an allegation of verbal abuse by CNA 1 to Patient 1. On 10/13/10 at approximately 9:30 p.m., CNA 2 and CNA 3 observed CNA 1 speaking to Patient 1 in a very loud, harsh manner. They reported this observation to Licensed Nurse (LN) 1 that evening ... The CNAs next reported the observation to LN 2 on ... Saturday, 10/16/10. LN 2 told them to write out their concerns. On Sunday (10/17/10), LN 2 told them to give their reports to the Director of Staff Development (DSD) who happened to be in the facility. "DSD immediately notified this writer (DON). This writer instructed (DSD) ... to place (CNA 1) on immediate suspension and remove her from the building."In a signed statement dated 10/16/10, CNA 2 recorded, "On Wednesday October 13, 2010, I witnessed (CNA 1) entering Patient 1's room. He was leaning towards the rail. She had grabbed him and yanked his body over towards the middle of the bed. He was screaming. He didn't want her to touch him because she was being so rough with him. She said, 'well, if I didn't have to come in here every five minutes to fix you, we wouldn't have a problem.' She had yanked him a second time. He was screaming don't let her touch me. It was apparent he was in pain, when she had yanked him." In a signed statement dated 10/16/10, CNA 3 recorded, "The door was open and the curtain was pulled. I heard Patient 1 say or yell out you are hurting me. So I went in the room and said (CNA 1), can I help you and she said no, she was fine. Patient 1's hand was around CNA 1's wrist ... I told CNA 1 that she needs to be very easy with him because he is stiff from sitting in his chair and it hurts him when you move him to rough or hard. She just walked away. (CNA 1) was making it look like Patient 1 was acting out on her. But really Patient 1 was just trying to protect himself from her being rough with him." The facility's employee file for CNA 1 contained a document dated 2/16/10 titled "HR/Evaluation Report." It recorded, "Patients complain that you are a little forceful with them at times." A second document dated 10/21/10, titled "Disciplinary Action Record," and signed by CNA 1 and the Human Resource Director, indicated she was terminated for Code 1A.In a document titled "Employee Handbook" dated May 2009 and provided by the Human Resource Director (HRD), it indicated, "Category One Violations: These are serious violations that may result in immediate termination or suspension without pay, pending investigation for discharge: 1A. Patient abuse or neglect (physical, sexual, verbal or mental)." In a telephone interview on 11/10/10 at 2:30 p.m. with CNA 2, she stated, "On the evening of 10/13/10, I saw CNA 1 yanking Patient 1 around in bed and being verbally abusive towards him."In a telephone interview on 11/10/10 at 3:10 p.m., CNA 3 stated that on 10/13/10, "I heard Patient 1 saying 'You're hurting me. Stop hurting me.' I knocked and asked CNA 1 if she needed help with him. He had a hold of CNA 1's wrist. I checked on him later and he said she hurt him. ... CNA 1 made it look like the Patients were acting out. I knew him well and he wouldn't act out unless he was hurt." In an interview on 11/9/10 at 10:45 a.m., the DON summarized the facility's investigative report on an incident witnessed on 10/13/10 by CNA 2 and CNA 3. They witnessed CNA 1 talking in a loud, harsh manner and turning Patient 1 in a rough manner. The DSD escorted CNA 1 from the building. She stated, "CNA 1 was terminated because of this and previous incidents in her file."In a telephone interview on 3/3/11 at 12:45 p.m., the Human Resource Director (HRD) was asked the meaning of termination codes. HRD stated, "A Code 1A violation means patient abuse." The Department determined the facility failed to prevent abuse when CNA 1 verbally abused and handled Patient 1 roughly on 10/13/10.This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 030000560 |
Pine Creek Care Center |
030010123 |
B |
17-Sep-13 |
SB9Q11 |
4715 |
Health & Safety Code 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a Patient of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. An unannounced visit was made to the facility on 11/9/10 to investigate complaint numbers CA00247096 and entity reported incident CA0024659. The Department determined the facility failed to report abuse to the department immediately or within 24 hours.This failure put all patients in the facility at risk for abuse when Certified Nursing Assistant (CNA) 1 was not immediately removed from patient care. Patient 1's record was reviewed on 11/9/10. Patient 1 was an 81 year old readmitted to the facility on 10/8/10 with a diagnosis that included a history of a stroke. Patient 1 did not ambulate. The Minimum Data Set (an assessment tool) dated 11/4/10, revealed Patient 1 required extensive 2 person assistance in bed mobility, transfer, toileting, and bathing; extensive 1 person assistance with locomotion in a wheelchair; and limited 1 person assistance with dressing and personal hygiene. In a document titled "Formal Investigative Report" (undated), the Director of Nursing (DON) described an allegation of verbal abuse by CNA 1 to Patient 1. On 10/13/10 at approximately 9:30 p.m., CNA 2 and CNA 3 observed CNA 1 speaking to Patient 1 in a very loud, harsh manner. They reported this observation to Licensed Nurse (LN) 1 that evening. The CNAs next reported the observation to LN 2 on Saturday, 10/16/10. LN 2 told them to write out their concerns. On Sunday (10/17/10), LN 2 told them to give their reports to the Director of Staff Development (DSD) who happened to be in the facility. "DSD immediately notified this writer (DON). This writer instructed (DSD) ... to place (CNA 1) on immediate suspension and remove her from the building." The Department received a fax of the SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) the following Monday morning (10/18/10), 5 days after the event was observed. In a signed statement dated 10/17/10, LN 2 stated CNA 1 & 2 told him of CNA 1's behavior towards Patient 1 on 10/16/10. He instructed them to write down their observations. In an interview on 11/9/10 at 11:30 a.m., DSD confirmed written allegations were received on 10/17/10. She stated, "I explained to CNA 2 and CNA 3 that it was inappropriate to wait for three days to report the 10/13/10 events. You need to report anything like this immediately/within 24 hours. I immediately notified the DON."In an interview on 11/9/10 at 2:35 p.m., LN1 stated, "I do not recall being notified of that event." In an interview on 11/9/10 at 2:10 p.m., LN 2 stated, "CNA 2 and CNA 3 were sharing their observations of 10/13 with me-I think on Friday afternoon. It was the beginning of the weekend so I told them to write down their observations and give them to the DSD or DON as soon as possible. The next time we saw the DSD was on Sunday and they talked to her then. I know now we should not have waited. We all should have known to report this right away." In a telephone interview on 11/10/10 at 2:30 p.m. with CNA 2, she stated, "I told LN 1 about it that night (10/13/10). When I came to work on 10/16/10, I noticed CNA 1 was still there, so I figured nothing happened. I told LN 2 of the incident and was told to, 'Write down what I saw and heard.' I brought in what I wrote and gave it to the DSD on 10/17/10." In a telephone interview on 11/10/10 at 3:10 p.m., CNA 3 stated that on 10/16/10, "I wrote down what happened on 10/13/10 and gave it to DSD on 10/17/10. I know we shouldn't have waited to report this." In an interview on 11/9/10 at 10:45 a.m., the DON summarized the facility's investigative report on an incident witnessed on 10/13/10 by CNA 2 and CNA 3. CNA 2 and CNA 3 witnessed CNA 1 talking in a loud, harsh manner and turning Patient 1 in a rough manner. The incident did not come to the attention of management until Sunday, 10/17/10. The DSD was told about this and contacted me. The DSD escorted CNA 1 from the building. "CNA 1 was terminated because of this and previous incidents in her file. The involved individuals did not report this timely." In an interview at 11 a.m. on 11/9/10, the Administrator confirmed, "The staff did not report their observations in a timely manner." The Department determined the facility failed to follow California Law when it failed to report abuse to the Department immediately or within 24 hours.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 040000932 |
Provident Health Care-Lulang |
040009713 |
AA |
24-Jan-13 |
NYGY11 |
14563 |
Title 17 Section 50510 (a) (8) Application of this Subchapter Each person with a developmental disability, as defined by this subchapter, is entitled to the same rights, protections, and responsibilities as all other persons under the laws and Constitution of the State of California, and under the laws and the Constitution of the United States. Unless otherwise restricted by law, these rights may be exercised at will by any person with a developmental disability. These rights include, but are not limited to, the following: (a) Access Rights (8) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse or neglect. Medication shall not be used as punishment, for convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program. The facility failed to ensure that Client A was free from neglect when Client A became ill 4/11/12, and treatment was delayed until 4/16/12, at which time Client A was transported by private auto to the primary care physician's office, where the Nurse Practitioner immediately called 911. Client A arrived at the acute hospital emergency department via ambulance in respiratory distress and unresponsive with a Glascow Coma Scale (GCS) of 6 (Scale used to determine consciousness with normal being 15). Client A had a diagnosis of bowel obstruction including sepsis, and shock. Client A died at 7:00 p.m., on 4/16/12. Complaint Number CA00306922 was investigated during an unannounced onsite visit 4/25/12. Client A's "Comprehensive Functional Assessment" (assessment of the client's overall abilities) dated 11/1/11, indicated [Client A] was dependent on staff for all of her routine care. She had chronic constipation and needed to have bowel regularity maintained by receiving adequate fluids, a high fiber diet, exercise as tolerated, and routine prn (whenever necessary) medications. [Client A] did not verbalize and needed help to make her needs known and understood.[Client A's] Individual Service Plan (plan of care used by staff to provide care and treatment) dated 11/1/11, indicated [Client A] was at risk for constipation related to inactivity, immobility, and hydration status. Medical and nursing staff would maintain bowel regularity by repositioning every two hours, providing passive range of motion twice a day, and providing fluids and nutrition as ordered. Medical and nursing staff were to monitor and document Client A's elimination pattern and administer routine and PRN (as needed) medications as ordered.The facility's undated "Special Incident Report" for Intake Number CA00306922, indicated "... On Wednesday evening, April 11, 2012, direct care staff (DCS) noted [Client A] was quieter than usual and had a rectal temp of 99.1§ (degrees) F (Fahrenheit). The night staff person noted that [Client A] 'acted like she was going to be sick.' " The Special Incident Report contained the statement, "Although it isn't noted, he notified the Nurse on Duty (NOD) [Registered Nurse 1] and [Client A's] gastrostomy (G tube) feedings (feeding through a tube into the stomach) were held." On Thursday, April 12, 2012, the day shift noted that [Client A] had a rectal temp of 101§ F for which Tylenol was administered. The evening staff notified [RN 1] of [Client A's] earlier temperature and that it had dropped to 98§ F following Tylenol administration. [RN 1] examined [Client A]. Her abdomen appeared distended, but soft, and she was breathing rapidly. DCS burped some air (released air) from Client A's G tube and her respiratory rate then returned to normal. During that shift, [Client A] voided four times, had three episodes of green-tinged emesis (vomit), and three small bowel movements. On Monday morning April 16, 2012, the staff (DCS 1 and DCS 2) noted an acute change in condition with [Client A] appearing in severe distress with a marked increase in her respiratory rate. The staff (DCS 1) called [Licensed Nurse (LN) 1] who had not yet arrived at work. [LN 1] drove [Client A] to the primary care physician's office. When they arrived [Client A] was in respiratory distress and the Nurse Practitioner gave the order to call paramedics who transported [Client A] to the acute hospital.A review of Client A's Computed Tomography (CT) scan (uses X-rays to make detailed pictures of structures inside the body) report dated 4/16/12, revealed a massive pneumoperitoneum (presence of a large amount of air within the peritoneal cavity) and findings consistent with a perforation of the small bowel with the exact site of the perforation being unclear.On 4/24/12 at 2:30 p.m., during an interview, Central Valley Regional Center (CVRC) Counselor 1 stated it was reported Client A had been seriously ill for six days with diarrhea, vomiting, and pain with no medical care provided. CVRC Counselor 1 stated Client A had gone six days with no feeding and with no physician consult due to licensed nurses' assumption that Client A had gastroenteritis (flu-like symptoms). CVRC Counselor 1 stated that on 4/14/12, the client was taken to the physician's office, where staff immediately called for emergency transport to the acute hospital. Emergency surgery was considered and ruled out due to the client's grave condition. Comfort measures were provided. The client expired at 7:00 p.m. on 4/16/12. On 4/25/12 at 8:50 a.m., during an interview, the Program Manager (PM) stated when she arrived to work on 4/12/12, the night staff reported Client A was not acting right. Registered Nurse (RN) 1 was called and came over. Client A had an emesis. The PM stated RN 1 thought Client A had the flu and would feel better in 48 hours. RN 1 instructed staff to hold the gastrostomy tube (G-tube) feedings but, give small amounts of water. The PM stated Client A's stomach was distended; RN 1 instructed staff to burp the feeding tube (allow air to escape) for relief.The PM further stated when she arrived at work on 4/16/12, she was met at the door by two DCS (DCS 1 and DCS 2) who stated they were really concerned about Client A. Staff (DCS 1 and DCS 2) went on to say they had called LN 1 at 6:30 a.m., to report their concerns that Client A was not doing well and had no strength. The PM stated that all weekend, DCS 1 and DCS 2 had called LN 1 and were told Client A had the flu and the client would "just have to get over it." The PM stated she then called LN 1 and told her the flu didn't last that long. LN 1 replied to the PM that Client A had a scheduled appointment for 11:00 a.m. that day (4/16/12) at her physician's office. The PM stated DCS 1 remained upset and called LN 1 back at 9:15 a.m. to tell her LN 1 needed to do something because Client A was moaning in pain. The PM stated that LN 1 responded saying she would call the physician's office to get an earlier appointment. On 4/25/12 at 9:45 a.m., during an interview, DCS 5 stated that on Thursday morning (4/12/12), the night shift staff reported that Client A wasn't feeling well. RN 1 came in and instructed staff to push fluids and give Client A Tylenol. DCS 5 stated at first Client A appeared to have the flu. By Friday 4/13/12 and Saturday 4/14/12, DCS 5 stated she thought Client A needed to see a doctor. DCS 5 stated that on Thursday and Friday, Client A's feedings were held, but were restarted slowly on Saturday 4/14/12.On 4/25/12 at 1:45 p.m., during an interview, DCS 1 stated that on Sunday 4/15/12, when Client A was not better, DCS 1 questioned the assumption that if the client really had the flu, why no one else in the house had the flu. DCS 1 stated Client A was restless in the bed and her feedings were resumed that evening. DCS 1 stated when she reported Client A's vital signs to LN 1 during the evening, LN 1 stated, "I don't know what you're seeing but Client A was fine when I saw her earlier."DCS 1 further stated that when she arrived to work on Monday morning 4/16/12, DCS 1 looked in on Client A at 6:30 a.m., Client A was laying sideways in the bed writhing in pain and crying. DCS 1 stated DCS 2 called LN 1. DCS 1 further stated as her coworker (DCS 2) was talking on the phone to LN 1, LN 1 instructed DCS 1 and DCS 2 to "just calm down." DCS 1 stated "We should have called [RN 1] but [LN 1] was on call." DCS 1 stated Client A was sweating and had a bowel movement that was hard and round, and her temperature was 101§F. DCS 1 stated cooling measures were done. DCS 1 stated she wanted to clean Client A up and as she sat the client up on the shower chair, Client A's breath smelled of feces. DCS 1 stated sitting upright seemed to make Client A feel better. After cleaning Client A in the shower, DCS 1 stated she laid her down and Client A began the writhing and crying in pain. DCS 1 stated she called LN 1 to report to her. LN 1 instructed DCS 1 to keep the client sitting upright. DCS 1 stated when she went to give Client A seizure medications via the G-tube, there was backflow of 50 cubic centimeters (volume measurement) of green fluid. DCS 1 stated when LN 1 was told about the volume of green fluid, LN 1 said "I got this, you just need to calm down." DCS 1 stated Client A's vital signs were abnormal [respiration rate 72 - (normal 16 - 20 breaths per minute)], and sweat was rolling down her forehead. DCS 1 and DCS 2 repositioned Client A from the recliner to a straightback chair. DCS 1 stated LN 1 arrived at the facility around 9:45 a.m., started talking to the PM, and "didn't even look at [Client A]." DCS 1 stated she and DCS 2 positioned Client A in the van and LN 1 drove the client to the appointment. DCS 1 stated, at the hospital later that afternoon, the physician told her there was nothing they could do for [Client A]. DCS 1 stated the physician said if Client A made it through a surgery, the client would die anyway because her bowel was perforated. On 4/25/12 at 11:35 a.m., during an interview, LN 1 stated she was off work on Thursday (4/12/12) and when she returned to work on Friday 4/13/12, Client A was ill with a low grade temperature. LN 1 stated there was a flu bug going around. LN 1 stated Client A had no abdominal distention and air came out of her G-Tube port when opened. She stated staff had been instructed by RN 1 to give the client water and broth to keep her hydrated. LN 1 stated Client A remained stable throughout the day. LN 1 stated that on Saturday 4/14/12, Client A seemed better; the G -Tube feeding was restarted at half the rate to see if it would be tolerated. LN 1 stated the night shift reported no gagging, so the G-Tube feedings were continued and Tylenol was given for the low grade temperature. LN 1 stated Client A seemed more relaxed, there was no abdominal distention, no pain, and her lungs were clear. There was no indication Client A needed to go to see a physician or go to the Emergency Room. LN 1 stated she received no calls throughout the night. LN 1 stated on Sunday (4/15/12), Client A's stomach was soft and air was coming out of the G-Tube port. LN 1 stated Client A had a large BM. LN 1 stated, she left the facility at 5:00 p.m. and told staff to call if there were any changes. LN 1 stated she received no calls on the PM or NOC shift. LN 1 stated on Monday morning (4/16/12) at 6:40 a.m., staff (DCS 2) called crying and reported that the client looked bad and was breathing fast. DCS 1 and DCS 2 were told to get a pO2 sat (measure of oxygen content in body) and LN 1 was on her way there. LN 1 stated she notified the physician's office she would be bringing the client earlier than her scheduled appointment at 11:00 a.m. LN 1 stated when she arrived at the facility Client A did not look good and by the time they arrived at the physician's office, Client A was "crashing" (breathing faster, moving her head around like something was bothering her). LN 1 further stated Client A's stomach was more distended than on the weekend. Upon arrival to the physician's office, the Nurse Practitioner called 911 and started Client A on oxygen. On 9/17/12 at 12:00 p.m., during an interview, RN 1 stated it was her decision to hold Client A's G-Tube feeding which was her normal procedure when someone was vomiting. RN 1 further stated, the physician was at no time notified of Client A's changing condition or of her decision to hold the G-Tube feedings. On 9/17/12 at 2:00 p.m., during an interview, LN 1 stated she had not notified the physician of Client A's changing condition. LN 1 further stated, there had been no physician intervention throughout the weekend (4/14/12 - 4/15/12). The facility document titled, "Client's Rights" dated 8/4/09, indicated the clients had the following rights: "11. A right to prompt medical care and treatment. 16. A right to be free from harm, ...including neglect. "The facility's policy titled, "Client Abuse and Neglect" dated 8/4/09 indicated, "Neglect, for the purpose of this policy, is the failure of a staff member to care for or give proper attention to clients entrusted to them ... " The facility failed to ensure that Client A was free from neglect when Client A became ill on 4/11/12 and treatment was delayed until 4/16/12. Client A was transported by private vehicle to her physician's office where the Nurse Practitioner immediately called 911. Client A arrived at the emergency department via ambulance unresponsive and in respiratory distress with a Glascow Coma Scale (GCS) of 6 (Scale used to determine consciousness with normal being 15). Client A was diagnosed with bowel obstruction, sepsis, and shock. Client A died at 7:00 p.m., on 4/16/12. The acute hospital's "Discharge Summary" dated 4/16/12, indicated Client A "Was initially seen by the ER physician of which work up revealed severe sepsis related to perforated bowel...she was noted to have a rock hard abdomen of which she had significant free air. It was felt because of her underlying condition and the severity of her sepsis that she would not survive this event... she died later in the day." The "CERTIFICATE OF DEATH" issued 5/4/12, indicated "CAUSE OF DEATH" was "SEPTIC SHOCK" (Septic shock is a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure), as the "IMMEDIATE CAUSE," and "SIGNIFICANT PNEUMOPERITONEUM (presence of a large amount of air within the peritoneal cavity) OF UNKNOWN ETIOLOGY "as the "UNDERLYING CAUSE."The above violation presented an imminent danger that death or serious harm to the patient would result and was a direct proximate cause of the death of the patient and therefore constitutes a Class "AA" Citation. |
| 050000043 |
Providence Ojai |
050011023 |
A |
05-Feb-15 |
3JD411 |
4879 |
CFR 483.25 (h) ACCIDENTS- The facility must ensure that- (2) Each resident receives adequate supervision and assistance devices to prevent accidents.The Department determined the facility failed to provide adequate supervision and a secure and safe environment by failing to ensure the outdoor iron gate, at the top of six concrete steps leading to the sidewalk and street, was securely latched to prevent unsafe access by Resident A. As a result, Resident A (wheelchair bound) fell down six concrete steps and sustained lacerations requiring sutures, abrasions, and bruising. Resident A was admitted to the facility with diagnoses including Alzheimer's/Dementia (problems with memory, thinking and behavior), coronary artery disease, and difficulty walking. Resident A had short term and long term memory problems, required limited assistance in locomotion (able to propel himself in a wheel chair) on the unit, and extensive assistance with walking, eating, and toilet use. During an interview on 9/8/14 at 6:40 pm, the director of nurses (DON) indicated Resident A's daughter comes to the facility almost every day to have meals with Resident A on the front porch of the facility and next to the iron gate that leads to the six concrete steps. During an interview on 9/10/14 at 3 pm, a certified nurses' assistant (CNA 1) confirmed Resident A eats most evening meals with his daughter on the front porch. CNA 1 described Resident A's usual habits as able to propel himself in his wheelchair every evening to the facility's main entrance, attempts to open the main door and go out on the front porch in search of his daughter.Review of the facility's plan of care dated 3/21/14, indicated Resident A was assisted to eat evening meals by his daughter and Resident A "looks for daughter during evening for meal time." The facility's interventions to the plan of care included making sure Resident A was in a "safe area on the porch." On 9/8/14 at 5:30 p.m., the iron gate at the top of six concrete steps leading to the entrance of the facility was observed to be unlatched. At 5:33 p.m., Resident B and C, who were identified by facility staff to be confused, were propelling themselves, each in a wheelchair, in the lobby eight to ten feet away from the unlatched iron gate and the concrete steps. Resident B was observed attempting to exit the main entrance door to the facility which would provide immediate access to the unlatched iron gate and the concrete steps. There was no staff within eyesight supervising these residents. On 9/7/14 at 6:30 p.m., Resident A exited the facility front entrance door by propelling himself in his wheel chair. Resident A sat in his wheelchair on the porch (where he often sat with his daughter for evening meals). However, this time he was alone and unsupervised. Resident A opened the iron gate at the top of the concrete steps leading to the sidewalk, tumbled down the steps while still in his wheelchair, and landed at the base of the sixth step next to the sidewalk and paved road. Resident A lay on the ground bleeding for over five (5) minutes without assistance. A passerby driving down the roadway saw Resident A lying on the sidewalk, stopped the vehicle, and ran into the facility to notify the staff of Resident A's fall.A physician ordered the facility to transfer Resident A to an acute care hospital for evaluation of the injuries from the fall. At the acute care hospital, Resident A was diagnosed with a "6 cm (centimeters) x 2 cm x 4 cm laceration above his left eyebrow; a 25 cm vertical laceration to muscle over the right shin; a 10 cm laceration of the skin through to subcutaneous fat with 10 cm continuation of skin tear to right dorsal forearm; and right upper outer arm skin tear." Additionally, Resident A complained of left shoulder and chest wall pain. The lacerations required sutures and Resident A was admitted to the hospital's Direct Observation Unit for continued observation and neurological assessment.The facility knew Resident A was an elopement risk but failed to implement elopement risk interventions to prevent the resident from going out to the front porch alone and unsupervised. The facility failed to securely close the iron gate leading to six concrete steps, which led to the sidewalk to prevent unsafe access by Resident A. The facility failed to provide supervision while Resident A was alone on the front porch. As a result of these failures, Resident A who was wheelchair bound opened the gate and fell down six concrete steps, leading to the sidewalk and paved roadway sustaining multiple injuries. A passer-by found Resident A at the bottom of the six (6) concrete steps bleeding and in pain and notified the facility.These failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 060001154 |
Park Vista at Morningside |
060008971 |
A |
03-Feb-12 |
4DIY11 |
7113 |
72311 (a) (2) Nursing Service-General. (a) Nursing service shall include, but not limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The facility failed to implement Patient 1's care plan to prevent falls by ensuring his personal alarm was in place to alert the staff he was getting up unassisted. This resulted in the Patient getting up by himself and falling to the floor. Patient 1 was found lying on the floor on his right side. Patient 1 was required to be transferred to an emergency room for an evaluation, x-rays and a computerized axial tomography (CT scan) of his head, to rule out a fractured hip and head injury. Patient 1 sustained a fractured right hip, head laceration and contusion related to his fall on 12/8/11. On 12/9/11, Patient 1 had an open reduction internal fixation (surgical repair) of his right hip, became unresponsive with minimal improvement. He was transferred back to the facility on 12/14/11, under hospice care, and expired on 12/19/11 at 0430 hours. Findings: Clinical record review for Patient 1 was initiated on 12/29/11. Patient 1 was admitted to the facility on 8/31/11, for rehabilitation, with diagnoses including status post fall resulting in a left hip fracture, and dementia. On 12/8/11, Patient 1 was transferred to the emergency room following a fall from a wheelchair, resulting in a right hip fracture and head laceration. Review of Patient 1's Minimum Data Set (MDS- an assessment tool) dated 9/24/11, showed his cognition was severely impaired. Review of Patient 1's Care Area Assessment (CAA) for falls dated 9/9/11, showed he had impaired balance during transitions (change in position) and had an unsteady gait. Review of Patient 1's Initial Nursing Assessment dated 8/31/11, showed his cognition was moderately impaired. His fall risk assessment showed a score of 17 (a score of 10 or higher represents a high risk for falls) and fall interventions included a bed and chair alarm. Review of Patient 1's physician's orders dated 8/31/11, showed Patient 1 was to have a personal alarm while in the bed and in the wheelchair to alert the staff if the patient got up unassisted. An order dated 11/21/11, showed Patient 1 was receiving Coumadin (anticoagulant/blood thinner, which increases the risk for bleeding) 3.5 milligrams every evening. Review of Patient 1's care plan problem dated 8/31/11, to address his potential for falls related to his unsteady gait and poor safety awareness, showed an approach plan for the use of a personal alarm and frequent visual checks. Review of Patient 1's Licensed Personnel Weekly Progress Notes dated 12/8/11 at 1500 hours, showed Patient 1 was found lying on the floor. The right side of his head was against the metal bar on the bed frame. Patient 1 was bleeding from an open area on the back of his head and he was lethargic. At 1515 hours, Patient 1 was transferred to the emergency room. Review of CNA 2's Interview Record dated 12/9/11, showed at 1440 hours, Patient 1's family member told her the alarm was not attached to Patient 1. CNA 2 stated she did not respond right away because she thought he was in his bed.Review of Patient 1's family member's Interview Record dated 12/9/11, showed at around 1440 hours, she left and explained to certified nursing assistant (CNA) 2 that Patient 1's personal alarm was not connected. Review of Patient 1's emergency report dated 12/8/11, showed Patient 1 has a full-thickness Y-shaped laceration to his right occipital (back of the head) area, requiring six sutures to close the wound and stop the bleeding. Review of Patient 1's CT scan of the brain without contrast dated 12/8/11 at 1654 hours, showed new subtle hyperdensities identified bilaterally, suggestive for areas of hemorrhage (bleeding). Review of Patient 1's history and physical dated 12/8/11, showed an impression as status post mechanical fall with blunt head trauma, scalp laceration, a cerebral contusion (brain injury) and a right hip fracture. Review of Patient 1's Orthopedic Surgery Consultation dated 12/8/11, showed Patient 1 fell and sustained a nondisplaced, right intertrochanteric hip fracture (top of the hip bone) and a cerebral contusion. During an interview on 12/29/11 at 1015 hours, Licensed Vocational Nurse (LVN) 1 stated Patient 1 was alert with confusion. She stated Patient 1 needed assistance from staff for all his activities of daily living and had required the use of a personal alarm (alarm to notify the staff of getting up unassisted). LVN 1 stated on 12/8/11 at approximately 1500 hours, a CNA came to the nurses' station and notified her Patient 1 was lying on the floor. She stated she entered Patient 1's room and found him lying on his right side with moderate bleeding from a gash on the back of his head. She stated Patient 1's personal alarm was on his wheelchair and was not alarming. During a telephone interview on 12/29/11 at 1415 hours, Patient 1's family member stated Patient 1 was a fall risk and on 12/8/11, after lunch, before she left the facility, she told LVN 1, Patient 1 did not have his personal alarm attached to him. She stated, she then found CNA 2 sitting in a break room and told CNA 2, Patient 1 did not have his personal alarm attached to him and to please go and check him. Patient 1's family member stated, approximately 30 minutes later, she received a telephone call from the facility notifying her Patient 1 had fallen and was being sent to the emergency room. She stated Patient 1's physicians told her Patient 1 was not going to survive, and Patient 1 returned to the facility on 12/14/11, under the care of hospice. Patient 1 expired on 12/19/11 at 0430 hours. Review of the death certificate showed Patient 1's immediate cause of death was coronary artery disease. "Hip fracture fall, senile dementia" was listed as "Other significant conditions contributing to death but not resulting in the underlying cause..." (coronary artery disease).During a telephone interview on 12/29/11 at 1500 hours, the Assistant Director of Nurses (ADON) stated a video tape was reviewed and showed a lapse of 19 minutes between the time Patient 1's family member entered the room where CNA 2 was sitting to the time CNA 2 entered Patient 1's room.During a telephone interview on 12/29/11 at 1503 hours, CNA 2 stated on 12/8/11, Patient 1's family member had told her to check on Patient 1 and talked about his personal alarm. CNA 2 stated 15 minutes later, she went to check on Patient 1. She stated it was too late, she found Patient 1 lying on the floor. She stated his personal alarm was attached to his wheelchair and was not sounding. When CNA 2 was asked the reason she waited 15 minutes, she stated, she tried to finish her charting and went to the restroom prior to checking on Patient 1. She stated she was aware Patient 1 was a high risk for falls. These violations of the regulation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 060001154 |
Park Vista at Morningside |
060009056 |
A |
01-Mar-12 |
D4V511 |
19317 |
72311(a)(1)(A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. 72311 (a)(2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 72311(a)(3)(B) Notifying the attending physician promptly of any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. The facility failed to assess and intervene for Patient 1 to prevent respiratory distress due to complications of COPD (Chronic Obstructive Pulmonary Disease, a condition causing difficulty breathing) and acute CHF (congestive heart failure, a condition where the heart can no longer pump enough blood to the body). The facility failed to develop a patient specific care plan to address the risk for development of acute respiratory distress. The facility failed to notify the physician of Patient1's changes in condition.Patient 1 has a history of COPD exacerbation and CHF. From 7/5/11 to 7/14/11, Patient 1 gained 8.8 pounds. On 7/13/11, Patient 1's oxygen saturation (the oxygen level in the blood) decreased to 77% (normal oxygen saturation level is 97% to 99%) with the use of two liters of oxygen during physical therapy treatments. On 7/14/11 at 1210 hours, Patient 1's oxygen saturation decreased to 90% with the use of two liters of oxygen via nasal cannula, and his respiratory rate increased to 24 breaths per minute (the normal respiratory rate in adults is 12 - 20 breaths per minute). On 7/15/11 at 0630 hours, Patient 1 was found with shortness of breath and acute respiratory distress; his oxygen saturation was 72%. The patient was transferred and admitted to the acute hospital on 7/15/11 at 0720 hours. On 7/16/11 at 1450 hours, the patient died. The physician documented the discharge diagnoses were respiratory distress, respiratory failure, acute CHF, and COPD exacerbation. Review of Patient 1's closed health record was initiated on 10/27/11. The patient was admitted to the facility on 6/24/11. The MDS (Minimum Data Set, an assessment tool) dated 7/1/11, showed Patient 1's cognition was intact. The MDS showed Patient 1 had shortness of breath or trouble breathing with exertion (walking, transferring) and when lying flat. He had a history of COPD exacerbation, and CAD (coronary artery disease, a heart disease). The Physician Progress Notes dated 7/12/11, showed he had CHF. The Initial Nursing Assessment dated 6/24/11, showed Patient 1's lung sounds were clear.Review of Patient 1's care plan showed a care plan problem dated 6/24/11, to address the risk for dehydration. The approaches included to monitor weight as ordered; call the physician if gaining more than three pounds in one week, or gaining or losing more than five pounds in one month.Review of the weight record and the Medication Administration Record (MAR) for the month of July, 2011, showed: * On 6/24/11, the patient's weight was 144. 2 pounds; * On 7/5/11, his weight was 131.5 pounds. He lost 12.7 pounds within 11 days; * On 7/11/11, his weight was 134.7 pounds. He gained 3.2 pounds within 6 days; * On 7/12/11, his weight was 138 pounds. He gained 3.3 pounds within one day; * On 7/14/11, his weight was 140.3 pounds. He gained 2.3 pounds within two days; or he gained 8.8 pounds in nine days. There was no documentation the physician or the Registered Dietitian were notified when the patient gained weight on 7/11, 7/12, and 7/14/11. There was no documented evidence the patient was assessed for lung sounds and edema from 7/13 to 7/15/11, to assess if the weight gain could be attributed to excess fluid build-up in the lungs or body tissues.Review of the physician's orders showed an order dated 6/27/11, to change ipratropium/albuterol hand held nebulizer treatments (breathing treatments used to open the airway) to every four hours as needed, and to change Mucomyst (a medication used to loosen the sputum) to every four hours as needed. A physician's order dated 6/29/11, showed oxycontin (a narcotic pain medication) 10 mg, one tablet every 12 hours for chronic pain.Lexi-Comp online (a drug reference) for oxycontin shows to use with caution for patients with pre-existing respiratory compromise (hypoxia or low oxygen levels in the blood), and COPD; critical respiratory depression may occur even at therapeutic doses.A physician's order dated 7/7/11, showed to give two liters of oxygen per minute via nasal cannula; may titrate to keep the oxygen saturation level above 90%. Another physician's order dated 7/11/11, showed to monitor oxygen saturation every shift for oxygen use. Review of the care plan showed a care plan problem dated 6/24/11, and revised on 7/11/11, to address alteration in the respiratory system manifested by shortness of breath, COPD, and pneumonia. The goals listed his respiratory rate will be between 14 and 22 per minute. The approaches included to observe for signs and symptoms of respiratory distress (shortness of breath, cyanosis [the appearance of a blue or purple coloration of the skin or mucous membrane due to low oxygen level]) and notify the physician; administer two liters of oxygen per minute via nasal cannula; and assess breath sounds as needed.Review of the Licensed Personnel Weekly Progress Notes from 7/7 to 7/12/11, showed Patient 1's oxygen saturation was 92% to 98% when receiving two liters of oxygen via nasal cannula; his respiratory rate was from 18 to 22; he had no fever. There was no documentation of assessing the patient's lung sounds. Review of the MAR for the month of July, 2011, showed to monitor oxygen saturation every shift starting on 7/11/11. Patient 1's oxygen saturation levels were from 92% to 99%.The Physician Progress Notes dated 7/12/11, showed Patient 1 had mild shortness of breath; his lung sounds were clear; he had no edema. Review of the Physician Progress Notes dated 7/13/11, showed the patient's attention appeared to be mildly impaired, though this may be confounded by a decrease in the oxygen saturation level.Review of the PT (Physical therapy) Daily Treatment Note showed an entry dated 7/13/11 at 1701 hours, showing Patient 1 was unable to attempt gait training. His oxygen saturation level was decreased to 77% with the use of two liters of oxygen via nasal cannula when he was in the therapeutic exercise session with the PT. The patient was instructed in pursed lip breathing, and his oxygen saturation increased to 88%. The patient's condition was reported to the ADON (Assistant Director of Nurses). The Licensed Personnel Weekly Progress Notes failed to show documented evidence of assessing the patient for lung sounds, respiratory rate, edema, blood pressure, heart rate, and shortness of breath when the patient's oxygen saturation level decreased during the PT session. The form also failed to show documented evidence the physician was notified of the patient's condition. Review of the Interdisciplinary Team Conference dated 7/14/11, showed Patient 1's family member was concerned about the patient being more tired. The form showed the DON (Director of Nurses) explained it was related to a drop in the patient's oxygen saturation level and a need for the use of oxygen. The form also showed the patient continued to have increased secretions in his mouth. Review of the Licensed Personnel Weekly Progress Notes showed an entry dated 7/14/11 at 1210 hours, showing Patient 1 was alert, awake and verbally responsive to staff. His skin was pale. No respiratory distress and no shortness of breath were noted. His oxygen saturation was 90% with the use of two liters of oxygen per minute via nasal cannula. His respiratory rate was 24. His family member felt he was drowsy on the current dose of oxycontin. The physician was called about reducing the oxycontin; the nurse was waiting for the physician to call back. There was no documented evidence Patient 1 was assessed for lung sounds, edema, or weight gain. The MAR for the month of July, 2011, showed oxycontin was administered to the patient on 7/14/11 at 2100 hours.The Licensed Personnel Weekly Progress Notes from 7/14/11 at 1210 hours to 7/15/11 at 0400 hours, failed to show documented evidence Patient 1 was assessed for his level of consciousness, respiratory rate, lung sounds, edema, temperature, shortness of breath, restless, or his mental status. The form also failed to show documented evidence the physician was notified of the patient's weight gain, and the patient's condition. Review of the Licensed Personal Weekly Progress Notes showed an entry dated 7/15/11 at 0400 hours, showing Patient 1 was asleep in bed; no signs and symptoms of distress or discomfort; respirations even and unlabored; no shortness of breath noted; his oxygen saturation was 92% with the use of two liters of oxygen per minute via nasal cannula; the patient did not complain of pain while awake. There was no documented evidence of assessing the patient's lung sounds, respiratory rate, skin color, temperature, or edema.The Licensed Personnel Weekly Progress Notes showed an entry dated 7/15/11 at 0700 hours, showing Patient 1 was alert, had no shortness of breath, was turned and changed during 0600 hours rounds by the Certified Nurse Assistants (CNA). The form failed to show documented evidence the patient was assessed for skin color, respiratory rate, lung sounds, temperature, edema, or his mental status at 0600 hours. Review of the Licensed Personnel Weekly Progress Notes dated 7/15/11 at 0700 hours, showed Patient 1 was found with shortness of breath and acute respiratory distress during the medication pass at 0630 hours; his oxygen saturation was 72%. His oxygen saturation level was increased to 93%, and fluctuated from 70 % to 80% when he was provided 15 liters of oxygen per minute via a nonrebreather mask. The physician was notified. The patient was transferring to the acute hospital on 7/15/11 at 0700 hours.Review of Patient 1's health record from the acute hospital was conducted on 11/10/11 at 1615 hours.Review of the acute hospital's health record dated 7/15/11, showed Patient 1 was seen by a physician at 0720 hours. The form showed the patient appeared to be in extremis (at the point of death); he was in severe respiratory distress, extremely hypoxic (an inadequate supply of oxygen to the whole body), tachypnea (increase in respiratory rate), and severe retraction (visible contraction of the muscle between the ribs to aid in respiration). His lungs were extremely congested with crackles all the way to the top of the lungs, with expiratory wheezes, and very tight. His extremities had 1+ pitting edema (a dent was left in the skin when pressing, due to excess fluid build-up). He was obtunded (mentally dulled, or out of it), and had no response to commands except to deep rub (deep pressure). Further review of the form showed Patient 1 was currently in critical illness at that time; he was provided a breathing treatment, and Solu-Medrol (a steroid medication, an injection was given for COPD exacerbation). His chest x-ray showed severe cardiomegaly (enlargement of the heart) and CHF. His hemoglobin (a substance in the red blood cells that carries the oxygen to the organs) was 8 (normal range is usually 13.8 to 18.0 for men) which was consistent with severe anemia (a decrease in the number of red blood cells, or hemoglobin, that leads to lack of oxygen in organs). He was admitted to the hospital and was diagnosed with acute respiratory distress, acute respiratory failure, acute pneumonia, acute COPD, severe hypoxia, and anemia.Review of the acute hospital's health record dated 7/17/11, showed the patient passed away as indicated in the nursing notes. The discharge diagnoses included respiratory distress, respiratory failure; acute CHF, unknown type; and COPD exacerbation. Review of the Certificate of Death showed Patient 1 died on 7/16/11 at 1450 hours. The immediate cause of death was respiratory failure. The sequential list of conditions that lead to the cause of death was CHF. On 10/27/11 at 1140 hours, Licensed Vocational Nurse (LVN) 1 was asked what should have been done when Patient 1's respiratory rate increased to 24 and his oxygen saturation decreased to 90% while receiving two liters of oxygen via nasal cannula on 7/14/11. She stated his lung sounds should have been assessed, he should have been given a breathing treatment, the Registered Nurse (RN) supervisor and the physician should have been notified. She reviewed Patient 1's health record, and was unable to find documentation Patient 1 was assessed for his lungs sounds, he was given a breathing treatment, the RN supervisor was notified, or the physician was notified about the patient's condition. She stated, whenever the nurse calls the physician, or notifies the physician about a patient's condition, the nurse will document in the Licensed Personnel Weekly Progress Notes. On 10/27/11 at 1230 hours, CNA 1 was asked how Patient 1 was from 7/7 to 7/15/11. The CNA stated he was more confused, more tired, was afraid to stand up, stayed in bed most of the time, and slept more.On 10/27/11 at 1405 hours, RN 1 was asked how often the resident should be reassessed when there is a change in his oxygen saturation level and his respiratory rate. She stated the patient should be checked more often. She also stated the LVN did not check the patient more often as she could. She stated the LVN should at least notify the RN supervisor.On 11/14/11 at 1425 hours, a telephone interview with Patient 1's family member was conducted. When asked how the patient was before he went to the hospital, she stated he was more tired and weaker when she visited him four days before he was transferred to the acute hospital on 7/15/11. On 11/14/11 at 1500 hours, a telephone interview with Physician A was conducted. The physician was asked what he expected from the nurses when Patient 1's oxygen saturation decreased to 90% while receiving two liters of oxygen per minute via nasal cannula. The physician stated he expected the patient to be assessed further. He stated, whenever a patient's oxygen saturation level decreases, the patient should be reassessed after five minutes. He also stated he expected the nurse to call and notify him about any change in the patient's condition. He was asked if the nurse called and notified him about Patient 1's condition. He stated he did not recall if the nurses called and notified him; however, he stated, if the nurses called and notified him, they should document it in the patient's health record. He was asked about the order for the breathing treatments for Patient 1. He stated the nurse should have assessed and given the breathing treatment to the patient when the patient needed it.An interview was conducted with the DON on 1/10/12 at 1245 hours, the DON reviewed the patient's health record and was unable to find documented evidence the physician was notified about Patient 1's weight gain. She was asked for, but was unable to find documented evidence of assessing the patient for lung sounds or edema on 7/13, and 7/14/11. She stated the patient was assessed for shortness of breath and respiratory distress, but there was no specific documentation Patient 1 was assessed for lung sounds and edema. She was unable to find documentation to show if the physician called back on 7/14/11.During an interview with LVN 1 on 1/10/12 at 1400 hours, she was asked what she did before she gave oxycontin to Patient 1. She reviewed Patient 1's health record and stated oxycontin was a routine pain medication; she just gave it to the patient. She was asked how the patient was in the last few days prior to being transferred to the acute hospital on 7/15/11. She stated the patient was more tired; not the same as usual. She was asked when the last breathing treatment was given to Patient 1. She reviewed his health record and was unable to find documented evidence of giving Patient 1 a breathing treatment since 6/27/11. During an interview with the PTA (Physical Therapy Assistant) on 1/10/12 at 1520 hours, he reviewed Patient 1's health record and stated the patient had one episode of decreased oxygen saturation to 77% during the therapeutic exercise from 7/11/11 to 7/14/11. He stated the ADON was notified of the patient's condition on 7/13/11. During an interview with the RD (Registered Dietitian) on 1/10/12 at 1530 hours, she was asked if she was notified about Patient 1's weight gain. She reviewed Patient 1's health record and did not answer.During an interview with LVN 2 on 1/10/12 at 1605 hours, she reviewed Patient 1's health record and confirmed she gave the patient oxycontin on 7/14/11 at 2100 hours. She stated the patient verbalized response to her at that time. She stated his usual respiratory rate was 18 to 22, and his usual oxygen saturation level was 92% to 96% with the use of two liters of oxygen via nasal cannula. She was asked how the patient was on 7/14/11. She stated the patient was more restless. She was asked if the patient was assessed for leg edema on 7/14/11. She stated she did not remember. She was asked if she counted his respiratory rate. She stated, not really. She was asked how the patient's lung sounds were. She stated his lung sounds were diminished. She was asked if she heard crackles in the patient's lungs. She stated, not really. She was asked if the patient had shortness of breath. She stated, when the patient was restless, he had shortness of breath. She was asked what she did for the patient when he had shortness of breath and was restless. She stated she gave the patient a breathing treatment. She was asked for, but was unable to find documented evidence of assessing the patient for edema, lung sounds, vital signs (including respiratory rate), level of consciousness, mental status, and shortness of breath on 7/14/11. She was asked for, but was unable to find documentation of giving a breathing treatment to Patient 1.During an interview with the ADON on 1/10/12 at 1620 hours, he was asked what he did for Patient 1 when the PT notified him about the patient's condition during the PT session on 7/13/11. He stated he told a nurse to give the patient a breathing treatment. He was asked for, but was unable to find documentation to show the patient was given a breathing treatment. He stated he probably titrated the oxygen up for the patient. He was asked for, but was unable to find documentation of titrating the oxygen up for Patient 1. He was asked for, but was unable to find documentation of assessing or reassessing the patient for lung sounds, edema, or a full body assessment when the patient's oxygen saturation decreased during the PT session. He stated he had to do something for the patient that day, but he did not remember what he did. He reviewed the patient's health record and was unable to find documentation to show what he did for the patient on 7/13/11. These violations of the regulations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 060000130 |
PARKVIEW HEALTHCARE CENTER |
060009777 |
B |
08-Mar-13 |
P2RX11 |
13770 |
The facility's documentation, the facility failed to have behavior data available to the prescriber in a consolidated manner and to have sufficient information to determine the effectiveness of the psychoactive medications (medications used to treat specific mental conditions) as prescribed for seven of 10 sampled residents (Residents 1, 2, 3, 4, 5, 7, and 9).* The facility failed to show an adequate indication and monitor for the use of Risperdal (antipsychotic medication) for Resident 1.* The facility failed to show the manifested behaviors for Resident 9 that requires the use of Celexa, (antidepressant medication) and the indication to administer the as needed Ativan (antianxiety medication). * The facility failed to show adequate indication of use of Ability (antipsychotic medication) and Ativan for Resident 3. The facility failed to show documentation of a gradual dose reduction for Abilify was evaluated. This has the potential of unnecessary use of medications with serious adverse effects that could affect the resident's well-being.* The facility failed to monitor Resident 5's Depakote (antiseizure medication) level as ordered by the physician. This has the potential for the physician not having the necessary information to evaluate the dosage of Depakote to achieve a therapeutic level of the medication.Findings: Review of the facility's Certification Surveys dated 7/09, 8/10, 7/11 and 5/12, shows the facility has had deficiencies at F-329 every year.On 1/16/13 at 0750 hours, an entrance conference was conducted with the DON. The DON provided the surveyor with the Physician Orders List dated 1/16/13, showing the facility had 20 of 29 residents who are receiving psychoactive medications. During an interview with the DON on 1/16/13 at 1100 hours, the DON stated she cannot access the computer data of monitored behaviors; the night shift nurse has the paper forms, but the DON does not know where the forms are kept and the DON has been unable to contact the night shift nurse.On 1/17/13 at 0730 hours, an interview and review of the facility's documentation was conducted with LVN 3. When asked if she is responsible for tallying the behavior of residents receiving psychoactive medications, she stated, yes. LVN 3 presented with a folder of reports she stated she generates from the computer. She stated, when the licensed nurse documents the behavior in the system, she is responsible for doing the monthly tallying. She stated she has not done the reports and is six months behind because the computer system was implemented in May, 2012. When ask how the physician is informed regarding monitoring of the residents specific behavior and response to the medication, she stated they just tell the physician if the resident is better or worse. 1. On 1/16/13, clinical record review was initiated for Resident 5. Resident 5 was admitted to the facility on 11/1/11. a. Review of the January, 2013, recapitulated physician's orders shows orders dated 6/28/12, to administer Zyprexa (antipsychotic medication) 10 mg in the morning and 15 mg in the evening for psychosis manifested by auditory hallucinations, delusional thinking and paranoia; an order dated 7/13/12, to administer Clozaril (antipsychotic medication) 50 mg twice a day for schizophrenia manifested by auditory and verbal hallucinations and disrobing; an order dated 11/1/11, to administer Prozac (antidepressant medication) 40 mg daily for depression manifested by sadness; an order dated 5/4/12, to administer Remeron (antidepressant medication)15 mg at bedtime for depression manifested by social isolation; and an order dated 11/1/11, to administer Ativan 1 mg ever six hours as needed for irritable moods manifested by yelling and screaming. Review of Resident 5's clinical record failed to show monitoring of any behaviors associated with the need for antipsychotic medications, antidepressant medications and antianxiety medications. Documentation to show a recommendation to attempt gradual dose reductions for Prozac and Remeron was not found in the clinical record. On 1/17/13 at 0720 hours, an interview and clinical record review was conducted with the DON. The DON verified the findings and was unable to provide documentation of behavior monitoring for Zyprexa, Clozaril, Remeron, Prozac and Ativan. The DON was unable to provide documentation showing an attempt for gradual dose reductions was made for the Remeron and Prozac. b. According to Lexi-Comp Online, a professional resource, Depakote carries a U.S. boxed warning. Hepatic failure resulting in fatalities has occurred in patients, and cases of life-threatening pancreatitis, have been reported in adults. Monitoring parameters include monitoring for serum valproic acid levels for therapeutic levels; suicidality (eg, suicidal thoughts, depression, behavioral changes).Review of the physician's orders shows an order dated 11/1/11, to administer Depakote 750 mg twice a day for seizures and an order dated 12/6/11, to perform a blood draw for valproic acid (Depakote) levels every six months. Review of the laboratory reports shows the last valproic acid level was obtained on 6/18/12. No further documentation was found in the clinical record.On 1/17/13 at 0720 hours, an interview and clinical record review was conducted with the DSD. The DSD verified the finding and stated the test for the valproic acid level was not drawn by the lab and it should have been done in December, 2012. 2. On 1/16/13, clinical record review was initiated for Resident 3. Resident 3 was readmitted to the facility on 9/24/09. Review of the physician's orders shows an order dated 1/14/10, to administer Abilify 5 mg at bedtime for psychosis manifested by delusions and auditory hallucinations, and an order dated 4/8/10, to administer Ativan 1 mg twice a day for anxiety manifested by irritable mood, pulling off restraints and undressing. Review of Resident 3's clinical record fails to show monitoring of any behaviors associated with the need for antipsychotic medication and antianxiety medication use. On 1/17/13 at 0910 hours, an interview and clinical record review was conducted with the DON. The DON was unable to provide documentation showing the monitoring of Resident 3's behaviors or an attempt for gradual dose reduction for the use of Abilify.3. According to the Lexi-Comp Geriatric Dosage Handbook, 12th edition, Risperdal carries a U.S. box warning: Elderly patients with dementia-related behavioral disorders treated with atypical antipsychotics are at an increased risk of cerebrovascular adverse events and death compared with placebo; risk may be increased with dehydration; and Risperdal is not approved for the treatment of dementia-related psychosis. On 1/16/13, Resident 1's clinical record review showed an order dated 7/13/12, to administer Risperdal 1 mg once per day for restlessness. The MDSs dated 7/25/12 and 10/24/12 showed Resident 1 has memory problems and is severely impaired in cognitive skills for daily decision making. The MDSs showed Resident 1 has total dependence on staff for her activities of daily living (transfers, dressing, eating, hygiene and bathing). On 1/16/13 at 0930 hours, Resident 1 was observed in the gerichair in the activities room with their eyes closed. At 1140 hours, Resident 1 was observed in the dining room for lunch with other residents. Resident 1 was in the gerichair and was fed by a CNA. Resident 1 was observed to eat quietly. On 1/16/13 at 1645 hours, during an interview, CNA 2 stated Resident 1 has no behaviors on the afternoon shift. CNA 2 stated Resident 1 needs total care with eating and other daily activities. Review of the clinical record did not show any documented monitoring of the resident's behavior of restlessness. On 1/16/13 at 1555 hours, the DON was asked for Resident 1's indication for the use of Risperdal, the monitoring of episodes of restless behavior and its side effects. The DON stated she needs to look for it. On 1/17/13 at 0921 hours, observation of wound treatment of a Stage III pressure ulcer to the back was initiated. Resident 1 was quiet and did not express any verbal or nonverbal reaction when the nurse tucked the arginaid strips into the wound with the depth of 0.6 cm. The treatment nurse stated Resident 1 was quiet and had no issues with care. On 1/17/13 at 0945 hours, the DON stated Resident 1 has no restless behaviors and, per the hospice RN, the resident needs the medication because she has no behaviors.The DON stated, per the previous hospice documentation, Resident 1 has Alzheimer's disease with behaviors. The DON stated, after reviewing the clinical record, the problem is resolved, as the hospice RN documented the new indicating behavior for using Risperdal. Review of clinical record with the DON showed a clarified order dated 1/17/13 at 0900 hours, to administer Risperdal 1 mg, one per day for end-stage Alzheimer's with behaviors, for restlessness manifested by "yelling out/climbing out of bed." When asked if the resident showed any behavior of yelling out or climbing out of bed since being in the facility, the DON stated, no, and referred to interview the hospice RN. On 1/17/13 at 1005 hours, during an interview, the hospice Nurse Assistant stated she has not seen any behavior of yelling out or climbing out of bed from Resident 1. On 1/17/13 at 1048 hour, during an interview with LVN 1 regarding Resident 1's behavior of yelling out or climbing out of bed, LVN 1 stated she has not seen Resident 1 show any of the above behaviors. On 1/17/13 at 1050 hours, LVN 4 stated Resident 1 does not show any behavior of yelling out, climbing out of bed or restlessness. On 1/17/13 at 1325 hours, when asked for the source of information showing Resident 1's behavior of yelling out or climbing out of the bed that requires Risperdal, the hospice RN could not answer.4. On 1/17/13, Resident 9's clinical record review showed the following orders: - dated 6/25/12, Celexa 40 mg once per day for depression with no manifested behavior. - dated 6/25/12, Ativan 0.5 mg as needed for anxiety with no manifested behavior. On 1/17/13 at 1116 hours, an interview with clinical record review was conducted with LVN 4. When asked what is Resident 9's manifested behavior of depression. The LVN reviewed the clinical record and stated it was not documented. LVN 4 stated the resident's manifested behavior may be crying. The LVN could not show documented evidence of Resident 9's episodes of depression or anxiety was monitored for the use of Celexa or Ativan. When asked to show how many times Ativan was given for anxiety in December, 2012, the LVN stated three times. Review of the clinical record with LVN 4 showed the licensed nurse administered the as needed Ativan two of three times in December without indication (on 12/3 and 12/17/12). 5. Clinical record review for Resident 7 was initiated on 1/16/13. Resident 7 was readmitted to the facility on 12/16/11. Diagnoses for Resident 7 includes depression and bipolar disorder (a mental disorder marked by alternating periods of elation and depression). Review of a psychiatric consult note dated 12/13/12, shows add Risperdal (an antipsychotic medication) 1 mg for five days and then increase dose to 2 mg at bedtime. Review of the recapitulation of the physician's orders dated January, 2013, shows an order for Risperdal 2 mg at bedtime for psychosis. The order does not identify what behaviors are to be monitored. Review of Resident 7's clinical record fails to show monitoring of any behaviors associated with the need for antipsychotic medications. 6. Clinical record review for Resident 2 was initiated on 1/16/13. Resident 2 was admitted to the facility on 2/3/10. Diagnoses included psychosis (a symptom of mental illness characterized by changes in personality, impaired functioning and a distorted or nonexistent sense of reality), schizophreniform (a psychotic disorder with symptoms of schizophrenia marked by severely impaired thinking, emotions and behaviors) and OCD (obsessive compulsive disorder- an anxiety disorder characterized by recurrent obsessions or compulsions, which may interfere with personal or social functioning).Review of the recapitulation of the physician's orders dated January, 2013, shows orders for sertraline (an antidepressant) 200 mg each day for OCD manifested by (m/b) social isolation, Risperdal (an antipsychotic) 6 mg twice per day for psychosis m/b screaming and yelling and Zyprexa (an antipsychotic) 20 mg at bedtime for schizophrenia m/b irritable mood. Review of Resident 2's clinical record shows Psychotherapeutic Drug Summary Sheets for Zyprexa and Risperdal. No behavior data is entered on either form. 7. Clinical record review for Resident 4 was initiated on 1/16/13. Resident 4 was readmitted to the facility 11/4/12. Diagnoses for Resident 4 include anxiety disorder and depression. Review of the recapitulation of the physician's orders for January, 2013, shows trazodone (an antidepressant) 50 mg at bedtime and Xanax (an antianxiety medication) 0.5 mg three times per day. Review of Resident 4's clinical record fails to show monitoring of any behaviors associated with depression or anxiety.During an interview with LVN 2 on 1/16/13 at 1045 hours, LVN 2 stated monitoring of behaviors associated with psychotherapeutic drugs is on the computer, but LVN 2 does not know how to access the data or print a report of manifested behaviors. LVN 2 stated a night shift nurse has all the data on resident behaviors and is supposed to enter the data in the computer. LVN 2 stated the IT (information technology) person does not know how to retrieve the data from the computer. The above violation has a direct relationship to the health, safety and security of residents. |
| 060000978 |
PARK REGENCY CARE CENTER |
060010517 |
B |
04-Mar-14 |
IAE311 |
11270 |
The facility failed to ensure they did not retain a patient for whom they were not capable of providing care.Patient 14 was wandering about the facility, into other patients' rooms, scaring the patients, invading their privacy and becoming angry and combative with staff when they attempted to redirect Patient 14. Three patients (Patients 1, 2 and 3) were involved in altercations with Patient 14:* Patient 14 allegedly attempted to forcibly remove Patient A, his roommate, from his room.* Patient B stated Patient 14 came into her room on 1/5/14, in the middle of the night and frightened her.* Patient C stated Patient 14 came into her room on four to five occasions and terrified her.These incidents were not investigated by the facility. The plan of care for Patient 14 was not updated to address the patient's wandering and aggressive behavior, or how to protect other patients in the facility. In addition, Patient 14 was not evaluated to determine if the facility could provide the appropriate care setting for this patient. This resulted in patients being terrified and losing sleep over fear for their safety. Findings: During the resident group interview on 1/7/14 at 1000 hours, Patient B stated Patient 14 wandered into her room on 1/5/14, in the middle of the night. Patient B stated she woke up and Patient 14 was standing over her staring at her. She stated she was frightened and began to scream. Some staff members assisted her and removed Patient 14 from her room. She stated she requested to speak to the Administrator the next day. According to Patient B, the Administrator told her the next time it happens, to run. Patient B stated she has not been able to sleep since then and she feels exhausted. During another interview with Patient B on 1/9/14 at 1130 hours, the patient stated she is so exhausted due to lack of sleep. She wants to take a nap, but is afraid she will wake up with Patient 14 in her room. Health record review for Patient 14 was initiated on 1/8/14. Review of the acute hospital's Psychiatric and Mental Status Examination dated 11/20/13, showed Patient 14 was admitted to the acute hospital under an involuntary psychiatric hold. Patient 14 had diagnoses of major depression with psychotic features (loss of contact with reality), dementia with behavioral disturbances and to rule out bipolar disorder (a serious mental condition causing shifts in mood, energy, and ability to function). The report showed Patient 14 was a danger to others manifested by being hostile, agitated and irritable. Review of the Record of Admission dated 11/25/13, showed Patient 14 was admitted to the facility on 11/25/13. Review of the Facility Verification of Informed Consent dated 11/25/13, showed Patient 14 was started on Zyprexa (an antipsychotic medication used to treat schizophrenia, a type of psychotic disorder, or bipolar disorder) 10 mg daily for behaviors of striking out and threatening staff. In addition, Patient 14 was prescribed Ativan (an antianxiety medication) 1 mg every six hours as needed for anxiety. Review of the care plan to address the problem of Antipsychotic dated 11/26/13, showed Patient 14 has psychosis. The goals for the problem are to have less than three episodes of psychosis per week. The interventions include explain all procedures to the patient, approach him calmly, listen attentively, refocus the Patient 14 and try again later should there be any behavior issues and to encourage the patient to verbalize his feelings. There was no documented plan should Patient 14 become combative, aggressive or how to protect other patients in the facility. In addition, there was no plan to address the patient wandering into other patients' rooms. Review of the Physician's Progress Note dated 11/26/13, showed Patient 14 was naked and aggressively declined clothing. An entry dated 11/27/13, showed Patient 14 is "long term care and needs a locked psych facility for his safety." Review of the Behavior Summary for Zyprexa for December 2013 showed Patient 14 had 13 behaviors of striking out at staff in December 2013.Review of the Nurses Note dated 12/12/13 at 1130 hours, showed Patient 14 was ambulating around the facility and attempting to exit the facility every five minutes. The patient began to strike out at staff for attempting to stop him from exiting. The note further showed Patient 14 was also entering other patients' rooms constantly and was hard to redirect. The nurse also documented Patient 14 was striking out during care. Other patients were moved for their safety. The note showed the patient was provided food and taken to the bathroom in an attempt to calm him down, but the interventions were ineffective.A Nurses Note dated 12/12/13 at 1435 hours, showed Patient 14 attempted to tip over another patient who was passing by in the hallway. The nurse documented Patient 14 was constantly following the other Patient 14round. The other patient was removed for safety. Patient 14 was offered antianxiety medication, but refused to take it. A Nurses Note on 12/12/13 at 1930 hours, showed Patient 14 was moved to another room due to roommate incompatibility. Review of the Physician's Progress Note dated 12/13/13, showed the physician documented Patient 14 was still wandering. The physician documented Patient 14 tried to physically lift another patient out of his wheelchair. The physician documented other patients were complaining Patient 14 was trying to get into bed with them. Review of the Psychiatric Evaluation Brief Form dated 12/20/13, showed Patient 14 has impaired insight, severely impaired judgment, delusions, is wandering around a lot and needs to be moved to a dementia unit. An interview with the Administrator was initiated on 1/8/14 at 1100 hours. The Administrator was asked for any investigations regarding Patient 14, including abuse or patient to Patient 14ltercations. At 1300 hours, the Administrator stated there were no investigations of any kind involving Patient 14. An interview with Patient C was initiated on 1/9/14 at 0830 hours. Patient C stated she has been at the facility for a few years. She is confined to bed and stays mainly in her room. Patient C was asked if anyone wanders into her room. The patient stated Patient 14 has wandered into her room on four or five occasions. She stated, the first time, she woke up and Patient 14 was standing next to her bed. She yelled for help. Three staff members ran in to assist her. She said the patient struggled and became combative with the staff, striking out. Patient C stated Patient 14 was right next to her and she could not protect herself or flee. Patient C stated she was terrified. Patient C further stated Patient 14 came into her room when she was behind her curtain using the bedpan. She stated he opened the curtain and watched her. She stated she had to yell for help. The patient stated her roommate cannot speak and protect herself, so she worries about her being hurt by Patient 14. Patient 14 has been in the roommate's closet, "riffling around," but she did not confront him because she was scared. Patient C stated the facility has had a staff member following the patient for one on one supervision, but she has observed the patient wandering alone. She stated there are some shifts Patient 14 is not being followed nor has the one on one supervision. Patient C stated the staff is not always available or able to control Patient 14. Patient C stated she observed a staff member being struck by Patient 14 last weekend. She further stated the one on one supervision does not appear to work. Patient C stated she has not slept well since Patient 14's admission to the facility. Review of Patient 14's Nurses Note dated 1/1/14 at 0500 hours, showed Patient 14 had episodes of rummaging through his roommate's things. A Nurses Note dated 1/1/14 at 2100 hours, showed the patient was ambulating in the hallway, getting into different rooms and patients were getting scared. Patient 14 was going through other patients' things and getting upset and aggressive. The Nurses Note dated 1/2/14 at 0500 hours, showed Patient 14 had an episode of getting aggressive when his roommate wanted to go to bed. Patient 14 did not want the roommate to enter the room. Patient 14 was documented as pushing staff to take the roommate out of the room. A Nurses Note dated 1/2/14 at 1300 hours, showed Patient 14 was having episodes of aggressive behavior and wandering into other patients' rooms. A Nurses Note dated 1/2/14 at 1400 hours, showed Patient 14 was aggressive and not allowing his roommate to enter the room. The Nurses Note dated 1/2/14 at 2100 hours, showed Patient 14 was wandering into other patients' rooms scaring them. A Nurses Note dated 1/3/14 at 0500 hours, showed Patient 14 became aggressive when the staff tried to stop him from entering other patients' rooms. The Nurses Note dated 1/4/14, showed the patient was wandering into other patients' rooms and became aggressive towards staff. The Nurses Note dated 1/5/14, showed Patient 14 was going into other patient's rooms and sometimes became aggressive. A Nurses Note dated 1/6/14 at 2100 hours, showed Patient 14 continued to wander the hallway, going room to room and scaring the other patients. A joint interview with RN 1 and the Administrator was initiated on 1/9/14 at 1200 hours. RN 1 was asked about the altercation or altercations involving Patient 14 on 12/12/13 and/or 12/13/13. RN 1 stated she was not present on 12/12/13, but she heard from other staff members. RN 1 stated Patient 14 was sharing a room with Patient A. The two patients were yelling at each other and the yelling got worse. She stated Patient 14 was then moved out of his room and across the facility to prevent any violence. RN 1 stated she was not aware if Patient A or any other patient was tipped out of the wheelchair or if Patient 14 tried to pick someone up. The Administrator was asked why he did not investigate the incidents on 12/12/13 and/or 12/13/13. He stated he was not aware of any incidents, only yelling by Patient 14. The Administrator stated he called the patient's insurance provider on 12/13/13, and asked for a one on one staff member to supervise Patient 14. The insurance agreed to pay for a one on one caregiver until 12/31/13. The Administrator stated he requested a psychiatrist evaluate Patient 14.Review of Patient A's health record failed to show documentation an altercation had taken place. A telephone interview with Patient A's surrogate decision maker was initiated on 1/10/14 at 1600 hours. Patient A's surrogate decision maker stated the patient is unable to speak. She stated she was not informed of any altercation the patient might have had with Patient 14. She stated she heard Patient 14 was moved to another room due to Patient 14 being too noisy at night. Review of the care plan showed no updates to Patient 14's care plan to document any new behavior management interventions, what to do if the patient gets violent, any plan to address the patient's behaviors of wandering into patients' rooms, trying to escape the facility, or how to protect other patents from Patient 14's behaviors. These failures have a direct and immediate relationship to the health, safety or security of patients. 1 |
| 060000127 |
PACIFIC HAVEN SUBACUTE AND HEALTHCARE CENTER |
060012053 |
B |
02-Mar-16 |
PO6H11 |
6210 |
F323: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Glossary: ADL - activities of daily living CNA - Certified Nursing Assistant DON - Director of Nursing MDS - Minimum Data Set The facility failed to provide the necessary care and services to ensure adequate supervision was in place to prevent a fall for Resident 1. Resident 1 fell to the floor when CNAs 1 and 2 were providing incontinence care to the resident. CNA 1 left the resident's bedside, leaving CNA 2 to care for Resident 1. As a result, Resident 1 fell to the floor, sustaining an abrasion to his nose and a fracture to his right femur (thigh bone). Findings:Closed clinical record review for Resident 1 was initiated on 1/4/16. Resident 1 was readmitted to the facility on 12/6/13.Review of Resident 1's plan of care showed a care plan problem dated 12/6/13, addressing the resident's high risk for falls. The interventions included to have two persons to assist the resident with bed mobility and transfers. Review of the Fall Risk Assessment dated 9/12/14, showed Resident 1 was assessed to be at high risk for falls. Review of the History and Physical dated 2/11/15, showed Resident 1 did not have the capacity to understand and make decisions.Review of Resident 1's MDS dated 12/1/15, showed the resident was severely cognitively impaired; the resident weighed 248 pounds and was 5 feet 9 inches tall. Resident 1 was totally dependent on staff for ADL care and required two persons' physical assistance for bed mobility.Review of the Event Investigation Form dated 12/4/15, showed Resident 1 was being assisted by CNAs 1 and 2 for incontinence care. Resident 1 was turned to his right side and grabbed the assistive bar (a small side rail at the upper end of the bed by the resident's head and shoulders). CNA 1 left Resident 1's bedside to respond to an emergency bed alarm of Resident 1's roommate. During this time, Resident 1 suddenly moved and rolled off the bed on to the floor. Review of the Narrative Notes - Nursing dated 12/4/15 at 0600 hours, showed Resident 1 was being assisted by two CNAs for peri-care. Resident 1 was turned to his right side, grabbed the assistive bar, suddenly moved, and rolled over onto the floor when one of the CNAs left Resident 1's bedside to respond to an emergency bed alarm at the next bed. Resident 1 landed on the floor sideways and hit his nose on the bedside drawer. The one CNA was not able to stop Resident 1 from falling due to the resident's size and weight. Resident 1 sustained a small abrasion on the ridge of his nose with minimal bleeding and the resident denied any pain.On 1/4/16 at 1432 hours, an interview was conducted with the DON. The DON stated Resident 1 fell and landed on the floor during incontinence care when CNA 1 left Resident 1's bedside to answer the bed alarm of Resident 1's roommate. Resident 1 was left under the care of CNA 2 who was standing behind the resident at the time of the fall, and CNA 2 was unable to stop Resident 1 from rolling forward due to his size and weight. The DON stated the assistive bar was up at that time; however, Resident 1 rolled over onto the floor. The DON stated Resident 1 had no history of falls in the facility and was able to grab the assistive bar with staff assistance to hold during care. There was no evidence the CNAs attempted to roll the resident onto his back before the CNA left his bedside to attend to the roommate's bed alarm.On 1/5/16 at 1605 hours, a telephone interview was conducted with CNA 2. CNA 2 stated she was assigned to care for Resident 1 on 12/4/15, and she worked the night shift (2300-0700 hours). CNA 2 stated on 12/4/15, sometime between 0500 and 0600 hours, she and CNA 1 provided incontinence care for Resident 1. CNA 2 stated Resident 1 was turned onto his right side while the resident's left hand grabbed onto the assistive bar. CNA 2 stated while they were providing care to Resident 1, Resident 1's roommate's bed alarm went off and CNA 1 left Resident 1's bedside to answer the emergency bed alarm. CNA 2 stated Resident 1 was left lying on his right side when he suddenly moved and rolled forward and off the bed onto the floor. The CNA stated she was unable to hold onto Resident 1 and keep him from falling out of bed due to the resident's size and weight. CNA 2 was asked if she was holding Resident 1 with both of her hands while CNA 1 was away from Resident 1's bedside. She stated her right hand was holding the back of the resident while she continued to provide incontinence care with her left hand. CNA 2 stated when Resident 1 fell, he hit his nose on the bedside drawer. On 1/6/16 at 0815 hours, a telephone interview was conducted with CNA 1. CNA 1 confirmed she had been caring for Resident 1 with CNA 2 on 12/4/15 between 0500 to 0600 hours. She stated Resident 1 required assistance from staff for bed mobility, including turning from side to side. She stated Resident 1 required two persons' assistance at all times due to the resident's weight and size. CNA 1 stated Resident 1 was repositioned on his right side with his left hand holding onto the assistive bar. CNA 1 was standing one side of the bed and CNA 2 was on the other side. Resident 1 was facing CNA 1. She stated CNA 2 was standing behind Resident 1 while providing incontinence care while she held onto Resident 1. She stated Resident 1's roommate's bed alarm went off, so she immediately went to answer the emergency bed alarm. This left Resident 1 lying on his right side without anyone standing in front of him to prevent him from rolling forward and off the bed while CNA 2 continued to provide incontinent care. CNA 1 stated a short time later, CNA 2 was calling for help because Resident 1 had rolled off the bed on to the floor. Review of the right tibia/fibula (leg bone) x-ray done in the facility dated 12/4/15, showed an acute, mildly impacted comminuted (broken into several pieces) distal femur (the thigh bone above the knee) fracture. These failures have a direct and immediate relationship to the health, safety or security of patients. |
| 060000255 |
PALM TERRACE HEALTHCARE & REHABILITATION CENTER |
060013120 |
A |
21-Apr-17 |
VBX011 |
29439 |
483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following:
During the Abbreviated Survey findings for Complaint No. CA00519873, a Federal deficient practice was identified at F309 with a scope and severity of a G; which resulted in the issuance of a Class A Citation No. 06-0371-0013120-F.
The facility failed to identify a significant change of condition in a timely manner for Resident 1. Over the course of two and a half days, Resident 1 became weak, could no longer participate in physical therapy, developed abdominal pain, became incontinent, and vomited blood. Facility staffs' failure to identify the significant decline in Resident 1's condition resulted in Resident 1 not receiving the necessary care and treatment timely to maintain her physical well-being, which resulted in Resident 1 to be transported urgently to an acute care hospital emergency department in an unstable condition. Three minutes after arrival at the emergency department, Resident 1 suffered a cardiopulmonary arrest and subsequently died.
Findings:
On 1/30/17 at 1030 hours, a telephone interview was conducted with Resident 1's family member (Family Member 1). Family Member 1 stated he and his family were concerned the facility did not address all of Resident 1's health issues, especially her low hemoglobin (a protein in red blood cells that carries oxygen; a low hemoglobin count may indicate anemia and need for a GI (GI = gastro-intestinal refers to stomach and small and large intestines) workup to rule out internal bleeding. Family Member 1 stated he had requested a care plan conference with the Case Manager and Administrator on Resident 1's admission to the facility, but the care conference was not scheduled until 12/30/17, 22 days later. Family Member 1 stated "nothing was done" after the care conference to address the "blood problem" until 1/20/17, when Resident 1 was transferred via 911 ambulance to the acute care hospital emergency department after her health had significantly declined. The family member stated according to the emergency department physician, Resident 1's hemoglobin level was 4.5 gm/dL (normal range: 11.0-15.0 g/dL; g/dL is grams per deciliter, unit of measurement for some medical tests results),). Family Member 1 stated Resident 1 received a blood transfusion in the emergency department but died shortly after arriving to hospital.
Medical record review for Resident 1 was initiated on 2/6/17. Resident 1 was admitted to the facility from an acute care hospital on XXXXXXXX 16, for rehabilitation following a traumatic injury.
Review of the Physician Discharge Summary from the acute care hospital dated 12/8/16, included the following discharge diagnoses: multiple injuries due to trauma, acute blood loss anemia (a condition that develops when blood lacks enough red blood cells or hemoglobin, resulting in inadequate oxygen to the body's cells), status post (recent) blood transfusion, pelvic hematoma (localized collection of blood outside a blood vessel), poorly controlled diabetes (disease that affects the body's ability to use insulin resulting in abnormal carbohydrate metabolism ) with hypoglycemia (low blood sugar level), hypertension (high blood pressure), chronic obstructive pulmonary disease (a lung disorder that causes increased airway resistance), urinary retention (inability to fully empty bladder) and urinary frequency. Documentation showed Resident 1 had chronic anemia (condition resulting in too few red blood cells or a decreased ability of the red blood cells to carry oxygen or iron). Resident 1's hemoglobin on discharge from the acute hospital was 8.1 g/dL. There was a pending GI workup as an outpatient and Resident 1 was to be discharged to the skilled nursing facility for rehabilitation.
Review of the History and Physical examination dated 12/12/16, showed Resident 1 had the capacity to understand and make decisions.
Review of the Licensed Nurse Initial Admission Record dated 12/8/16 at 2348 hours, showed a comprehensive nursing assessment was completed by LVN 3 (Licensed Vocational Nurse) and LVN 4. There was no documented evidence to show an RN (Registered Nurse) assessment was completed upon Resident 1's admission to the facility.
Review of the RAI (Resident Assessment Instrument, a standardized assessment tool) dated 12/15/16, showed majority of the assessments, except for the PT (Physical Therapist) and OT (Occupational Therapist) sections, had not been completed during Resident 1's six week stay at the facility. For example, the sections of the RAI used to measure residents' functional abilities, strengths, weaknesses, and risk factors were all blank. The Care Area Assessment Summary was also left blank. According to the RAI Manual dated 10/2014, for the Care Area Assessment Summary should be used to guide decision-making, direct facility staff to specific areas of concern, and develop a comprehensive plan of care.
Review of the laboratory results for Resident 1 showed the following:
* On 12/13/16, the CBC (complete blood count, a blood test to determine health status, including anemia and infection) results showed the hemoglobin level was 7.1 g/dL (normal hemoglobin range: 11.5-15.0 g/dL) and the physician was notified with no new orders.
* On 12/30/16, the CBC test results showed the hemoglobin level was 8.8 g/dL and the physician was notified with no new orders.
* On 1/10/17, the CBC test results showed the hemoglobin level was 8.6 g/dL and the physician was notified with no new orders.
* On 1/20/17, the CBC test results showed the hemoglobin level was 4.5 g/dL and the WBC (white blood cell) count was 25.8 thousand (normal WBC range: 4.0-10.5 thousand) and the physician was notified and ordered Resident 1 to be transferred to the acute care hospital emergency department.
On 2/6/17 at 1545, an interview was conducted with the Case Manager who stated she had been covering for the vacationing Social Service Director. The Case Manager stated she and the rest of the Interdisciplinary Team held a care conference with Resident 1 and her family sometime after 12/28/16. The Case Manager stated Resident 1's progress, nursing care, and laboratory test results were all discussed. The Case Manager stated the family had been concerned about the resident's hemoglobin level (7.1 g/dL) obtained on 12/13/16. The Case Manager stated she reassured the family that a hemoglobin level of 7.1 g/dl result did not fall within the parameters for a blood transfusion, but she would request another blood count from the physician.
Review of Resident 1's Progress Notes showed a nurse's Change of Condition note dated 1/19/17 at 1800 hours, was documented by LVN 1. The note showed Resident 1 reported vomiting blood. LVN 1 notified the resident's physician (Physician 1) and received an order for anti-nausea medication and a CBC test to be done the following morning. A second nurse's progress note dated 1/19/17 at 2207 hours, showed Resident 1 was forgetful and complaining of abdominal pain. LVN 1 documented he notified his supervisor to assess Resident 1 and notified the physician. LVN 1 documented Physician 1 ordered a CMP (comprehensive metabolic panel, a blood test to evaluate organ function and check for conditions such as diabetes, kidney function and liver function) test and abdominal x-ray; both orders were to be carried out in the morning. There were no vital signs documented in the nurse's note at or around this time.
On 2/15/17 at 1605 hours, a telephone interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked to review his documentation for Resident 1 from 1/19/17. When asked if he observed the vomit Resident 1 reported to him, LVN 1 stated no, he did not see it. He stated he did not know how much there was or what it looked like because Resident 1 could not remember, just that it was red with blood. LVN 1 was asked if he checked Resident 1's abdomen. He stated no, he requested his supervisor (RN 1) to assess Resident 1. He stated RN 1 did assess Resident 1 and notified the resident's physician. LVN 1 stated Resident 1 appeared to be "fine" and remained alert and oriented.
On 2/16/17 at 1600 hours, a telephone interview and concurrent medical record review was conducted with RN 1. RN 1 stated he remembered working the evening shift on 1/19/17 with LVN 1. RN 1 stated the DON 1 (Director of Nursing) informed LVN 1 via text to have him (RN 1) assess Resident 1, but RN 1 did not remember what time. RN 1 stated he remembered assessing Resident 1 but did not recall the time. He stated there was a family member at her bedside. RN 1 stated her vital signs were taken and were "normal." He said Resident 1 was complaining of abdominal pain. He stated the family told him Resident 1 had been complaining of abdominal pain for the last three months and all of her tests were "negative." RN 1 stated he informed LVN 1 to call the physician who ordered the KUB (kidneys, ureters, bladder, and x-ray of the abdomen, providing information about abdominal organs) and CMP tests to be done the following morning. RN 1 stated he recalled LVN 1 informing him a CNA 1 (Certified Nursing Assistant) had helped Resident 1 clean up the "coffee ground" vomit earlier in the shift on 1/19/17.
When RN 1 was asked where he documented his assessment of Resident 1, RN 1 stated he normally did not document anything in the medical record when he was asked to help another nurse. When asked what his assessment findings were for Resident 1 on 1/19/17, he stated her abdomen was soft but tender, her vital signs were stable, and the resident was not "tachycardic" (rapid heart rate) and not vomiting, pale or weak. RN 1 did not think there was a "significant change" in her condition.
Review of the Physical Therapy Notes showed Resident 1 was experiencing a change of condition from 1/18/17 to 1/20/17 as evidence by the following notes:
a. Review of Physical Therapy Treatment Encounter note dated 1/18/17, signed by PTA 1 (Physical Therapy Assistant), showed Resident 1 was feeling fatigued, had increased pain, and required frequent rest periods due to fatigue and pain. Review of PT 1's note dated 1/19/17, showed Resident 1 refused to ambulate due to feeling nauseous and having stomach pain, and the nursing staff were notified.
B. Review of Physical Therapy Treatment Encounter Note dated 1/18/17, signed by PTA 2 showed Resident 1 reported feeling fatigued and had increased pain. On 1/19/17, PTA 2 documented Resident 1 refused to attempt ambulate due to feeling nauseous and having stomach pain, and the nursing staff were notified.
C. Review of Physical Therapy - Therapy Addendum notes dated 1/20/17 from 0830-0840 hours, showed a summary note documented by PT 1. PT 1 and OTA 1 (Occupational Therapy Assistant) asked to help assess Resident 1 for a decline in her functional mobility. The note showed PT 1 performed an assessment and asked Resident 1 how she was feeling. Resident 1 responded, "yucky."
On 2/16/17 at 0955 hours, a telephone interview and concurrent medical record review was conducted with PT 1. PT 1 confirmed she assessed Resident 1 for a change in her functional status on 1/20/17. PT 1 stated she assessed Resident 1 to rule out a possible stroke such weakness on one side. PT 1 stated OTA 1 stated she had informed the nursing staff Resident 1 was not feeling well.
On 2/16/17 at 1000 hours, a telephone interview and concurrent medical record review was conducted with PTA 1. PTA 1 stated she had worked with Resident 1 on 1/16 and 1/17/17. PTA 1 stated Resident 1 was motivated and functioning well on these two days. The resident did not complain of any decreased energy or fatigue; the only thing the resident mentioned was that she had a long history of chronic hip and back pain.
On 2/16/17 at 1008 hours, a telephone interview and concurrent medical record review was conducted with PTA 2. PTA 2 stated he took care of Resident 1 on 1/18 and 1/19/17. PTA 2 stated on 1/18/17, Resident 1 felt weak and had abdominal pain, and he let the nurse know. PTA 2 stated Resident 1 was able to get out of bed, sit in the chair, and walk to the bathroom. PTA 2 stated they stayed in Resident 1's room to do her treatment on that day; however, normally, Resident 1 would walk (using her walker) to the gym to do her exercises. PTA 2 stated Resident 1 had not been feeling well and refused therapy twice on 1/19/17. He stated he let the nurse know how Resident 1 was feeling and that she had refused treatment. PTA 2 added Resident 1 looked "off."
However, review of the medical record showed no documented evidence the licensed nursing staff had assessed the resident and reported the resident's change in health condition to the physician for proper and prompt medical interventions after the PT staff had informed the licensed nursing staff of the resident's change in condition.
Review of the Occupational Therapy Treatment notes showed Resident 1 was experiencing a change of condition from 1/18/17 to 1/20/17 as evidence by the following documented notes:
a. Review of Occupational Therapy Treatment Encounter Note dated 1/18/17, signed by OTA 1, showed Resident 1 was able to work in her room only, declined to have a shower three times because she was too cold, complained of nausea, and was not feeling well enough. The nursing staff were notified Resident 1 refused to shower.
B. The Occupational Therapy Treatment Encounter Note dated 1/19/17, signed by OTA 1, showed Resident 1 appeared confused, notified the nursing staff of the change of condition. The OTA documented Resident 1 required a lot of encouragement to participate with her therapy treatment.
C. Review of Occupational Therapy Treatment Encounter Notes dated 1/20/17, signed by OTA 1, showed Resident 1 had increased fatigue and was lethargic, the nursing staff were notified STAT, and both CNA and OTA assisted Resident 1 with positioning and incontinent brief management. PT 1 was called into room to assess Resident 1. Resident 1 was encouraged to eat but had no appetite; the nursing staff member was present in room; the OTA went back to check Resident 1 later, but she had been transferred to the ED.
On 2/17/17 at 0945 hours, a telephone interview and concurrent medical record review was conducted with OTA 1. OTA 1 stated she was very familiar with Resident 1, knew her well, and had worked with her throughout her stay. OTA 1 was asked to review her documentation in Resident 1's medical record for the dates 1/18/17-1/20/17.
After reviewing her documentation, OTA 1 spoke of the following timelines for Resident 1:
* On 1/18/17 (Wednesday), Resident 1 was functioning at a high level.
* On 1/19/17 (Thursday), Resident 1 had a decline in her function status; prior to Thursday, Resident 1 had been ambulating to the bathroom with standby assistance and the use of her walker and was able to toilet herself. Resident 1 had been cognitively intact and was doing "great." She stated on Thursday (1/19/17), Resident 1 was not "herself." OTA 1 observed Resident 1 lying in bed wearing only her robe. OTA 1 stated Resident 1 was a modest woman who would normally not be in that state of undress. She said Resident 1 seemed a little "loopy and out of it."
* On 1/20/17 (Friday), OTA 1 stated she was a little "alarmed" to find Resident 1 lying in bed wearing a hospital gown and an incontinence brief as she had was always continent and always wore underwear. She stated she immediately went to the charge nurse and the charge nurse went into the resident's room. OTA 1 stated she also notified PT 1 to help evaluate Resident 1 as they were both concerned Resident 1 might have had a "stroke." She stated Resident 1 had no appetite and refused to eat. PT 1 recommended letting Resident 1 rest and try to work with her later in the morning. OTA 1 stated she went back to Resident 1's room later in the morning and learned the resident had been transferred by ambulance to the hospital.
Review of the licensed nurses' progress notes showed on 1/18/17, there were no vital signs documented. In addition, there was no documentation to show Resident 1 had any changes of condition such as nausea, vomiting, or abdominal discomfort as identified by PT, OTA, and CNA staff.
Review of the meal percentage intake for Resident 1 for January 2017 showed Resident 1 had a decline in her oral meal intake between 1/16/17 to 1/20/17. For example, on 1/16/17, she ate 100% of all meals. On 1/17 and 1/18/17, she ate an average of 50% of her meals. On 1/19/17, she only ate 25% of each meal and on 1/20/17, she refused to eat her breakfast and was later transferred to the ED.
On 2/21/17 at 1550 hours, a telephone interview was conducted with CNA 1. CNA 1 stated she was not assigned to Resident 1 on Thursday (1/19/17), but remembered helping her at around 1800 hours on that day. CNA 1 stated she was in the hallway and went into Resident 1's room because she had vomited on herself and on the floor. CNA 1 stated the vomit was bloody but also had "black" in it like "coffee grounds." CNA 1 stated she went out of the room to tell LVN 1 Resident 1 vomited; however, LVN 1 was busy so she went back to clean up the resident's vomit.
On 2/22/17 at 1050 hours, a telephone interview was conducted with CNA 2. CNA 2 stated she had cared for her many times. CNA 2 stated during the last two days, the resident was in the facility complaining of "belly pain." CNA 2 stated she did not recall Resident 1 complaining of belly pain before 1/18/17. She stated when Resident 1 got up to the bathroom, she was "holding her belly" and said her "belly hurt." CNA 2 stated she "knew something was wrong" with Resident 1 and reported her change of condition to the nurse in charge. CNA 2 further stated on 1/20/17, Resident 1 was wearing an incontinence brief. CNA 2 Resident 1 was not herself because she had never been incontinent before. She stated she reported her observations to LVN 2. She stated LVN 2 told her that Resident 1 was "fine" and that they were monitoring her.
CNA 2 stated she changed Resident 1's incontinence brief and observed dark urine and that Resident 1 was very weak and sweaty. She said she reported Resident 1's condition to LVN 2 again. LVN 2 told CNA 2 they were monitoring Resident 1 and they were trying to get an order for an IV.
CNA 2 stated there was a family member (Family Member 2) at Resident 1's bedside the entire morning of 1/20/17. He was very concerned about her change of condition and wanted her transported to the acute care hospital. The CNA stated the Medical Director came into Resident 1's room and took her pulse, and stated her heart rate was up and asked everyone to leave the room. The resident was transferred to the ED.
Review of the resident's plan of care showed no documented evidence the staff developed a care plan problem to address Resident 1's anemia. A short-term care plan problem showed Resident 1 vomited on 1/19/17, however, it did not address Resident 1 had vomited blood. In addition, there was no other care plan problem to address Resident 1's change of condition related to her incontinence, inability to perform PT/OT exercises, loss of appetite, abdominal pain, fatigue, or her altered mental status from 1/18/17 to 1/20/17, found in the medical record.
On 2/22/17 at 1110 hours, a telephone interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated she was familiar with Resident 1 and worked as a desk nurse on the day shift from 1/17/17-1/20/17. LVN 2 was asked to review a nurses' progress note she designated as a Late Entry on 1/19/17 at 1146 hours. LVN 2 stated she wrote the note but did not remember exactly what time the assessment of Resident 1 took place; it just occurred sometime before lunch. LVN 2 verified she did not write down the actual time of the assessment. When asked what prompted her to perform an assessment for Resident 1 at the time, LVN 2 stated because Resident 1 vomited on the afternoon shift the day before and she had received a text from DON 1 at approximately 1030 hours on 1/19/17, asking her to assess Resident 1. LVN 2 stated Resident 1 was alert during the assessment, and had no discomfort, nausea, or vomiting.
LVN 2 described the course of events that occurred with Resident 1 on the morning of 1/20/17. LVN 2 stated LVN 6 asked LVN 2 to assist her with Resident 1 because Family Member 2 was in the room and asking Resident 1 being transferred to the acute care hospital. She stated she "checked" on Resident 1 was awake but not talking like she normally did and did not respond verbally when her name was called.
LVN 2 stated another LVN (LVN 6) took Resident 1's vital signs and was going to take them again because they were abnormal. LVN 2 called the Medical Director and DON 1 to inform them of Resident 1's condition. LVN 2 remembered Resident 1 had laboratory tests drawn earlier that morning and went to check the results in the computer. LVN 2 stated she retrieved the CBC results from the computer and identified a critical value notification from the laboratory company. She stated she then texted Physician 1 and told him about the laboratory notification and asked for an order for an IV. She said the Medical Director came into the room to assess Resident 1 and took her pulse. The Medical Director stated Resident 1's pulse was weak and rapid and ordered staff to call 911. LVN 2 called 911 at 1005 hours.
When LVN 2 was asked if she had been notified of Resident 1 inability to do PT or OT the two days prior to her being transferred to the emergency department, LVN 2 stated no, the report would have been given the nurse assigned to Resident 1.
On 2/22/17 at 1450 hours, a telephone interview was conducted with DON 1. DON 1 was asked to explain how the nursing staff responded to Resident 1's change of condition. The DON stated on the morning of 1/19/17 (Thursday), she received a "forwarded" text from the Administrator regarding Resident 1's "stomach." The DON asked LVN 2 to assess Resident 1 sometime before lunch. She stated LVN 2 told her Resident 1 "was fine" and even better by the end of LVN 2's shift on 1/19/17. Later, DON 1 heard from LVN 1 that on the evening on 1/19/17, Resident 1 had vomited. The DON stated she told LVN 1 to text Physician 1 and obtain an order for laboratory work and asked RN 1 to assess Resident 1. The DON stated the staff's assessments should have been documented in the resident's medical record.
On 2/23/17 at 1600 hours, a telephone interview was conducted with Family Member 2. The family member stated he had visited Resident 1 on multiple occasions at the facility. Family Member 2 stated he was with Resident 1 on Tuesday (1/17/17) and she was "okay." He stated he was with Resident 1 on Thursday (1/19/17) for most of the day, and she was "not well," so he asked Family Member 3 to come stay with her so he could leave.
Family Member 2 stated on 1/19/17, the facility called him told him Resident 1 had been incontinent. He stated he went to the facility at 1000 hours on 1/19/17, and noticed Resident 1 was not feeling well and told him her stomach was "upset." He stated he tried to assist the resident to the bathroom, but she was unable to make it and became "sweaty." Family Member 2 called for help and the staff put Resident 1 on a bedpan. He stated Resident 1 could not eat because her stomach hurt. He stated he informed the nurses something was not right with Resident 1, especially as the day progressed. He stated he had to leave the facility but returned later that evening. One of the staff had informed him the resident had vomited and there was blood in it. Family Member 2 stated he noticed a definite decline in Resident 1's mental status and was uncomfortable leaving her. He stated he asked Family Member 3 to come and stay with her.
Family Member 2 stated he went to the facility early on 1/20/17, because Family Member 3, who had been with her the night before, was very worried about Resident 1's condition. He stated both he and the other family members wanted Resident 1 to be transferred to the acute care hospital early Friday morning (XXXXXXXX17), but the facility staff had refused. He stated two days prior, Resident 1 was able to walk, eat, and could get out of bed to the bathroom with minimal assistance; however, on Friday (1/20/17), Resident 1"could not do anything."
Family Member 2 stated a nurse came into Resident 1's room on 1/20/17 around 0945 hours, and checked the resident's oxygen saturation rate. The nurse then called for help and four staff members came into the room including the Medical Director. The Medical Director asked Resident 1 questions, but the resident did not respond. The Medical Director instructed someone to call an ambulance. Family Member 2 stated he heard a staff member was overheard inform the Medical Director the resident s blood test results. The Medical Director responded by saying "she is septic, we need to call 911." The Medical Director told Family Members 2 and 3 Resident 1 had a WBC count of 27 thousand and her hemoglobin was 4.5.
The family member stated the paramedics arrived and administered oxygen to Resident 1; she became verbally responsive and complained she had "pain all over." Resident 1 was transferred to the acute care hospital ED. The family member stated when they arrived to the ED, Resident 1 was "gasping for air" and her eyes were "rolled back" and a Code Blue (A medical emergency in which a team of medical personnel work to revive an individual in cardiac arrest) was called.
Review of the acute care hospital ED records dated 1/20/17, showed the following:
a. The History of Present Illness dated 1/20/17 at 1116 hours, Resident 1 was admitted to the emergency department with increasing generalized weakness, altered level of consciousness, and a WBC count of 27 thousand (normal range: 3.7-10.5 thousand), and she had abdominal distention. While in the emergency department Resident 1 went into cardiac arrest and a code blue was called. On 1/20/17 at 1140 hours, Resident 1 was placed on a ventilator.
B. Review of the laboratory test results for Resident 1 dated 1/20/17 at 1116 hours, showed the WBC level was 26.7 thousand and the hemoglobin level was 4.4 g/dL (normal range: 11.0-16.0 g/dL).
C. Review of Medical Decision-Making Progress notes for Resident 1 dated 1/20/17, showed at 1119 hours, a Code Blue was called and Resident 1 was intubated (breathing tube placed). At 1202 hours, Resident 1 was pronounced dead.
D. Review of a Physician's note dated 1/20/17 at 1509 hours, showed the following:
Course - Resident 1 was brought to the emergency department by EMS (emergency medical service) after she became weak and obtunded (having diminished arousal and awareness) for the past couple of days. On arrival to the emergency department, Resident 1 was severely obtunded, pale, and had agonal respirations (shallow breathing pattern that is often related to cardiac arrest and death). Resident 1 lost pulse and a Code Blue was called. Resident 1 was intubated and received blood transfusion. The resident had evidence of coffee ground substance present on the NG tube (nasogastric tube, a tube used to suction stomach contents that is inserted through the nose and down the esophagus to the stomach) as well as during the intubation. Resident 1 coded a second time requiring ACLS. The Code was called at 1202 hours due to prolonged resuscitation and a grave prognosis. The patient most likely had a "severe upper GI bleed," leading to severe anemia, hypertension, myocardial infarction (heart attack, changes in the heart muscle that occur due to the sudden deprivation of circulating blood), and ultimate cardiac arrest.
The facility failed to identify significant changes in Resident 1's condition and transfer her to the acute care hospital in a timely manner. Resident 1 had become weak, was no longer able to participate in physical therapy, developed abdominal pain, became incontinent and vomited blood. Failure to identify and address these changes resulted in Resident 1 being transported urgently to an acute care hospital emergency department in an unstable condition. Resident 1 suffered a cardiopulmonary arrest and subsequently died within minutes after arriving at the emergency department.
These failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 070000048 |
PACIFIC HILLS MANOR |
070010981 |
B |
04-Sep-14 |
SRLB11 |
3695 |
F226, 483.13(c) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The Department determined the facility failed to implement the facility's abuse policy when an alleged resident abuse was not reported within 24 hours to the appropriate agencies. Also, certified nurse assistant A (CNA A) worked in direct resident care with an unverified nurse assistant certification. These failures had the potential for unreported abuse incidents.1. Review of form SOC 341 (a form used to report alleged abuse) received by the California Department of Public Health (CDPH) via facsimile on 8/20/14, indicated an alleged abuse incident occurred on 8/18/14. During an interview with Resident 1 on 8/25/14 at 9:30 a.m., she stated that on 8/18/14 she informed certified nurse assistant A (CNA A) while CNA A was providing care that her neck was sore, but CNA A continued to turn her and stated "you are ok". Resident 1 also stated CNA A called her a baby when she started crying because of pain while she was being turned. During an interview with Resident 1's personal caregiver (PC) on 8/25/14 at 2 p.m., she stated on 8/18/14, she was in the room with Resident 1 and confirmed the above incident. The PC immediately reported the incident to the assistant director of nursing (ADON).During an interview with the administrator (ADM) on 8/26/14 at 10:45 a.m., she stated she should have reported the incident within 24 hours. During an interview with the ADON on the same date at 11:40 a.m., she stated she received the complaint from the PC on 8/18/14 and the incident should have been considered an alleged abuse, and should have been reported to the appropriate agencies within 24 hours. Review of the facility's September 2011 policy entitled "Abuse Prevention, Intervention, Investigation and Crime Reporting Policy, Reporting" indicated that regulations require employees (mandated reporters) to report instances of suspected or alleged abuse to the local ombudsman or local law enforcement and to the State Licensing and Certification Agency immediately or as soon as practically possible within 24 hours of detection. It further stated the facility administrator or designee will report immediately or as soon as practically possible within 24 hours of receiving an allegation or forming a suspicion, to the appropriate state agencies. 2. Review of the employee file for certified nurse assistant A (CNA A) indicated her CNA certification expired on 5/5/14. Review of the certification verification detail indicated the certification was not verified until 5/19/14, which was 14 days after the expiration. Review of the CNA employee assignment sheet for 5/5/14 to 5/18/14 indicated that CNA A worked on 5/6 to 5/9, 5/11 to 5/14, 5/17, and 5/18/14 which was a total of 10 days she worked in direct resident care without a verified certification. During an interview with the director of staff development (DSD) on 8/26/14 at 9:20 a.m., the DSD stated CNAs are required to have an active certification to work with residents. She stated she did not have verification documented for CNA A's active certification after 5/5/14. Review of the facility's September 2011 policy entitled "Abuse Prevention, Intervention, Investigation and Crime Reporting Policy, Screening" indicated that nurse assistants will be screened prior to hire and regularly monitored for active, unencumbered licensure and/or certification verification. The violation of this regulation had a direct relationship to the health, safety, or security of the residents. |
| 070000078 |
PACIFIC GROVE CONVALESCENT HOSPITAL |
070012195 |
B |
20-Apr-16 |
SO8W11 |
1855 |
F226, 483.13(c) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to follow their abuse policy when the facility did not notify the California Department of Public Health, in a timely manner of alleged abuse of two residents (Resident 1 and Resident 2).The Department received a faxed report containing two SOC 341 forms, "Report of Suspected Dependent Adult/Elder Abuse" on 4/7/16, which indicated a witness notified the facility on 4/4/16 of alleged abuses which occurred on 4/3/16.During an interview on 4/13/16, at 11 a.m., the director of staff development (DSD) stated she was approached on 4/4/16 by a visitor who reported seeing an alleged abuse the day before. The DSD stated she informed the ombudsman and the administrator (ADM) of the alleged abuse. The DSD stated the ADM had told her not to notify the Department as he wanted to do that himself. The DSD stated the ADM faxed the two SOC 341 forms to the Department, and confirmed the received dated as 4/7/16. A review of the facility's undated "Elder Abuse Prevention and Investigation Policy", section 8, indicated all mandated reporters are required by law to report incidents of known or suspected abuse in two ways: 1) by telephone immediately or as soon as practically possible (within 24 hours), to the local Ombudsman or the local law enforcement agency and to the Department of Public Health. 2) Department of Social Services Form (SOC Form 341), "Report of Suspected Dependent Adult/Elder Abuse" sent to the Ombudsman's Office and to the Department of Public Health within (2) working days. The facility failed to notify the Department of alleged abuses of two residents in a timely manner. |
| 070000049 |
PACIFIC COAST MANOR |
070012253 |
B |
16-May-16 |
1CCP11 |
3430 |
F206 - 483.12(b)(3) POLICY TO PERMIT READMISSION BEYOND BED-HOLD A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services. The facility failed to readmit Resident 1 following a hospital visit during a seven-day bed-hold period, and failed to follow the Department of Health Care Services', Administrative Appeals' order to readmit Resident 1. These failures violated the resident's right to readmission as required by law.Resident 1's clinical record was reviewed. She had diagnoses including angina (chest pain), rheumatoid arthritis (joint pain), generalized arthritis (joint pain), depressive disorder (depression), anxiety disorder, and chronic pain. Her Minimum Data Set (MDS, an assessment tool), dated 4/13/16, indicated she needed extensive assistance for activities of daily living (ADLs).On 4/19/16, Resident 1 was transferred to the acute hospital for evaluation and remained hospitalized. The hospital's medical doctor's (HMD) report, dated 4/19/16, indicated Resident 1 did not have acute findings and was able to be returned to the facility, but the facility called to inform the hospital Resident 1 could not return to the facility. During an interview with the administrator (ADM) on 5/9/16, at 2:05 p.m., she stated she did not discuss a bed-hold with Resident 1 or her family members when the resident was transferred to the hospital for a pain evaluation. The ADM stated she called the hospital a few hours after Resident 1 was transferred on 4/19/16 and stated she informed the hospital not to return the resident to the facility because the facility was unable to take care of the resident. The ADM stated the hearing office of the Department of Health Care Services informed the facility to take back Resident 1 "last week", but the facility decided not to readmit Resident 1 to the facility. During an interview with the hospital case manager (HCM) on 5/11/16, at 1:56 p.m., she stated Resident 1 was stable enough and could return to the facility a few hours after the hospital's evaluation for pain on 4/19/16, but the facility informed the hospital not to send back Resident 1.During an interview with the hospital social worker (HSW) on 5/12/16, at 9:44 a.m., he stated the hospital's staff contacted the facility multiple times regarding Resident 1's readmission, but the facility refused to readmit Resident 1. The HSW stated Resident 1 did not need acute hospital care after 4/19/16. Review of the Department of Health Care Services' Administrative Appeals final Decision and Order, dated 5/4/16, indicated the facility "...must immediately readmit" Resident 1 to "...the first available female bed." The facility failed to readmit Resident 1 following a hospital visit during a seven-day bed-hold period, and failed to follow the Department of Health Care Services' Administrative Appeals' order to readmit Resident 1. These failures violated the resident's right to readmission as required by law.The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 220001046 |
PALO ALTO SUB-ACUTE AND REHABILITATION CENTER |
070013341 |
B |
14-Jul-17 |
T04O11 |
3354 |
F223--483.12(a)(1) FREE FROM ABUSE/INVOLUNTARY SECLUSION
483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms.
483.12(a) The facility must-
(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
The facility failed to protect the residents' rights to be free of abuse of Residents 1 when a staff member used force during care.
The Department received a faxed report from the facility on 6/22/17 which indicated Patient 2 observed certified nursing assistant B (CNA B) had forced Resident 1 to comply with her care, which resulted in some skin discoloration.
During an interview on 6/30/17 at 9:39 a.m., Resident 2, who had a BIMS (mental status measuring tool) score of 15, stated CNA B was not assigned to her room, but had taken it upon himself to help Resident 1. Resident 2 stated CNA B went to help Resident 1 who was leaning. Resident 2 stated CNA B grabbed Resident 1's breasts, she resisted and CNA B threw her on the bed. He then picked her up and threw her into her wheelchair. Resident 2 stated she told CNA B to stop and he responded by telling her to shut up and mind her own business. Resident 2 stated CNA B had both of his hands on Resident 1's breasts and rushed her into the bathroom, and then out the other side (into neighboring room). She stated he brought Resident 1 back approximately an hour later and threw her onto her bed.
During a telephone interview on 7/5/17 at 12:05 p.m., CNA A stated she had not seen anything, but Resident 2 had told her that CNA B had treated Resident 1 roughly. CNA A stated Resident 2 told her that CNA B changed Resident 1 by force.
During an interview on 6/26/17 at 2:25 p.m., the facility's executive director (ED) stated the facility had substantiated an allegation of abuse by CNA B and had terminated him. ED stated Resident 2 had told CNA A that she did not want CNA B in her room, because he was too rough with Resident 1 who resides in the same room.
A review of the facility's "Verification of Incident Investigation/Administrative Summary" signed by ED on 6/25/17, indicated, Resident 2 had told ED that CNA B was changing Resident 1 and became very aggressive with her. Resident 1 resisted the changing, so CNA B took Resident 1 into the bathroom. Resident 2 could hear Resident 1 yelling. CNA B brought Resident 1 back in the room and forcefully put her down on the bed and forcefully held her down. Resident 2 told CNA B to stop, and he replied it was none of her business and not to concern herself.
A review of Resident 1's progress note dated 6/22/17 at 12:43 p.m. indicated Resident 2 informed facility of what she felt was abuse of Resident 1 on 6/19/17, and Resident 1's family member had noticed bruising on her arm.
The facility failed to protect the residents' rights to be free of abuse of Resident 1 when a staff member used force during care.
The failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 220001046 |
PALO ALTO SUB-ACUTE AND REHABILITATION CENTER |
070013342 |
B |
14-Jul-17 |
T04O11 |
4635 |
F225--483.12(a)(3)(4)(c)(1)-(4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS
483.12(a) The facility must-
(3) Not employ or otherwise engage individuals who-
(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;
(ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or
(iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.
(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff.
(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
(2) Have evidence that all alleged violations are thoroughly investigated.
(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
The facility failed to report the allegation of resident abuse in a timely manner when Resident 2 notified a staff member of rough handling of Resident 1 by another staff.
During an interview on 6/30/17 at 9:39 a.m., Resident 2, who is fully cognitive, stated she had witnessed CNA B handling Resident 1 too rough on the evening on 6/18/17, and had reported it on the morning of 6/19/17.
During an interview on 7/5/17 at 12:05 p.m., CNA A stated, she did not see anything so she did not say anything. CNA A stated Resident 2 had told her that CNA B had treated Resident 1 roughly and had changed Resident 1's brief by force. CNA A again stated she did not tell anyone what Resident 2 had told her.
During an interview on 6/26/17 at 2:25 p.m., the executive director (ED) stated Resident 2 notified certified nursing assistant A (CNA A), on the morning of 6/20/17, that CNA B had handled Resident 1 too rough the evening of 6/19/17. ED stated CNA A did not let anyone know. ED stated, on the morning of 6/22/17, Resident 2 notified ED of the rough handling of Resident 1 by CNA B. ED stated CNA A had said that Resident 2 tends to exaggerate and CNA A did not take the allegation seriously. ED stated using the words "too rough" should have escalated to an abuse investigation. ED stated she started the investigation on 6/22/17, and had terminated CNA B on 6/23/17.
The Department received a faxed report from the facility on 6/22/17 which indicated Resident 2 observed CNA B had forced Resident 1 to comply with her care, which resulted in some skin discoloration.
A review of the facility's "Abuse Prevention, Intervention, Investigation, & Crime Reporting Policy" revised 11/2016, indicated, In response to allegations of abuse, ... , are reported immediately; but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; ... ; to the administrator of the facility and to other officials ... in accordance with State law.
The facility failed to report the allegation of resident abuse in a timely manner of Resident 1 when a staff member did not notify appropriate sources after being notified of alleged abuse.
The failure had direct or immediate relationship to the health, safety, or security of patients. |
| 070000078 |
PACIFIC GROVE CONVALESCENT HOSPITAL |
070013421 |
B |
9-Aug-17 |
UZ4Q11 |
3964 |
TITLE 22
72541 UNUSUAL OCCURRENCES
Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal.
The facility failed to submit an unusual occurrence report regarding a 7/23/17 incident involving a resigned certified nursing assistant (CNA A) who came to the facility, threatened staff, and allegedly vandalized a car and a door. This failure had the potential of exposing patients, staff, and visitors to violence from a disgruntled former employee.
During an interview with registered nurse B (RN B) on 7/31/17 at 1:48 p.m., she stated CNA A came into the facility on 7/23/17, threatened nurses, vandalized the director of staff development's (DSD) car, and broke the downstairs door. RN B stated the police were called but CNA A had left the facility. RN B stated the nurses and CNAs were not comfortable and expressed fear that CNA A might return. RN B stated the facility hired a security guard for that night and the next. RN B stated that the following day the facility had an in-service but staff were still uncomfortable and were in constant communication with the police department, who reassured them that they would do rounds of the area.
During an interview with licensed vocational nurse C (LVN C) on 7/31/17, at 2:00 p.m., she stated that on 7/23/17, CNA A came from downstairs, started yelling at staff, and said he would start throwing things around. LVN C stated one staff told him to leave, but he said he didn't have to. LVN C stated they called the police and CNA A walked back towards the back door and left. LVN C stated the police arrived shortly but CNA A was gone. LVN C stated this happened at around change of shift and when the DSD went downstairs, he saw his car was vandalized. The DSD came back up and the police were called again. LVN C stated, "The back door was broken, it looked like it was kicked, maintenance fixed it and the code has been changed".
During an observation on 7/31/17 at 2:10 p.m., the door from the parking lot looked reinforced with two by four inch (2" x 4") wood. A handwritten notice inside the door read: "Make sure door remains closed at all times". In a concurrent interview with LVN C, who was present during this observation, she stated the door used to lock by itself, but after it was kicked and fixed, staff had to physically close it.
During an interview on 7/31/17 at 2:15 p.m. with the administrator (ADM), he stated he did not submit an unusual occurrence report as no patients were involved. The ADM stated the patients were in the dining hall or somewhere else, there was no workflow or disruption of service, and no patients were compromised. The ADM stated it was an assumption that CNA A broke the door or vandalized the car since nobody witnessed CNA A vandalizing the car and kicking the door.
The facility policy and procedure titled, "Unusual Occurrence Reporting" dated October 2010, indicated "as required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors".
This failure had a direct relationship to the health, safety, or security of patients, staff, and visitors. |
| 070000048 |
PACIFIC HILLS MANOR |
070013465 |
B |
30-Aug-17 |
VL6R11 |
6513 |
F323-483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight
The facility failed to ensure adequate assistance to prevent accident and injury for Resident 8. The facility failed to assist the resident during activities of daily living (ADLs, such as bed mobility, transfer, toileting, personal hygiene, and ambulation); failed to provide a mattress on the floor; and failed to implement interventions in response to Resident 8's frequent falls. These failures resulted in Resident 8's left forehead laceration (tear in skin) and acute right subdural hematoma (a collection of blood under the skull and outside the brain as a result of a blow to the head).
Review of Resident 8's clinical record indicated he was admitted on XXXXXXX17 with diagnoses including falls, dementia (memory problem), dysphasia (communication disorder), Alzheimer's disease (progressive mental deterioration), muscle weakness, and lack of coordination. His Minimum Data Set (MDS, an assessment tool) dated 2/25/17, indicated the resident had severely impaired cognition (mental process), and required assistance for bed mobility, transfer, ambulation, toileting, and personal hygiene. Resident 8's Situation, Background, Assessment, Recommendation (SBAR, a technique that can be used to facilitate prompt and appropriate communication) Fall Report of Incident indicated he had falls on 3/14/17, 3/16/17, 3/19/17, 4/6/17, 4/18/17, 4/27/17, 4/29/17, 5/7/17, 5/11/17, 5/12/17, 5/21/17, 5/29/17, 6/6/17, and 8/17/17 (total of 14 falls).
Review of Resident 8's Fall Risk Assessment dated 3/20/17 indicated he had a score of 75. A score of 45 and higher represents a high risk for fall.
Review of Resident 8's Self Care Deficit care plan dated 2/18/17 indicated the resident required assistance with ADLs related to confusion and weakness.
Review of Resident 8's High Risk for Fall Care Plan related to history of falls, weakness, dementia, and lack of safety awareness, dated 2/18/17, indicated the resident used a bed or sensor pad alarm (to indicate if a resident is getting up from a bed).
Review of Resident 8's Actual Fall Care Plan, dated 2/22/17, indicated use of a mattress on the floor and sensor pad alarm in bed.
Review of Resident 8's SBAR Fall Report of Incident, dated 5/13/17, indicated the resident had an unwitnessed fall from his bed when he tried to ambulate with no assistance. Resident 8 was found on the floor next to his bed with no mattress on the floor. The intervention to prevent falls was to place a mattress on the floor.
Review of Resident 8's SBAR Fall Report of Incident 5/21/17 indicated the resident had an unwitnessed fall from his bed when he tried to get up with no assistance. Resident 8 was found on the floor with a laceration to his forehead and was later transferred to the acute hospital. There was no documentation the mattress on the floor was in place. The intervention was to place a sensor pad alarm and mattress on the floor.
During an interview with licensed vocational nurse H (LVN H) on 8/17/17 at 9:40 a.m., LVN H acknowledged Resident 8 had no mattress on the floor when he fell on 5/21/17. LVN H stated the resident was found on the floor next to his bed, hit his head, and there was blood on the floor.
A review of the consulting physician's notes from the acute hospital dated 5/21/17 indicated Resident 8 fell and struck his head on a hard surface resulting in closed head injury with left frontal laceration.
Review of Resident 8's Acute Hospital Chart Print Report dated 5/24/17 indicated the resident had left forehead stitches and a diagnosis of acute right subdural hematoma. Resident 8 was admitted to the intensive care unit (ICU) for close neurological surveillance (observe and monitor the patient's condition).
During an observation on 8/16/17 at 8:25 a.m., Resident 8 was lying on his bed sleeping with the sensor pad alarm, but the cord was not connected to the machine.
During an observation and interview with certified nurse assistant I (CNA I) on 8/17/17 at 9:25 a.m., she confirmed the sensor pad alarm cord was not connected to the machine. She stated the sensor pad alarm would not work if the cord was not connected. CNA I acknowledged the sensor pad alarm should have been connected to the machine to work.
During an observation on 8/16/17 at 8:26 a.m. and 8/18/17 at 8:02 a.m., Resident 8 was sleeping on his bed with the floor mattress folded and placed on the side of the bedside table.
During an observation and interview with the director of staff development (DSD) on 8/18/17 at 8:10 a.m., Resident 8 was sleeping on his bed and there was no mattress on the floor. The DSD stated the resident should have a mattress on the floor to prevent injury, especially because he had previously hit his head on the floor during a fall.
During an interview and record review with the director of nursing (DON) on 8/18/17 at 11:35 a.m., she stated Resident 8 was a high risk for falls and required assistance during his ADLs. She stated the fall care plan intervention should have been implemented to prevent falls. The DON confirmed the mattress on the floor should have been in place to prevent injury.
Review of the facility's 8/2014 policy, "Fall Management", indicated nursing staff and interdisciplinary team (IDT, team members from different department involved in a resident's care) will evaluate the risk factors, provide interventions to minimize the risk, injury, and occurrences; review, revise, evaluate care plan effectiveness to minimize falls, and injuries.
These failures had a direct relationship to the health, safety, or security of residents. |
| 080000012 |
Poway Healthcare Center |
080009727 |
B |
01-Feb-13 |
KKDZ11 |
9902 |
F323 483.25(h)(1)(2) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility failed to transfer Resident 1 with two-person assistance and the use of a mechanical lift (Hoyer). As a result, the resident sustained a left femur (thigh) fracture during the transfer and suffered severe pain. Twelve days after the injury Resident 1 was transferred to the acute care hospital and required surgical repair of the fractured thigh. Resident 1 was initially admitted to the facility on 9/2/11 with diagnoses that included left-sided paralysis due to a stroke and severe osteoarthritis (progressive arthritis with loss of cartilage and fluid around the joint) of both knees, according to the Record of Admission. Resident 1 was interviewed on 7/9/12 at 10 A.M. The resident stated she was showered by Certified Nursing Assistant (CNA) 1 on the morning of 5/30/12. Afterwards, she felt chilled and wanted to get back into bed to warm up. CNA 1 called for staff assistance, however, no one responded. CNA 1 said he could get her back to bed by himself. Resident 1 asked him to wait for help and to get the Hoyer lift (a mechanical device with a sling used for transferring patients in and out of bed or wheelchair). CNA 1 insisted he could put her back to bed by himself. CNA 1 held Resident 1's upper arms, put one of his knees against her "bad" knee (i.e. her paralyzed left knee) and got her up to the edge of the bed. As he turned Resident 1 to move her body and legs onto the bed, she felt something "pop" in her left leg and then felt terrible pain. CNA 1 pulled the resident up to the head of the bed, covered her, and left the room. No one responded when she cried out. The resident said she phoned her son and told him what happened. Resident 1 stated the pain got progressively worse over the next 12 days, to the point where staff could not adjust the head of her bed upwards for her to eat, because the pain was so bad. Resident 1's clinical record was reviewed on 7/10/12. According to the Minimum Data Set (MDS) dated 9/9/11, the facility assessed Resident 1 as alert, oriented, and capable of making her own decisions. In addition, Resident 1 was assessed with poor sitting balance and inablity to walk, which required the assistance of two staff members and the use of a mechanical lift, for transfers from the bed to a chair. Resident 1's care plan, dated 9/2/11, indicated the resident should be transferred with the use of a mechanical lift (Hoyer).CNA 1 was interviewed on 7/9/12 at 12:30 P.M. He stated he showered Resident 1 on 5/30/12, shortly before lunch, and then wheeled her back to her room in a shower chair. CNA 1 said since the resident was shivering, he was anxious to get her back to bed. He called for staff assistance, but no one responded. CNA 1 confirmed that he transferred the resident, without the assistance of another staff member and without the use of the Hoyer lift. He said he was able to get Resident 1 propped up on the edge of the bed, but when he turned her and brought her legs up, Resident 1 screamed and cried. CNA 1 said he immediately got the medication nurse, although he could not recall the nurse's name. He said the regular medication nurse was off that day and a different nurse was on duty. There was no documentation in Resident 1's clinical record on 5/30/12 regarding the incident or the completion of a nursing assessment after the incident. Licensed Nurse (LN) 2 was interviewed on 7/9/12 at 1:10 P.M. LN 2 said she was the treatment nurse on 5/31/12. She said she approached Resident 1 to apply the routine medication patches to the resident's knees. She said Resident 1's left knee was swollen, warm to the touch, and reddened. She reported this observation to the Director of Nursing (DON). LN 2 said she called the nurse practitioner and got a verbal order for a stat (immediate) x-ray. According to the clinical record, the resident's left knee was x-rayed on 5/31/12 at 4:05 P.M., more than 24 hours after the resident sustained the injury. The x-ray was negative for a knee fracture.The DON was interviewed on 7/20/12 at 4 P.M. She said that CNA 1 did not report the injury on 5/30/12, nor did he report the injury on 5/31/12, until she questioned him about it. She said LN 2 discovered the injury to Resident 1's knee on 5/31/12.According to the facility's policies and procedures, revised August 2006 and titled, Accident and Incidents - Investigating and Reporting, "Regardless of how minor an accident or incident may be, including injuries of an unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned...The Nurse Supervisor/Charge Nurse must be immediately informed of accidents or incidents so that medical attention can be provided...The Nurse Supervisor and/or Charge Nurse shall: Examine all accident/incident victims; Notify the Medical Director or the victim's personal or Attending Physician, and inform the physician of the accident or incident..." According to the nurse's notes dated 5/31/12 at 3:32 P.M., LN 2 documented that Resident 1 reported severe left knee pain, 7 out of 10 on a pain scale (zero (0) being no pain and ten (10) being excruciating pain); however, LN 2 documented the resident's pain level as zero on the Medication Administration Record (MAR). The licensed nurses who worked the evening and night shifts on 5/31/12 also documented the resident's pain level as zero. Per the May 2012 MAR, Resident 1 received no medication for pain on 5/31/12.LN 2 was interviewed by phone on 9/17/12 at 2:30 P.M., and asked why she did not offer Resident 1 pain medication on 5/31/12, given that she documented the resident's level of pain as 7 out of 10. LN 2 stated, "She (Resident 1) complained all the time ...the topical (medication applied directly to the skin) patches usually took care of it."The resident's Family Member (FM) was interviewed on 7/2/12 at 10 A.M., and stated he visited Resident 1 on Sunday, 6/3/12. He said Resident 1 did not receive any pain medication between the time she called him on 5/30/12 and his visit on 6/3/12. The FM stated he could not adjust the head of Resident 1's bed upwards without her crying out in pain. When the nurses came in to change her brief, Resident 1 could barely shift onto her right side for a moment. The FM said he asked the medication nurse (LN 1) if she would request an order for Norco (a narcotic pain medication) and if she would put a cold compress on Resident 1's left knee.According to the Nurse's Notes dated 6/3/12 at 1:37 P.M., the resident received Tylenol 325 milligrams (mg) for complaints of left knee pain "with little relief." Despite the resident getting little relief from the Tylenol, the attending physician was not contacted until the resident's son requested the facility to contact the physician for pain medication orders, as documented in the Nurse's Notes dated 6/3/12 at 1:57 P.M. At that time, the resident was prescribed Norco (narcotic pain medication) every 4 hours as needed for pain. The resident was to receive 1 tablet for mild and 2 tablets for moderate to severe pain.According to the Narcotic Drug Record, the resident received 1 tablet of Norco on 6/3/12 at 11 P.M. for pain rated 6/10. The resident continued to receive Norco 2 tablets every 4 to 6 hours between 6/4/12 and 6/8/12. According to documentation on the Medication Administration Record (MAR), the pain was rated as 7/10 to 9/10 (severe pain per the pain scale) prior to the medication and 2/10 to 8/10 (mild to severe pain) after the pain medication was administered.According to the Nurse's Notes, dated 6/4/12 to 6/8/12, the resident continued to complain of pain when her left leg was moved; was assessed with a green-purple discoloration (15 by 15 centimeters) on her left knee; and was assessed with swelling to the left knee. On 6/4/12, testing was ordered to rule out a blood clot in the leg. According to the Nurse's Notes, dated 6/7/12, the resident was seen by a pain specialist. The pain specialist (MD 1) ordered 2 new medications, Celebrex (anti-inflammatory medication) 200 milligrams (mg) once daily and a Flector patch (used to treat pain) to be applied every 12 hours. MD 1 also increased the dose of Neurontin (used for nerve pain) from 100 to 300 mg three times each day.On 6/11/12, twelve days after the incident, Resident 1 was transferred to an acute care hospital for evaluation.The resident's Attending Physician (MD 2) was interviewed by phone on 9/18/12 at 3:30 P.M. MD 2 stated she was in the facility doing her Monday rounds on 6/11/12, when LN 6 asked her to see Resident 1 for the resident's unresolved pain. MD 2 stated the resident's left knee was swollen and warm to touch. She wrote orders to send the resident to the hospital for an evaluation. According to hospital records, reviewed on 7/10/12, Resident 1 arrived at the emergency room (ER) on 6/11/12. An x-ray of her left leg showed a mid-shaft fracture of her left femur (thigh) with soft tissue swelling.Surgical repair of the resident's left femur fracture was completed on 6/12/12. Post-operative complications necessitated a stay in the intensive care unit, a blood transfusion, and hospitalization for a total of 9 days.The facility failed to ensure Resident 1 was transferred appropriately, with two-person assistance and the use of a mechanical lift (Hoyer). As a result, the resident sustained a left femur (thigh) fracture and suffered severe pain. Twelve days after the injury Resident 1 was transferred to the acute care hospital and required surgical repair of the fractured thigh. This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 080000012 |
Poway Healthcare Center |
080010173 |
B |
02-Oct-13 |
GFKW11 |
10219 |
483.25 (c) Treatment/Services to Prevent/Heal Pressure Sores The facility failed to implement preventive heel protector measures for 1 of 3 sampled residents (2). As a result Resident 2 developed a Stage III (open blood blister/s - full skin tissue thickness to the muscle) right heel and left heel Stage III pressure sore/s. In addition, Resident 2 required 30 days additional skilled facility care for treatment of heel pressure sores and home care for additional dressing change treatment that has impaired his quality of life. On 5/8/13 Resident 2's closed clinical record was reviewed. Resident 2 was admitted on 3/15/13 for rehabilitation after surgical repair of a fractured right hip. According to the Resident Admission Record, Resident 2 was responsible for decision making.MD 1's physician admission order's for Resident 2, dated 3/15/13, included Occupational Therapy and Physical Therapy to regain function following hip surgery. Per the OT Progress Note on 3/19/13, Resident 2's bed mobility required maximum assistance and functional transfers (bed to wheelchair) required two caregivers. The facility Minimum Data Set assessment tool, on 3/22/13, Resident 2 scored 15 of 15 points on the Brief Interview for Mental Status meaning no short or long term memory losses.Per Resident 2's full nursing admission assessment, completed by LN 5 on 3/15/13, the right heel was reddened with blanchable skin/tissue. This meant blood circulated more slowly to this area increasing the risk for breakdown. Resident 2's surgical fracture site was on the right side. LN 5's assessment recorded deep tissue injury to the right and left buttocks (bottom). Per the Care Plan History, initiated by the night shift on 3/16/13, LN 8 listed Altered Skin Integrity related to cardiovascular disease (Congestive Heart failure and high blood pressure), "Right heel redness blanchable" in relation to the deep tissue injury to both buttocks and Nutrition/Hydration. Resident 2's heels were to have heel protectors (foam shaped cushions) per LN 8's documented intervention.On 6/4/13 at 10 A.M., Resident 2 was interviewed by telephone. The resident said, "The therapy people didn't believe me when I warned them my heels were bad from lying in bed." Resident 2 explained that "bad" meant "sore". The resident told "a couple of people" his heels were sore at different times, but could not remember who they were.During a follow-up telephone interview on 6/11/13 at 11 A.M., Resident 2 was asked about the heel protectors for pressure relief. The resident said, "No, before my heels broke down, they used nothing. They didn't do anything until there was blood on the sheets. Then they put the pillows under my heels (legs)." Per the OT Progress Notes written on 4/2/13 at 8:50 A.M., Resident 2 was in bed and noted to have an open wound on his right heel. The Certified Occupational Therapy Assistant (COTA) wrote the nursing staff was "alerted immediately." The COTA visited Resident 2 in the morning to get him ready for therapy. This included placing shoes on his feet.On 4/2/13 at 10:15 A.M., LN 3 documented in the Progress Notes, "Noted with blood blister (2) sites to right foot, surrounding area with redness & warm to touch, kept area clean & dry, dressing applied."Per the Observation Report on 4/2/13 at 2:58 P.M., LN 3 indicated Resident 2 had two (2 by 2 cm or size of penny coin) blood blisters on the right foot. LN 3 listed the tissue surrounding the blood blisters as red but did not include a measurement.On 6/6/13 at 4:40 P.M., The acting facility wound nurse was interviewed. LN 3 said, "[On 4/2/13] the COTA was going to put his shoes on and called me in saying I needed to see. There were two small blisters on the outer right heel. The entire foot was red and warm to the touch." LN 3 acknowledged this detailed description was not documented in the medical record. LN 3 said the blisters and area of erythema (redness) were not measured. LN 3 said the DON was immediately informed after the discovery of the blood blisters. LN 3 stated the DON observed the blisters she was instructed to get a Doppler (ultrasound) study, which was negative for deep vein thrombosis (clot blocking blood vessels).During the same interview, LN 3 said the blood blisters on the right heel were broken open with blood on the resident's sock and sheet. LN 3 said she did not observe or assess Resident 2's other heel.On 6/10/13 at 2:50 P.M., the COTA, who worked with Resident 2 on the morning of 4/2/13, was interviewed. The COTA said, "There was blood on the sock from broken blood blisters. It was his right heel that had two small blood blisters. I don't remember any redness to his heel or foot. There wasn't a lot of edema (swelling) in his right foot from [right hip] surgery." The COTA said the resident's shoes were examined and found to be free of any pressure points that could cause blisters. The COTA, who saw Resident 2 on 3/22/13, 3/25/13, 3/26/13, 3/27/13, 3/29/13, 4/1/13 and 4/2/13, said Resident 2's heels were not off loaded or cushioned in any manner from touching the bed. The COTA further said, "When I saw him, his heels were generally on the bed. I came in to find one pillow at the foot of the bed but not enough to keep his heels off the bed.On 6/11/13 at 2:30 P.M., CNA 4, who regularly cared for Resident 2 prior to discovery of the blood blisters, was interviewed. CNA 4 said that his heels were never floated or cushioned before he got "the heel problem (pressure sores)." CNA 4 could not remember heel protectors in use for Resident 2. On 6/20/13 at 7:30 A.M., LN 8 was interviewed. LN 8 created Resident 2's admission Care Plan for heel protectors. LN 8 could not remember ever seeing heel protectors on Resident 2.The WS consultation, dated 4/3/13 at 3:52 P.M., was reviewed. Resident 2's broken right heel blister/s was assessed as an ulcer/pressure sore that measured the size of a half dollar coin, 3.0 cm by 3.2 cm. The right heel pressure sore depth could not be determined due to "90% eschar (dead, leathery, black tissue)." This was the right blood heel blister/s identified by LVN 3 on 4/2/13 as the size of a penny. The WS assessed the lateral (side) of the right heel and foot as cold and red. According to the facility's Wound Treatment Protocols, a wound with eschar was a Stage III or IV (both full tissue thickness). The WS also identified a new left heel ulcer/pressure sore, previously unidentified by the facility. It measured 1.6 cm by 1.4 cm by 0.1 cm deep, the size of a dime coin. The WS staged the pressure sore as a Stage III. Attempts to contact the WS for interview were unsuccessful... Per MD 1's Physician Order Sheet, on 4/3/13 at 4 P.M., Resident 2's order indicated, "R (right) pressure relieving heel protector (Prevalon Boot) at all times." Prevalon was a brand name for a soft boot designed to lift the heel off of the mattress to minimize heel pressure.On 4/5/13 at 2 P.M., MD 1 wrote an order for Prevalon boots in bed and legs elevated with heels suspended when in chair.Per the Physician's Progress Note dated 4/5/13 at 2 P.M., "Bilateral heel pressure ulcers [direct quote was underlined]" MD 1's documentation indicated Resident 2 had bilateral developing heel ulcers that were probably a Stage III without evidence for infection. The physician went on to chart that the venous Doppler was negative [for deep vein thrombosis or clot] and an arterial study showed moderate peripheral vascular disease. The physician's plan included dressing both pressure ulcers/sores, off-loading both heels (pressure relief by floating heels from the mattress). On 6/20/13 at 7:15 A.M., the MRD reviewed Resident 2's medical record and acknowledged there was no documentation of heel protectors in the staff Progress Notes or Treatment Administration Record prior to 4/2/13. The facility provided no written evidence that heel protectors were provided to Resident 2. On 7/30/13 at 10:55 A.M., a telephone interview was held with MD 1. MD 1 said, "If the nurses' identified a need for heel protectors and wrote it in the [resident's] care plan, then they should have implemented them to relieve the heel pressure." Per the medical record, Resident 2 was transferred on 4/12/13, to the local hospital. Resident 2 was discharged from the local hospital on 4/17/13 with diagnoses of asymptomatic (without symptoms) hyponatremia and pressure sores. The resident was admitted to another facility (SNF 2) for continued care under the care of MD 2 on 4/17/13.SNF 2 provided Resident 2's medical record for review on 5/29/13. The resident was admitted on 4/17/13 with diagnosis that included rehabilitation, and pressure ulcer (sore) right and left heel. Resident 2 received treatment to his heels until discharge home, on 5/18/13. Discharge orders included, "Cleanse bilat. heel wnds (wounds) with NSPR (normal saline spray), pat dry. Apply nickel thick layer of Santyl Oint (enzymatic ointment used to dissolve dead tissue), cover with Oil Emulsion gauge (oil impregnated) & secure with Kerlix (brand of fluffy gauge wrap) - change [dressing] every day."On 8/13/13 at 1:45 P.M., Resident 2's attending physician during the SNF 2 admission on 4/17/13 until discharge home on 5/18/13, was interviewed by telephone. MD 2 said, "[Resident 2's] admission to [SNF 2] was mainly to treat both heel pressure sores..." MD 2 explained, "[Resident 2's] discharge home included Home Health [Agency] care to perform heel pressure sore dressing changes."On 9/3/13 at 10:30 A.M., Resident 2's family member stated the home health nurse continued to visit three times per week to change the right heel pressure sore dressing. The family member said Resident 2's quality of life been impaired by the resident's difficulty walking due to the heel pressure sores. The facility P&P, dated October, 2010, and titled Prevention of Pressure Ulcers (sores listed, "Use foam, gel or air cushion as indicated to relieve pressure."The facility failed to provide the heel protectors that were care planned from 3/16/13 resulting in bilateral Stage III heel pressure development diagnosed on 4/3/1. This violation had a direct or immediate relationship to patient health, safety, or security of the patient. |
| 080000050 |
Palomar Vista Healthcare Center |
080011611 |
B |
14-Jul-15 |
J1YP11 |
28570 |
F309Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to: 1. Provide the necessary care, based on the residents' plan of care, and within recognized standards of practice, for 17 total residents which included 5 sampled residents (14, 37, 42, 45, and 51) and 11 nonsampled residents (9, 10, 13, 19, 22, 29, 34, 47, 48, 56, and 64) with a diagnosis of Diabetes Mellitus (a group of metabolic diseases in which there are high blood sugar levels over a prolonged period), and 1 nonsampled resident (Resident 54) on routine glucometer tests (a test using a medical device to determine the approximate concentration of glucose in the blood); and 2. Clarify and implement physician's orders for pain medication, assure pain medication was available from the pharmacy for administration, and accurately document the administration of pain medications for 1 of 21 sampled residents (22). As a result, residents requiring routine glucometer testing were at risk of inaccurate monitoring of their blood sugar levels, uncontrolled blood sugar levels, over and under dosing of insulin, insulin shock (hypoglycemia), and diabetic coma (hyperglycemia). In addition, Resident 22 did not receive her pain medication as ordered, experienced continued severe pain, loss of sleep, and there was the potential for Resident 22 to experience opiate (a drug with morphine like effects, derived from opium) withdrawal symptoms.1. On 5/13/15, at 10:30 A.M., LN 10 was observed conducting a quality control test on the glucometer kept on medication cart #3 (Cart#3 glucometer). The test checks the accuracy of the meter using a manufacturer's provided test strip and solution (Normal & High) and preset parameters listed on the test strip container to assure the glucometer is working properly. LN 10 proceeded to turn the glucometer "ON", placed a test strip into the glucometer, and applied high control solution to the top of the test strip. After several seconds, the glucometer displayed a result of 362 mg/dl (number of milligrams per deciliter). LN 10 said during a concurrent interview the result was outside the parameters printed on the test strip container and indicated there might be something wrong with the glucometer. LN 10 stated she would repeat the test to get a result within the control parameters. LN 10 could not state the facility procedure for glucometer quality control test failure and could not provide a copy of the glucometer operator's manual.An online copy of the glucometer operator's manual (dated; rev 05/2014) was reviewed with LN 10. LN 10 acknowledged the manufacturer's instructions for operation included; putting the glucometer into the control solution mode, placing the control solution at the tip of the test strip, and not using the system if the control result was out of range. LN 10 stated, "I have not seen the instructions; this is how everyone does it", and "Night shift usually does it."LN 10 further stated, "I haven't had any training, they just showed me how to do it." On 5/13/15, at 10:40 A.M., during an observation, interview, and record review, DSD 1 acknowledged that Cart #3 glucometer needed to be in the control solution mode and the solution sample be placed at the tip of the test strip for the quality control test to be both valid and accurate. DSD 1 acknowledged that the glucometer had a memory which kept a record of the last 500 tests conducted, and that the quality control tests would have a special indicator display on the screen to separate them from the tests done on residents. A joint review of the operator's manual confirmed this. DSD 1 acknowledged the night shift LNs were responsible for the daily quality control testing, as per facility policy for Glucometer Calibration, dated 5/2007. DSD 1 stated, "Don't bother looking in the staff files for training records, there are none." DSD 1 acknowledged that there were no records related to staff training on the glucometers, and stated, "They just learn from the other nurses." DSD 1 acknowledged that those results were likely the incorrectly done daily quality control tests resulting in the out of range high results. A joint review of the facility Quality Control Record for Cart #3 glucometer, correlated with the glucometer memory, indicated: On 5/10/15, the Quality Control Record high control result was documented within range as 279 mg/dl. The glucometer memory indicated the actual reading displayed as 439 mg/dl, outside of the acceptable range. On 5/11/15, the Quality Control Record high control result was documented within range as 294 mg/dl. The glucometer memory indicated the actual number displayed as 456 mg/dl, outside of the acceptable range. On 5/12/15, the Quality Control Record high control result was documented within range as 241 mg/dl. The glucometer memory indicated the actual number displayed as 436 mg/dl. Outside the acceptable range. On 5/13/15, the Quality Control Record high control result was documented within range as 301 mg/dl. The glucometer memory indicated the actual number displayed as 439 mg/dl. Outside the acceptable range. DSD 1 acknowledged the documented results did not match what was recorded on the glucometer memory and that any of the actual out of range high results should have led to the removal of the glucometer from service, as it may not have been functioning properly. DSD 1 acknowledged an inaccurate glucometer reading could result in the resident being given an overdose of insulin resulting in insulin shock or denied insulin resulting in diabetic coma. DSD 1 identified the LNs responsible for documenting the quality control test results for Cart #3 glucometer as LN 11 and LN 12. On 5/13/15, at 12 P.M., the Quality Control Record for the Cart #2 glucometer was reviewed with DSD 1 and compared with its internal memory. According to the Quality Control Record, the LNs documented the "high control result" was within range from 5/1/15-5/13/15 and there was no corrective action taken. The internal memory of the glucometer was reviewed with DSD 1. DSD 1 stated there were no quality control tests done on Cart #2 glucometer according to the glucometer's memory. DSD 1 stated the glucometer memory was 500 tests. A joint review of the facility Quality Control Record for the Cart #2 Glucometer, correlated with the glucometer memory, indicated: On 5/10/15, the Quality Control Record high control result was documented within range as 288 mg/dl. The glucometer memory indicated the actual reading displayed as 448 mg/dl. Outside of the acceptable range. On 5/11/15, the Quality Control Record high control result was documented within range as 296 mg/dl. The glucometer memory indicated the actual reading displayed as 406 mg/dl. Outside of the acceptable range. On 5/12/15, the Quality Control Record high control result was documented within range as 287 mg/dl. The glucometer memory indicated the actual reading displayed as 429 mg/dl. Outside of the acceptable range. On 5/13/15, the Quality Control Record high control result was documented within range as 273 mg/dl. The glucometer memory indicated the actual reading displayed as 403 mg/dl. Outside of the acceptable range. DSD 1 confirmed the entries on the Quality Control Record did not match the memory of the glucometer stating, "Those numbers aren't even in the meter." DSD 1 identified the LNs responsible for documenting the quality control test results for Cart #2 glucometer as, LN 11, LN 12 and LN 20. On 5/13/15, at 2:51 P.M., the Quality Control Record for Cart #1's glucometer was reviewed with DSD 1 and compared with its internal memory. DSD 1 was unable to locate the glucometer's daily quality control tests. DSD 1 stated, "I'm not finding any controls. I don't think they were clicking the control button." On 5/13/15, at 3:03 P.M., DSD 1 identified the LNs responsible for performing the quality control test results for Cart #1's glucometer as LN 11 and LN 12. On 5/13/15, at 3:15 P.M., during an interview and record review, LN 11 stated she had been a nurse for, "about 3 years" and at the facility for, "six months."LN 11 stated, "I oriented for about 4 or 5 shifts, I didn't get any diabetic training, and the nurse just showed me how to use the glucometer." LN 11 stated, "I was never told you have to put the glucometer in quality control mode." LN 11 acknowledged she was responsible on the night shift to do the daily quality control testing and that she did it the same way she did the resident testing (omitting putting the glucometer into quality control mode as required by the manufacturer). LN 11 stated, "I did the quality control test (incorrectly) on May 1st, 2nd, 7th, 9th, and 11th for Cart #3; May 1st, 2nd, and 10th for Cart #2, and May 10th for cart #1. I wrote down the wrong numbers so that they would be in range. I should've told the DSD that the glucometer wasn't working, but I didn't."LN 11 acknowledged that she did not document accurate results in the facility Quality Control Record for 3 of 3 glucometers because, "That's what everyone else does." LN 11 further acknowledged that incorrect glucometer results could lead to residents receiving the incorrect dose of insulin, no insulin at all and could result in unstable blood sugar and adverse consequences for the residents. On 5/13/15, at 4:10 P.M., during an interview and record review, LN 12 stated, "I've been a nurse for less than a year, I oriented to the facility over 3 or 4 shifts and I was shown how to use the glucometer by my preceptor. I didn't get any other glucometer training." LN 12 stated, "For the quality control test I turn on the glucometer, insert the test strip and put the control solution on it. If it's too high, I try twice more and if still high, I disregard the test."LN 12 stated his preceptor (LN 11), "told him not to worry about the high (out of range) test result. LN 12 stated, "75% of the time I get high test results out of range. It's very unlikely the test result is accurate; I just document a number on the record that is within range. I was following what my preceptor said, just put in a number that is within range."LN 12 then stated, "When I do the testing on my patients I know the numbers are inaccurate so I just watch them [residents] closely".LN 12 reviewed the facility Quality Control Record for May 2015 and indicated that he had documented the following quality control test results for Cart #3 glucometer: On 5/10/15, the Quality Control Record high control result was documented within range as 279 mg/dl. The glucometer memory indicated the actual reading displayed as 439 mg/dl. Outside of the acceptable range. For Cart #2 glucometer: On 5/09/15, the Quality Control Record high control result was documented within range as 271 mg/dl. The glucometer memory indicated the actual reading displayed as 431 mg/dl. Outside of the acceptable range. On 5/11/15, the Quality Control Record high control result was documented within range as 296 mg/dl. The glucometer memory indicated the actual reading displayed as 406 mg/dl. Outside of the acceptable range. On 5/12/15, the Quality Control Record high control result was documented within range as 287 mg/dl. The glucometer memory indicated the actual reading displayed as 429 mg/dl. Outside of the acceptable range. On 5/13/15, the Quality Control Record high control result was documented within range as 273 mg/dl. The glucometer memory indicated the actual reading displayed as 403 mg/dl. Outside of the acceptable range. LN 12 confirmed he purposely documented inaccurate information in the Quality Control Record. On 5/13/15 at 5 P.M., during a joint interview and record review, LN 20 stated she had been a LN for less than 1 year, received 2 days of training at the facility, and LN 11 trained her to perform glucometer quality control testing. LN 20 was unaware the glucometer must be in quality control mode in order to perform the testing according to the manufacturer's guidelines. LN 20 stated she followed what others were doing and, "just put the right number down" in the Quality Control Record. LN 20 confirmed all of the documented high control results on the May 2015 Quality Control Record were not the actual results she obtained. LN 20 reviewed the facility Quality Control Record for May 2015 and indicated that she had documented the following quality control test results for Cart #3 glucometer: On 5/12/15, the Quality Control Record high control result was documented within range as 241 mg/dl. The glucometer memory indicated the actual number displayed as 436 mg/dl. Outside the acceptable range. On 5/13/15, the Quality Control Record high control result was documented within range as 301 mg/dl. The glucometer memory indicated the actual number displayed as 439 mg/dl. Outside the acceptable range. On 5/13/15, at 5:26 P.M., a joint interview and record review of the facility's policy on Glucometer Calibration (dated; revised 05/2007) was conducted with the Administrator and Director of Nursing (DON). The DON stated he expected the LNs to document accurately. Both the Administrator and DON acknowledged it was facility policy to ensure the glucometers were calibrated correctly and quality control test results were to be recorded accurately. A review of the American Diabetic Association website (http://www.diabetes.org/) indicated, "Keeping your blood glucose levels as close to normal as possible can be a lifesaver. Tight control can prevent or slow the progress of many complications and harmful effects of diabetes such as damage to the eyes, heart, blood vessels, nervous system, teeth and gums, feet and skin, or kidneys. Studies show that keeping blood glucose, blood pressure and low-density lipoprotein cholesterol levels close to normal can help prevent or delay these problems of diabetes, giving you extra years of healthy, active life. Keeping a log of your results is vital." A review of the U.S. Food and Drug Administration website (http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDeviceSafety/ucm109449.htm) pertaining to glucometer operations indicated, " All operators, from patients to non-lab health care workers to medical technologists and physicians, should be thoroughly familiar with any device prior to using it. The best way to do this is to read the package insert and user manual carefully before using a device for the first time. If you have any questions, ask someone who is familiar with the device. Another option is calling the customer service telephone number located on most package inserts. The people on the other end are there to help. Another good tip is to reread the package insert every few months. It is a good practice and there may be changes. " 2. Resident 22 was admitted to the facility on 4/7/15, with diagnoses which included chronic pain and was able to make her own medical decisions, according to the History and Physical, dated 4/9/15. On 5/18/15 at 7:20 A.M., LN 1 was observed during Resident 22's medication pass. LN 1 asked Resident 22, "What is your pain level?" and Resident 22 responded, "9/10". LN 1 prepared Resident 22's scheduled 8 A.M., medications. LN 1 also prepared 30 mg of Oxycodone (an opiate pain medication). LN 1 stated, "She has a prn (as needed) pain medication I can give her." LN 1 stated, "One pill is missing, I need to call the pharmacy." LN 1 stated, Resident 22 should have received Tizanidine 4 mg (a fast acting muscle relaxant) but the medication had not been delivered by the pharmacy. LN 1 administered Resident 22's medication with the exception of the Tizanidine. During an interview on 5/18/15 at 8:10 A.M., the Assistant Director of Nursing) ADON stated the pharmacy requested the order for the Tizanidine be faxed so that they could fill the medication. During a joint interview and review of Resident 22's Medication Administration Record (MAR) on 5/18/15 at 8:45 A.M., the ADON stated the LNs documented they administered Resident 22's Tizanidine on 5/15/15, 5/16/15, and 5/17/15 at 8 A.M. The ADON stated, "The pharmacy said they have no record of the medication being requested." The ADON stated, the facility did not have the medication and it could not have been administered. During a joint interview and review of Resident 22's MAR on 5/18/15 at 9:30 A.M., LN 1 confirmed she documented she administered Resident 22's Tizanidine at 8 A.M. on 5/15/15. LN 1 confirmed she did not actually administer the Tizanidine. LN 1 stated, she intentionally inaccurately documented on the MAR. LN 1 stated, "I didn't have the medication; I thought it would come from pharmacy on my shift, so I charted I gave it." LN 1 stated she did not notify the physician Resident 22 did not receive the medication and did not notify a supervisor the medication was not available to administer. During a joint interview and review of Resident 22's MAR on 5/18/15 at 9:45 A.M., LN 2 confirmed she documented she administered Resident 22's Tizanidine at 8 A.M., on 5/16/15 and 5/17/15. LN 2 confirmed she did not actually administer the medication either day. LN 2 stated, "I documented I gave it, but it wasn't available to give." LN 2 further stated, "When I charted I gave it but I didn't, I falsified the MAR." LN 2 stated, she did not notify the DON or follow up on the status of the Tizanidine when the medication was still unavailable when she returned the next day (5/17/15). LN 2 stated she did not notify the physician Resident 22 had not received her Tizanidine as ordered. On 5/18/15, at 10:10 A.M., during a joint interview and record review the DON stated he spoke with the dispensing pharmacy and the pharmacy had no record of the Tizanidine order and never dispensed the medication to the facility. During an interview on 5/18/15 at 11 A.M., Resident 22 stated, she had an appointment with her pain management physician on 5/14/15. Resident 22 stated she brought her pain management orders back to the facility. The resident stated, the orders were for scheduled pain medication, "So that I don't have to wait and ask for it and a different muscle relaxant (also to be scheduled) because the previous muscle relaxant was not working." Resident 22 stated she had not received a muscle relaxant since she returned from her pain management appointment and she had not received her scheduled pain medication as ordered by her pain management physician. Resident 22 stated, she asked the LN (she did not remember which LN) when she would receive her muscle relaxant and the LN told her she'd, "check on it", but never came back.Resident 22 stated, she experienced constant pain in her lower back and left hip at a level of 7-9 out of 10 (on a scale of 1 being the least and 10 being the worst pain). Resident 22 stated, "I'm having more spasms, that's for sure." Resident 22 reported spasms in her lower back were at a level of 9 out of 10. The resident stated she had trouble sleeping because the spasms woke her at night. Resident 22 stated, "It would help if I got my pain med for the spasms, I haven't gotten it for 3 days." Resident 22 stated, she had been followed by her pain management physician for, "years" and he was familiar with her past medical history and her pain management needs. Resident 22 stated, "The nurses don't believe me [regarding her pain] and they think they know better." On 5/18/15 at 11:15 A.M., Resident 22's clinical record was reviewed: According to the Physician's Progress Notes, dated 5/7/15 at 3:50 P.M., Resident 22's primary physician wrote "... I'm not able to reverse pain management orders and she [Resident 22] needs to go through her pain management physician... Please direct pain management questions to [Resident 22's pain management physician]..." According to the pain management physician's order, dated 5/14/15 at 10:46 A.M., "... Tizanidine 4 mg- 1 tab Q day. Oxycodone 30 mg- 1 tab po every four hours. Oxycodone 15 mg- 1 tab five times per day..." According to the pain management physician's orders dated 5/14/15, Resident 22 was to receive a total of 255 mg of Oxycodone in 24 hours. According to Resident 22's MAR, the resident received a total of: 60 mg of Oxycodone in 24 hours on 5/15/15, 60 mg of Oxycodone in 24 hours on 5/16/15, and 30 mg of Oxycodone in 24 hours on 5/17/15 According to Resident 22's MAR, between the dates of 5/1/15- 5/18/15, the LNs documented Resident 22's daily pain level was 6-9/10 on each date.According to Resident 22's MAR, the LNs documented Resident 22 slept 2 hours on 5/14/15, 3 hours on 5/15/15, 7 hours on 5/16/15, and 6 hours on 5/17/15 for evening and night shifts combined. According to Resident 22's Controlled Drug Record, between the dates of 5/1/15- 5/18/15, the LNs documented 133 tablets of Oxycodone 15 mg tablets were removed from the narcotic count. According to Resident 22's MAR, between the dates of 5/1/15- 5/18/15, the LNs documented 91 tablets of Oxycodone 15 mg were administered to Resident 22. Forty two tablets of Oxycodone were unaccounted for within 18 days. During a joint interview with the ADON and LN 3 on 5/18/15 at 2:15 P.M., the ADON stated, the pain management physician's order should have been clarified with Resident 22's primary physician and faxed to the pharmacy when Resident 22 returned from her appointment at the pain clinic. The ADON stated there was no documentation in the clinical record Resident 22's primary physician had been notified. The ADON stated, LN 2 sent a fax to the primary physician notifying him of the new pain medication orders on 5/15/15 at 2:20 P.M. (over 24 hours after the new pain medication orders were written), but, "there was no follow up." LN 3 stated, he spoke with Resident 22's primary physician at 2 P.M. on 5/18/15 to clarify the orders and implemented them (4 days after the orders were received). LN 3 and the ADON were both unaware of the orders from the pain management physician until 5/18/15. The ADON confirmed, "It should not take 4 days to clarify orders" with the primary physician and implement the orders. LN 3 stated Resident 22 could experience increased pain with the delay in implementing the new pain medication orders. On 5/18/15 at 2:20 P.M., Resident 22's primary physician clarified the pain medications orders, "... Oxycodone 30 mg every 4 hours routine and Oxycodone 15 mg every 4 hours as needed for moderate to severe pain..." (4 days after the orders were written by the pain management physician) During a follow up telephone interview on 5/18/15 at 2:40 P.M., LN 1 stated, she worked the PM shift on 5/17/15 and did not follow up to assure Resident 22's pain medication orders had been implemented. LN 1 further stated, Resident 22 routinely requested pain medication every 4-5 hours. LN 1 stated, Resident 22 often described her pain as lower back aching and complained of cramps and spasms. LN 1 confirmed the Tizanidine ordered by the pain management specialist was to treat Resident 22's back spasms. During an interview on 5/18/15 at 4 P.M., LN 4 stated, Resident 22 complained of back pain every 3-4 hours and requested pain medication. LN 4 stated he was responsible to complete an audit of Resident 22's clinical record which included looking for new orders to assure they had been carried out and implemented on 5/15/15 and 5/16/15. LN 4 stated, he was unaware that Resident 22 went to the pain management clinic and received new orders and was unaware the new orders had not been implemented. On 5/19/15 at 8:20 A.M., Resident 22's MAR and Controlled Drug Record were reviewed with the DON. The DON stated, the MAR and Controlled Drug Record should match and the LNs should have documented on the MAR when they administered the Oxycodone tablets removed from the narcotic count or documented the medication was wasted, per facility policy. During an interview on 5/19/15 at 8:30 A.M., LN 5 stated Resident 22 frequently complained of pain in her legs and he noticed Resident 22 grimacing. LN 5 stated, Resident 22 reported her pain as 7-8 out of 10 and requested Oxycodone every 4 hours. LN 5 stated he received orders from the pain management physician on 5/14/15. LN 5 stated he endorsed to the oncoming nurse that Resident 22's new pain medication orders needed to be clarified and approved by the primary physician. LN 5 stated he was surprised when he returned to work on 5/18/15 the orders had not been implemented. LN 5 stated pain medication orders should have been clarified immediately so that the resident did not experience unnecessary pain. During an interview on 5/19/15 at 9 A.M., Consultant Pharmacist 1 (CP 1) stated she expected the LNs documentation on the MAR to be accurate since the MAR was a crucial part of her medication review. CP 1 stated if the information documented on the MAR was not accurate, she could make a medication recommendation based on false information which could adversely affect the resident.CP 1 stated, when the pain management physician ordered 255 mg of Oxycodone in 24 hours based on Resident 22's history of opiate usage, and the resident only received 30-60 mg of Oxycodone per day, the resident could not only experience increased pain, but could also experience withdrawal symptoms. CP 1 stated, the pain management physician's Oxycodone order was appropriate for the resident and, "There is no maximum dose of opiate." CP 1 stated, she reviewed Resident 22's clinical record on 4/20/15 and made a recommendation to consider ordering scheduled pain medication in lieu of as needed dosage. During a telephone interview on 5/19/15 at 10:10 A.M., the Medical Director stated he expected resident's MARs to be accurate. The Medical Director stated, he reviewed the MAR for frequency of pain medications and inaccuracy of the MAR could adversely affect resident care. The Medical Director stated the LNs should clarify consulting physician's orders for pain medication and implement them the same day. During an interview on 5/19/15 at 11:45 A.M., the DON confirmed the Interdisciplinary Team did not meet to discuss Resident 22's pain management needs. The DON stated, he instructed the LNs to verify orders received by the consulting physician with the primary physician prior to implementing the order. The DON stated the facility did not have a written policy and procedure detailing this practice. The DON stated 72 hours was an acceptable timeframe for the primary physician to verify consulting physician's orders, "Unless it was an emergency." The DON stated he did not consider the pain medication order clarification an emergency. The DON stated he was still looking for documentation related to the 42 unaccounted for Oxycodone tablets. During a follow up interview on 5/19/15 at 1 P.M., the DON stated he misunderstood and wanted to clarify his previous statement. The DON stated four days was not an acceptable time frame to clarify Resident 22's pain medication orders with the primary physician. The DON stated, the LNs should have clarified the orders the same day. According to the facility's policy and Procedure entitled, Medication Administration Documentation and Charting, revised 5/2007, "... Document on the MAR as the medications are administered..." According to the facility's policy and procedure entitled, Pain Management, revised 06/2013, "... consult physician for additional interventions if pain is not relieved by currently ordered treatment modalities..." According to the facility's policy and procedure entitled, Documentation and Charting, revised 05/2007, "... documentation should also include... any time the physician is called about the resident as well as their response..." The facility failed to ensure licensed nurses conducted glucometer testing in accordance with the manufacturer's guidelines. Licensed nurses knowingly documented inaccurate test results on the Quality Control Record and administered insulin to residents based on those inaccurate results. Licensed nurses also failed to ensure that medication to control pain and spasms for a resident was obtained from the pharmacy and administered to the resident as ordered by the resident's physician. Licensed nurses also documented the administration of medication that was not available to be administered and failed to account for the use of controlled medications accurately. The above violations had a direct relationship to the health, safety or security of residents. |
| 080000050 |
Palomar Vista Healthcare Center |
080012896 |
A |
19-Jan-17 |
8TK911 |
9662 |
The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Complaint # CA00501920 The investigation was limited to the specific complaint and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 2841, Pharmaceutical Consultant II, Specialist. Glossary: ADM - Administrator ADON - Assistant Director of Nursing DON - Director of Nursing DSD - Director of Staff Development IV - intravenous: medication administered directly into the vein MAR - Medication Administration Record LN - Licensed Nurse mg - milligram PI - Prescribing Information The facility failed to ensure Resident 1's pain medication was not excessive. The facility failed to question an order for a high dose of morphine sulfate ER (morphine extended release, long-acting medication for pain, also known as MS Contin (r)) with the physician prior to administering three (3) doses of this medication to 1 of 1 sampled resident (Resident 1). According to the American Hospital Formulary Service (r) Drug Information (AHFS DI), a national drug information resource for healthcare providers, "Morphine sulfate [opiate] is a strong analgesic used to relieve severe, acute pain or moderate to severe, chronic pain. Extended-release preparations of morphine are used orally for the management of moderate to severe pain when a continuous, around-the-clock analgesic is needed for an extended period of time." According to the manufacturer's prescribing information for MS Contin (r) (PI), "MS Contin (r) is an opioid agonist indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate." As a result of this medication administration, Resident 1 was transferred to the Emergency Department (ED), and subsequently admitted to the hospital for the treatment of an opiate overdose. Findings: Review of Resident 1's clinical record on 11/9/16, starting at 2:20 P.M., revealed Resident 1 was admitted to the skilled nursing facility on XXXXXXX, upon discharge from the hospital, with diagnoses which included after surgery care, high blood pressure, and chronic pain. The discharge instructions from the hospital included a medication MS Contin (r) 200 mg, give 1 tablet every 12 hours for pain management. The total daily dose was 400 mg. Continued review of Resident 1's clinical record with the ADON and DSD, revealed on 8/26/16, Resident 1's skilled nursing facility physician (Physician 1) prescribed MS Contin 200 mg by mouth every 12 hours for pain management. Physician 1 authorized one dose of Percocet 5/325 mg (a strong opiate pain medication, a combination of oxycodone and acetaminophen), which was administered at 10:59 P.M. on 8/26/16 from the emergency drug supply, because MS Contin (r) was not yet available. Physician 1 also instructed the nurse to administer MS Contin (r) 200 mg when the medication arrived from the pharmacy, and to administer a second dose of this medication 10 hours later. Resident 1 received the first dose of MS Contin (r) at 00:55 A.M. on 8/27/16, a second dose of MS Contin (r) 200 mg at 11:09 A.M. on 8/27/16 and a third dose of MS Contin (r) at 7:30 P.M. on 8/27/16. Resident 1 received a total of 600 mg of MS Contin (r) within approximately 19 hours. According to LN 2's notes from the skilled nursing facility, on 8/28/16 at 8:28 A.M., Resident 1 was assessed and noted to have "anxiety & shortness of breath." At 8:35 A.M., Resident 1 was sent to the Emergency Department [ED] at Hospital A via ambulance for "shortness of breath." According to the PI, "MS Contin (r) 100 mg and 200 mg capsules, a single dose greater than 60 mg, or a total daily dose greater than 120 mg, are only for use in patients in whom tolerance to an opioid [opiate] of comparable potency has been established." Opiate tolerant patients are those who are chronically receiving opiate analgesic on a daily basis. Review of Resident 1's hospital's record revealed, he arrived at Hospital A's ED at 9:34 A.M., with the chief complaint of "shortness of breath, altered mental status." At 10:52 A.M., Resident 1 was administered naloxone intravenously (IV Narcan (naloxone) is an opioid antagonist indicated for the emergency treatment of known or suspected opiate overdose). ED Notes written by LN 3 on 8/28/16 at 11:19 A.M., stated "After giving narcan [sic] 0.4 mg IV pt [patient] ... began speaking, continued with slurred speech and states, '[W]hat did you give me [sic].' Informed him it was narcan [sic] he received... [Patient] states, 'I can open my eyes much easier.' ... sitting up in bed speaking with wife.?." On XXXXXXX, at 2:08 P.M., an IV infusion of naloxone was begun and Resident 1 was admitted to the Intensive Care Unit at 5:12 P.M. According to the Hospital A's Discharge Summary, dated 9/10/16, Resident 1 remained in the hospital from XXXXXXX (14 days total). Resident 1's list of "Active Hospital Problems" included the diagnosis of opiate overdose. An interview was conducted on 11/9/16 at 2:50 P.M. with LN 1 at the skilled nursing facility who administered one dose of MS Contin (r) 200 mg on 8/27/16 at 7:30 P.M. LN 1 stated she had been a LN since 2007, and from her experience, the usual dose for MS Contin (r) was 100 mg. LN 1 acknowledged it was the first time she administered a 200 mg dose. LN 1 said, "I know it's high "and she would normally verify the dosage with the physician. However, in this case, she just "assumed" it had already been verified with the physician by someone else. LN 1 added, when the medication dose was high, she would usually clarify the dosage with the supervisor, and the supervisor would clarify with the physician. LN 1 acknowledged she was not aware if Resident 1 was previously on such high dose, and she did not remember clarifying it with the supervisor. On 11/9/16 at 3:35 PM, Resident 1's clinical record, including the history of pain medication administration from the hospital which was available to LNs and physicians, was reviewed with the DON. When Resident 1 was in the hospital, his pain medications included oxycodone (a strong opiate medication) and morphine for pain. According to the MAR, the maximum amount of pain medication Resident 1 could have received daily was 120 mg morphine equivalent (morphine milligram equivalent, MME). According to the Centers for Disease Control and Prevention (CDC), MME is defined as "the amount of morphine a opioid [opiate] dose is equal to when prescribed, often used as a gauge ... of the amount of opioid that is being given at a particular time." Resident 1's clinical record had no documented history of receiving more than 120 mg of morphine equivalent daily. According to the PI, "Patients receiving other oral morphine formulations [such as immediate-release oral morphine] may be converted to MS Contin (r) by administering one-half of the patient's 24-hour requirement as MS Contin (r) on an every-12-hour schedule or by administering one-third of the patient's daily requirement as MS Contin (r) on an every-8-hour schedule." In addition, "MS Contin (r) ... 200 mg capsule, a single dose greater than 60 mg, or a total daily dose greater than 120 mg, are only for use in patients in whom tolerance to an opioid of comparable potency has been established." The DON acknowledged Resident 1's prior usage history from the hospital did not justify why the LN at the skilled nursing facility administered 400 mg of MS Contin (r) a day. The DON stated LNs had access to Resident 1's clinical record from the hospital, and should have reviewed the medication history, and questioned the appropriateness of the high dose of MS Contin (r). The DON further indicated the LNs should have brought this to Physician 1's attention. On 11/10/16 at 10:30 A.M., Physician 1 was interviewed via telephone. Physician 1 stated when a resident came into the facility with medication orders from another physician; she would continue the same medications. Physician 1 indicated since she would not usually see the resident for another 48 to 72 hours, she would not have access to the whole medical record that came with the resident, so she would continue the same medications unless they [the medication orders] were "questionable." Physician 1 confirmed she did not have access to Resident 1's medical record when she originally prescribed MS Contin (r). Physician 1 verified she came in to the facility on 8/27/16 to see Resident 1; she indicated she had access to his the medical record at that time, and added Resident 1 appeared "comfortable," therefore she did not question the dose of MS Contin (r). Physician 1 acknowledged 400 mg of MS Contin (r) a day was high, stating "Agreed it's kind of too high." According to the facility's policy, Medication Orders, revised 5/07, "Any dose or order that appears inappropriate considering the resident's age, condition, or diagnosis is verified with the attending physician." According to the facility's policy, Medication Administration - Oral, revised 5/07, "If there is any question in regard to the dosage, the person in doubt should not give the drug until she has obtained information which clarifies drug dosage." The facility's failure to follow its existing medication administration policy and procedures resulted in significant medication errors for Resident 1, resulting in an emergent hospital admission. This failure presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 090000011 |
Point Loma Post Acute Center |
090009562 |
B |
17-Oct-12 |
8JII11 |
7440 |
72311 (a) (2) Nursing Services - General(a)-Nursing service shall include, but not limited to, the following: (2)-Implementing of each patient's care plan according to the methods indicated. Each patient's care plan shall be based on this plan.The facility failed to ensure that the plan of care for safe transfers from wheelchair to bed for Patient A was implemented. As a result, Patient A slipped with bended knees on the floor during a one-person transfer and sustained a fractured left knee that required the patient to be transferred to acute hospital emergency room for evaluation. The patient required further surgical intervention with an orthopedist specialist.Patient A was admitted to the facility on 7/25/06 with diagnoses that included paralysis agitans (impaired muscular coordination and tremor) and dementia (loss of intellectual abilities) per the Admission Information sheet. The minimum data set (MDS) assessment dated 10/18/11 indicated that Patient A had impaired cognition. The same MDS revealed that Patient A's "surface-to-surface transfer (transfer between bed and chair or wheelchair) was not steady, only able to stabilize with human assistance." The functional status section of the same MDS indicated that Patient A was totally dependent on transfers and required two plus person's physical assist. The ADLS (activities of daily living) profile sheet for Patient A, which was posted behind the door on Patient A's closet, used by certified nurse assistant (CNA)s, as a plan of care for the patient included direction that Patient A required mechanical lift. The "Fall Risk Assessment" form dated 7/17/11 and 10/15/11 indicated that Patient A scored 10. Patient A scored 10 which indicated, "Score of 10 or above represents HIGH RISK."According to Patient A's "rewritten and accelerated care plan" dated 6/1/11 indicated, "Self-care deficit AEB requiring assist with ADLS...Transfers: Dependent with Maxi lift (mechanical lift)..."On 12/19/11 at 10:30 A.M., a telephone interview was conducted with CNA 1. He stated that on 10/30/11 around 9:00 P.M., he prepared to transfer Patient A from wheelchair to bed. He stated that he positioned Patient A's wheelchair next to the bed and instructed Patient A to place her arms around his neck. He stated that he placed his arms around her waist and grasped the back of her pants and lifted her. CNA 1 stated that as he was transferring her, "Patient A became heavier and heavier" and he noticed that Patient A's knees were touching the floor. He stated that he pushed the wheelchair back and yelled for help. CNA 1 stated that licensed nurse (LN) 1 came and took over his position. CNA 1 stated that LN 1 instructed him to look for another staff to help. During the interview, CNA 1 stated, "It was difficult to ask for assistance because they were also busy." CNA 1 stated that he was aware that Patient A required two persons physical assist on transfers. He also stated that he was aware he had to use maxi lift but he decided to transfer the patient by himself. He stated that he had always transferred Patient A by himself without using the maxi lift. CNA 1 acknowledged that because of inappropriate transfer, the patient's safety was compromised which resulted in the fall and injury.On 1/24/12 at 2:30 P.M., an interview was conducted with CNA 2. He stated that when he entered Patient A's room, he saw Patient A's both knees were on the floor in a kneeling position. CNA 2 stated that CNA 1 should have postponed the transfer until he was able to get help. CNA 2 stated that Patient A was totally dependent on staff for transfers and required two person's physical assistance. CNA 2 acknowledged that CNA 1 did not follow the patient's ADLS profile instruction to use a maxi lift.On 1/24/12 at 3:35 P.M., an interview was conducted with LN 1. LN 1 stated that she was by the nursing station when she heard someone yelling for help. She stated that when she entered Patient A's room, she saw Patient A standing in front of CNA 1 with her knees bent few inches from the floor. CNA 1's hands were under the patient armpits. She stated that she "stood a little on the right side behind Patient A and tried to help pull the patient up but the patient was heavy. She stated she decided to sit the patient down on the floor and CNA 1 straightened the legs while the patient remained on sitting position. According to a late entry in the nursing notes for 10/30/11 at 2100: "Per CNA 1 he was transferring from w/c to bed, when she put all her weight down...He was holding resident six inches from the floor with her knees bent."The next documentation in the nursing notes dated 10/31/11 at 10:55 A.M. indicated, "Noted swelling to (L) knee...per CNA as she was turning resident to render care resident noted to be moaning indicating pain." The same nursing notes indicated that physician ordered medication for pain and x-ray of the left knee.The medication administration record (MAR) dated 10/31/11 at 5:30 P.M., indicated, Patient A was given Tramadol (pain reliever medication) 150 mg (milligrams) for pain on her left knee.A review of the x-ray result dated 10/31/11 indicated, "Results: There are fractures involving left proximal tibia and fibula with displacement. Conclusion: Left knee fractures.Per the acute hospital emergency record dated 10/31/11, "Per the paramedic report, she was found in bed with swelling over the left knee." Patient A was admitted with a consult to orthopedics for surgical intervention.According to the operative report sheet, Patient A underwent "Closed treatment without reduction, bi plateau fracture on 1/1/11. She was placed into a knee immobilizer." The hospital "Emergency Report" (ER) notes dated 10/31/11 indicated, "She was given morphine (medication for severe acute pain) 2 mg IV (intravenous) for pain, Zofran (medication to help treat nausea and vomiting), 4 mg IV for nausea, Tylenol 650 mg rectally for her fever...She was also treated ...with Sozyn (antibiotic) 3.375 g (gram) and vancomycin (antibiotic) 1 g..." The Emergency Department Admission and Discharge notes dated 10/31/11 indicated, "Fx (fracture) (L) knee, Cellulitis (L) tib/fib (tibia (inner and larger of the two bones in the lower leg. /fibula (outer and narrower of the two bones of lower leg.), fever..." The same ER notes indicated, "... It was 38.4 (101.12 degrees Fahrenheit) by bladder temp."The Physical Therapy Evaluation and Plan of Treatment form dated 11/5/11 indicated, "Reason for referral: Patient exhibits exacerbation of reduced functional activity tolerance and pain indicating the need for PT to assess need for environmental adaptations..., increase functional activity tolerance, minimize falls and decrease complaints of pain."The Activity Assessment Comments dated 11/14/11 indicated, "...Requires 1:1 re-direction for participation. Resident receives 1:1 room visit..." The facility failed to implement the patient's care plan according to the methodology identified in the plan. Facility nursing staff transferred the patient inappropriately that compromised patient's safety and security. As a result, the patient knees hit on the floor that caused fracture to her left knee. This required her to be sent to the hospital emergency room for evaluation and surgical intervention by an orthopedic specialist.The violation of the above regulations had a direct or immediate relationship to patient health, safety, or security. |
| 090000140 |
Pryor Street Group Home |
090009796 |
B |
22-Mar-13 |
11CJ11 |
4306 |
The following reflects the findings of the California Department of Public Health during the investigation of an entity reported incident. CLASS B CITATION - DEVELOPMENTAL PROGRAM SERVICES - BEHAVIOR MANAGEMENT PROGRAM Pryor Street Group Home Entity Reported Incident: CA00342723 Representing the Department: xxxxxxx, RN, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. 76869 (c) (4) (A) The procedure to be used is the least restrictive and most effective intervention for the maladaptive behaviors. The facility failed to ensure that one client (1) was protected against abusive treatment when a Behavioral Specialist (BehSp) did not follow the behavioral plan, which was decided upon earlier that day (2/6/13). The BehSp prevented Client 1 from entering her home unless Client 1 used the walker to ambulate. Client 1 sat in urine-soaked clothing, in cold weather, on the steps of the transport van for 45 minutes because she would not or could not use her walker to enter her home. According to the Emergency Information Form, Client 1 is a 53 year old female, who was admitted to the facility on 1/21/02 with diagnoses, which included severe mental retardation, anxiety disorder with several obsessive compulsive features and autistic tendencies. In January 2013 Client 1 was also diagnosed with congestive heart failure (CHF).On 2/14/13 at 5:10 P.M. an interview was conducted with the Residential Supervisor (RS) of Pryor Group Home. The RS stated that there was a staff meeting on 2/6/13 in which Client 1's behavior was discussed. The RS further stated that a plan was developed that, due to Client 1's behavior of refusing to walk coupled with recently diagnosed CHF, Client 1 would be allowed 10 to 15 minutes to decide if she wanted to walk. If, after 15 minutes, she still didn't walk, she would be transported to the house by wheelchair. The RS stated that the BehSp was present at this meeting. A review of the minutes of the staff meeting, dated 2/6/13 revealed "All staff discussed ideas on how to work with (Client 1) and encourage her to use walker" and "The team agreed & decided that we would wait 10-15 minutes before offering her the wheelchair for the rest of the week." A written statement by DCS 2 revealed that on 2/6/13 "we arrived home from transport and unloaded the other consumers... (Client 1) started getting off but when she got to the steps she sat down and refused to walk ... all tried to coax her into the house. Realizing she would only go in the house with the wheelchair (DCS2) suggested getting it for (Client 1). BehSp said 'Don't get it' and 'let her walk' and if it was up to her she could 'sit there all night.'" On 2/14/13 at 5:25 P.M. an interview was conducted with direct care staff (DCS) 1, who stated she witnessed Client 1 as Client 1 leaned on the door of the transport van and looked a little off balance. DCS 1 stated that she told BehSp that Client 1 was wet and at one point, the BehSp asked (DCS 1) to return inside the house. DCS 1 wrote in a statement , "After 20 minutes of leaning backwards against the steps of the van she (Client 1) finally sat down on the middle step... yelling, soak & wet & on & off banging the side of her head on the van by the door."After 45 minutes, according to DCS 1, BehSp still insisted Client 1 use the walker. Per DCS 1, "It was cold outside and (Client 1) needed to be changed and get her meds." On 2/14/13 at 5:45 P.M. an interview was conducted with the licensed nurse (LN). LN stated that Client 1 was seated on the van step with the walker in front of her when LN arrived. Client 1 was urine-soaked and shivering, per LN, and said, "Help". No staff members were with her. The BehSp was in the house, seated at the dining room table and told LN that Client 1 would stay there until she used the walker. The facility failed to ensure that a developmentally disabled client (Client 1) was protected from physical and psychological distress which resulted from the Behavioral Specialist not following the behavioral plan which she helped formulate. The above violation was likely to cause significant humiliation, indignity and anxiety and had a direct relationship to the health, safety and security of Client 1. |
| 090000011 |
Point Loma Post Acute Center |
090010181 |
B |
31-Jan-14 |
N18M11 |
8795 |
F329 - 483.25(l)Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. The facility failed to notify Resident A's attending physician of a possible adverse drug interaction after receiving a written warning from the facility's pharmacy who was filling a new prescription for Resident A. The adverse drug reaction between the current medication of Coumadin (blood thinner) and the new medication Bactrim (antibiotic used to treat urinary tract infection) according to the pharmacy's written warning was, "use of both of these medications in an elderly resident increases the risk of bleeding." The facility staff followed the physician's orders for the administration of Bactrim despite being notified that the drug interaction could cause increased risk of a major or fatal internal bleeding. The resident had been administered antibiotics and Coumadin during previous general acute care hospital (GACH) stays with no ill effects.On 1/26/13, at 8:30 A.M. Resident A was transferred to a general acute care hospital (GACH) after developing a change in condition with the development of black tarry stools (an indication of internal bleeding). The GACH physicians administered fluids, vitamin K (used to help blood to clot), transfused units of blood and plasma to increase Resident A's blood volume.Resident A was an 89 year old female that had been re-admitted to the facility on 1/11/13, with diagnoses that included SIR (systemic inflammatory response), UTI (urinary tract infection), bacterial infection, sinoartial node dysfunction (causes irregular heart rates), cardiac pacemaker (machine that controls heart rate), leukocytosis (elevated number of white cells in the blood). The admitting licensed nurses' note dated 1/11/13 at 22 (10:00 PM) indicated that Resident A was "alert and verbally responsive... Foley cath (tube inserted into bladder to drain urine) in place with urine yellow slight amber... Coumadin tx (treatment)..." The admitting physician order dated 1/11/13 at 1700 (5:00 PM) indicated "Coumadin 4mg (milligrams) PO (by mouth) QHS (at bedtime)-Afib (atrial fibrillation [abnormal heart rhythm]) PT/INR (prothrombin time/ international normalized ratio [blood test for clotting time, done when taking Coumadin]) on Monday 1/14/13." The lab results dated 1/15/13 indicated "prothrombin time-INR 2.3 H (high) normal range for Coumadin: 2.0-3.0, PT 22.6 H normal range: 9.0-11.5." Physician order dated 1/15/13 indicated "cont. Coumadin 4mg po QHS PT/INR in 2-weeks 1/29/13."A physician's order dated 1/14/13 indicated "stat (now) UA (urinalysis) C&S (culture and sensitivity)." The urinalysis lab results dated 1/15/13 indicated "bacteria FEW, WBC (white blood cells)" and handwritten on the lab form indicated, "awaiting C&S (culture and sensitivity) faxed to (medical doctor [MD] 1's name). A physician order dated 1/16/13 indicated, "Bactrim D/S 800/160 1-tab po BID (two times a day) x 10days (for 10 days) UTI 1st dose from E-kit (emergency kit)." On 1/16/13 the facility's pharmacy filled the new prescription for Resident A. The pharmacy spoke to Resident A's charge nurse (LN1) and also sent a Written Drug Interaction Warning via a FAX to the facility.The faxed document dated 1/16/2013 was titled, "Drug Interaction Report for Healthcare Professionals for the following two medications: sufamethoxazole; trimethoprim (includes Bactrim DS)... Warfarin (Coumadin)..." with Resident A's name handwritten on top of the fax and "Attn: (LN 1's name)." This fax indicated, "...Most of the reported cases of an interaction between warfarin and a sulfonamide drug involved the combination of sufamethoxazole and trimethoprim... among older patients receiving long-term warfarin therapy, recent sufamethoxazole; trimethoprim use (i.e. within 14 days) was associated with an increased risk of hospitalization for upper GI bleed... compared to other antibiotics commonly used for the treatment of UTI... Due to the potential severity of excessive anticoagulation, sulfonamides should be administered cautiously to a patient already stabilized on warfarin..." The second page of this fax indicated "Action 1: Call resident's nurse/prescriber & recommend additional INRs TALKED TO (LN 1'S NAME) AND RECOMMENDED TO DO PT/INR EVERY 3 DAYS AND 3 DAYS AFTER BACTRIM AND MONITOR FOR BLEEDING."Licensed nurses administered Resident A's Bactrim and Coumadin medications as ordered by the physician from 1/16/13 through 1/25/13. There was no documented evidence that the physician was notified nor was there any evidence of any increased monitoring of Resident A's blood as recommend by the facility's pharmacy.The LN note dated 1/26/13 at 0800 indicated, "...Noted resident alert & appears confused, refusing care and being combative, sending everybody out of the room. CN (charge nurse) & LN attempted to speak to the resident calmly & explained what were going to do but continue to fight. LN had a hard time taking her VS (vital sign [blood pressure, heart rate, respiratory rate]) because of her being combativeness. VS 80, 24, 107/47 O2 (oxygen) sat 77% with 5 L (liters)/NC (nasal cannula [tube in nostrils to give oxygen]) - CN holding the cannula but continues to be combative..." The LN note dated 1/26/13 at 0810 or 0815 indicated, "noted black tarry stool; no vomiting noted. Foley cath patent + draining clear yellow urine, 0 hematuria noted color very pale & cold to touch." The LN note dated 1/26/13 at 8:20 A.M. indicated "(MD 1's name) was called & reported regarding patient's change of condition +T.O (telephone order) to transfer patient to (name of general acute care hospital [GACH] 1) under (MD 2's name)." The LN note dated 1/26/13 at 830 A.M. indicated "911 was called & reported change of condition." The LN note dated 1/26/13 at 8:43 A.M. indicated "transferred to (GACH 2's name) per paramedics they can't transfer pt. to (GACH 1's name) she has to go to (GACH 2's name) - B/P (blood pressure) is not registering."The physician order dated 1/26/13 at 0830 A.M. indicated, "transfer to (general acute care hospital name [GACH 1]) via 911 secondary decreased O2 sat (amount of oxygen in the body), black tarry stool, combative, very pale." On 8/16/13 at 12:55 P.M. a joint interview and record review was conducted with the skilled nursing facility's director of nursing (DON). The DON acknowledged that the pharmacy's faxed document indicated the adverse interaction between the medications of Bactrim and Coumadin. The DON stated that the interaction should have been forwarded to the physician. Licensed nurses should have documented that the physician was made aware and any new orders given recorded in the nurses' notes. The DON further acknowledged the nurse's initials that took off the order for the Bactrim was LN 1 and that LN 1 was no longer employed with the facility. The DON acknowledged that there was no indication that the drug interaction warning received from the facility's pharmacy was ever forwarded to the ordering physician or that the interactions were documented. On 9/16/13 at 2:34 P.M., an interview was conducted with Resident A's physician (MD) 1 at the skilled nursing facility. MD 1 stated that he did not receive a call from the facility regarding any drug interaction with the Bactrim and Coumadin or he would not have ordered it. MD 1 further stated if he was made aware, "I would have changed the medication." On 9/16/13 at 2:47 P.M., an interview was conducted with LN 1. LN 1 stated she remembered Resident A.LN 1 stated that when she would receive a call from the pharmacy on a drug to drug interaction she would wait until she received the fax or until she read the interaction herself before she would contact the physician. When asked what happens if the fax wasn't received, the phone call was ended by LN 1, and LN1 did not call back and there was no further contact made by LN 1. The facility failed to: 1. Notify Resident A's attending physician of a drug interaction that could cause major or fatal bleeding; 2. Document the interaction that was received by the facility's consulting pharmacy. 3. Relay the recommendation of the pharmacy to the attending physician to increase the monitoring of the blood levels. As a result of the facility's failure to notify the attending physician of the drug interaction, put Resident A at risk for developing excessive bleeding. These violations had a direct or immediate relationship to the health and safety of patients. |
| 090000034 |
Parkside Health and Wellness Center |
090011283 |
B |
27-Feb-15 |
WQOZ11 |
11165 |
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 (RP). The policies shall be accessible to the public upon request. (9)Patients shall have the right to be free from mental and physical abuse. The facility failed to ensure that the facility staff implemented the facility's abuse policy, and that Patient A had the right to be free from abuse. An allegation of abuse incident for Patient A was not reported to the Department within 24 hours, and an unnecessary restraint was used for Patient A for the staff's convenience. The facility staff used a gerichair (a recliner wheelchair) with a lap tray (a tray attached to wheelchair armrests) for Patient A for their convenience, which prevented Patient A from unrestrained movement of his body and extremities. The gerichair and laptray became unnecessary physical restraints. The facility staff failed to follow the facility's policy and procedure regarding abuse and the use of restraints, which resulted in harm to Patient A as evidenced by bruises and behaviors evident of anxiety and distress such as yelling, kicking, struggling to get out of the gerichair, and biting own shirt. Patient A was re-admitted to the facility on 7/24/13, with diagnoses which included generalized anxiety disorder, per the Face Sheet. The Verification of Patient Informed Consent sheet for psychotherapeutic medications (medications which affect behavior and mood), dated 7/24/13, indicated that Patient A did not have the capacity to understand and make decisions. On 2/28/14 at 3:05 P.M., the Director of Nursing (DON) was interviewed. The DON stated that the certified nursing assistant (CNA) 1 placed Patient A in a gerichair with a lap tray, in a rough manner, on 2/22/14, without a physician's order nor an informed consent signed by the RP. The DON stated that this incident was witnessed by CNA 2. The DON further stated that this suspected abuse incident was reported to the Department on 2/25/14. The DON acknowledged that the facility failed to ensure that an allegation of employee to resident physical abuse was reported to the Department in a timely manner. On 2/28/14 at 3:45 P.M., the director of staff development (DSD) was interviewed. DSD stated that CNA 2 did not report the incident to the licensed nurse (LN) 2 immediately when she witnessed it on 2/22/14. LN 2 denied receiving a report from CNA 2. An in-service training record of CNA 2, dated 2/1/13, titled "Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders," indicated "California law requires certain persons to report known or suspected abuse dependent adults or elders. As an employee at a licensed facility, you are one of those persons - a 'mandated reporter.'...Any mandated reporter...shall report the known or suspected instance of abuse. " The DSD acknowledged that CNA 2 did not report the suspected instance of abuse immediately. On 2/28/14 at 3:50 P.M., Patient A's medical record was reviewed. There was no physician's order for the use of a gerichair with a lap tray, no pre-restraint assessment, and no informed consent from the RP for approval to use restraints,found in the record.On 2/28/14 at 4:00 P.M., CNA 2 was interviewed. CNA 2 stated that she witnessed CNA 1 placed Patient A in a gerichair with a lap tray on 2/22/14 at 10:34 P.M. CNA 2 stated that Patient A was calm and cooperative at the time when CNA 1 approached. CNA 2 stated that CNA 1 placed a gerichair behind Patient A without talking to the patient, and applied a lap tray in a rough manner. Patient A tried to get out from the gerichair, yelled, and kicked her legs up and down. CNA 2 stated that CNA1 grabbed Patient A's ankles and pulled them 3 times in a forced manner, and then he applied a lap tray. CNA 1 yelled to Patient A "If you don't cooperate, how we can cooperate with you." CNA 2 stated that CNA 1 was angry and hit the top of the tray with CNA 1's hand. CNA 2 stated that when she walked by the nursing station at 10:46 P.M., on 2/22/14, Patient A was moved from her room to the front of the nursing station, and was still yelling and struggling to get out of the gerichair, and was biting her own shirt with her frustration because Patient A was retrained in the gerichair. CNA 2 stated that Patient A often had a behavior to bite her shirt when she got frustrated or had high anxiety. CNA 2 further stated that she reported an allegation of abuse to LN 2 on 2/22/14.On 2/28/14 at 4:15 P.M., Patient A's RP was interviewed and stated that the facility did not ask her consent before using the restraints. She stated that she noticed multiple bruises on Patient A's legs on 2/24/14 when she visited Patient A.On 2/28/14 at 4:20 P.M., Patient A's medical record was reviewed. The Weekly Nurses's Progress note, dated 2/4/14, 2/11/14, and 2/18/14, indicated that Patient A's skin was intact with no skin issues. The Weekly Nurses's Progress note, dated 2/25/14, indicated that Patient A had bruises on knee/shin. The Departmental Notes, dated 2/20/14, 2/21/14, and 2/22/14, indicated that there was no documentation of Patient A's skin problems. The Departmental Notes, dated 2/24/14 at 11:49 A.M., indicated that "Noted to bruising left knee/lower leg. Redness/light purple bruising observed..." During the same record review, the Interdisciplinary Team (IDT) meeting notes, dated 2/28/14 at 10:59 A.M., indicated "IDT meeting done to discuss an incident of skin bruise that was noted to left knee and left shin last 2/24/14, reddish in color, with varying sizes, skin intact, no evidence of swelling noted... Patient has an incident last Saturday 2/22/14 that she was placed in the gerichair with a lap tray when she was trying to get out of bed multiple times, resident probably might have hit her knees that could cause the bruise by kicking the lap tray when she was trying to get out..." On 7/22/14 at 10:10 A.M., LN 2 was interviewed. LN 2 stated that CNA 1 had placed Patient A in the gerichair because CNA 1 had to make rounds and CNA 1 was not able to watch Patient A. LN 2 stated that she witnessed CNA 1 place Patient A in the gerichair with a lap tray at least 3 times in February 2014. LN 2 also stated that she did not know that there had not been a physician's order to use the gerichair with a lap tray for Patient A. LN 2 further stated "CNAs had been using gerichair with a lap tray for Patient A, so I thought it was OK to use..." LN 2 stated that she did not assess Patient A's skin on her shift, on 2/22/14. LN 2 also stated that CNA 2 did not report to her an allegation of abuse on 2/22/14. On 7/31/14 at 8:25 A.M., CNA 1 was interviewed. CNA 1 stated that he had placed Patient A in a gerichair in February and the end of January 2014. CNA 1 stated that CNA 1 placed Patient A in a gerichair with a lap tray at 10:30 P.M. on 2/22/14 as this had been CNA 1's routine at beginning of his shift. CNA 1 stated that Patient A resisted when CNA 1 put her in the gerichair. Patient 1 screamed, kicked and moved her legs for 30 to 40 minutes and later fell asleep in the gerichair. CNA 1 stated that CNA 1 put Patient A back to bed around 1:00 A.M. CNA 1 stated that Patient A was in the gerichair for more than 2 hours because CNA 1 had to make rounds and was not able to watch Patient A. CNA 1 stated that the facility staff including AM, PM, and Night shift had used a gerichair with a lap tray for Patient A. CNA 1 stated, "the gerichair was given to Patient A to make the staff's job easier." CNA 1 acknowledged that a gerichair with a lap tray was used for Patient A for the staff's convenience.7/31/14 at 9:20 A.M., LN 1 was interviewed. LN 1 stated that CNA 2 reported to her a suspected abuse incident at 2:30 P.M. on 2/23/14. LN 1 stated that she told CNA 2 to report the suspected abuse to the DON and DSD. LN 1 stated that she did not report to the DON, or DSD, or the Administrator at the time when CNA 2 reported to her. LN 1 also stated that she did not assess Patient A or conduct a skin assessment on 2/23/14. LN 1 further stated that she reported the abuse allegation to the DON on 2/24/14. The departmental Notes which documented by LN 1, dated 2/25/14 at 4:24 P.M., indicated "Late entry for 2/23/14 at approximately 2:30 P.M. CNA spoke about last night (Sat [2/22/14]) the NOC [night] CNA assisting this resident into a gerichair with lap tray and he handled her little roughly and that the NOC CNA held her leg down as resident kicked her leg up." A review of the facility's policy and procedures, dated December 2008, titled "Use of Restraints," indicated "Restraints shall only be used for safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls...Prior to placing a resident in restraints, there shall be pre-restraining assessment and review to determine the need for restraints...Restraints shall only be used upon the written order of physician and after obtaining consent from the resident and/or representative..." A review of the facility's policy, dated August 2006, titled "Abuse Prevention Program," indicated "Our residents have the right to be free from abuse, neglect, misappropriation of resident property." The facility's undated policy, titled "California Elder and Dependent Adult Abuse Reporting Policy," indicated: "Physical abuse: any unreasonable physical restraint...alleged, suspected or observed physical abuse...must make report...within 24 hours of observing, obtaining knowledge of suspecting physical abuse [to]...Department of Public Health." On 7/31/14 at 5:30 P.M., DSD was interviewed. DSD acknowledged that the facility staff used a gerichair with a lap tray for Patient A for their convenience and it was an unnecessary use of physical restraints. The DSD also acknowledged that the staff did not follow the facility's policy for the use of restraints and abuse program, which resulted in resident harm including bruises and high anxiety. The facility staff violated the patient's rights. The facility staff applied unnecessary restraints which resulted in increased risk for mental and physical stress. This placed Patient A in a distressed condition more than 2 hours, which contributed to a negative outcome and physical injury. The facility staff failed to follow the facility's policy and process for abuse. A mandated reporter observing, obtaining knowledge of suspecting the physical abuse did not report to the Department within 24 hours. This practice resulted in a prolonged period of unnecessary restraint and distress to Patient 1. Patient A's safety and rights were compromised and violated.A violation of these regulations had a direct or immediate relationship to the health, safety or security of the patient. |
| 010000043 |
Park View Post Acute |
110007292 |
B |
05-Jul-12 |
LZC611 |
7472 |
F157?483.10(b)(11) NOTIFY OF CHANGES (INURY/DECLINE/ROOM, ETC.) 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). The facility must also promptly notify the resident and, if known, the residents' legal representative or interested family member when there is a change in room or roommate assignment as specified in 483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member.F309?483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility violated the regulations by failing to inform Resident 1's physician, per the facility's protocol, when Resident 1 suffered a fractured hip and communicated, non-verbally, she was experiencing acute pain. This failure resulted in a delay of treatment for Resident 1's fractured hip and a decrease in the Resident 1's quality of care leaving Resident 1 "grimacing" in pain when she was moved for two days.Review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on 6/13/06 with diagnosis which included diabetes, hypertension and dementia with behavioral disturbances. The Quarterly MDS (Minimum Data Set) Assessment, dated 4/19/2010, indicated Resident 1 had short and long term memory problems, severely impaired cognitive skills for daily decision making. Resident 1's ability to understand was assessed as responding adequately to simple direct communication. Resident 1 is dependent physically and mentally for care and supervision. Review of the facility's policy and procedure titled, "Change of Condition Reporting" indicated "It is the policy of this facility that all changes in resident condition will be communicated to the physician" The purpose was to clearly define guidelines for timely notification of a change in resident condition. Under the heading of "Acute Medical Change" were listed guidelines which included: 1. Any sudden or serious change in a residents condition manifest by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician. 2. If unable to contact attending physician or alternate physician timely, notify Medical Director for follow-up to change in resident condition. Under the heading of "Routine Medical Change" were listed guidelines which include: 1. All symptoms and unusual signs will be communicated to the physician promptly. 2. The nurse in charge is responsible for notification of physician prior to end of assigned shift when a significant change in resident's condition is noted. 5. If unable to contact attending physician or alternate physician timely, notify Medical Director for follow-up to change in resident condition Licensed nurse's notes, dated 5/31/10 at 3:50 p.m. indicated "the CNA (Certified Nursing Assistant) reported to me that resident is having difficulty in walking. I went to resident and assess(sic) her there is a 5/10 pain noted in her right thigh and resident is noted to have difficulty in her walking on her right side...there is a grimace noted when flexing the right thigh.Licensed nurses notes, dated 5/31/10 at 11:00 p.m. indicated "Not verbally responsive. Placed in bed this shift due to grimacing to(sic) right thigh when knee flexed.Licensed nurses note's, dated 6/1/10 (no specific time given) a.m. indicated, "phone call from (Gerontological Nurse Practitioner named) this a.m. concerning fax he received yesterday. He asked me to assess resident and phone him back. Upon assessing resident she appeared to be in severe pain when moving her right hip, thigh area. Not able to stand...Phone (Gerontological Nurse Practitioner named) back and he gave order for x-ray of right hip and pelvis to be done today. Bed rest until we get results of x-ray". Licensed nurses note's, dated 6/1/10 NOC's, (time not legible) indicated "...complaining of leg pain which increased with movements..." A later entry, dated 6/1/10 at 4:30 a.m. indicated the facility received the x-ray results via fax from the x-ray vendor, "...x-rays show acute right hip fracture". During an interview on 6/4/10 at 12:05 p.m., Licensed Staff A stated a CNA reported to him on 5/31/10 around 11:00 a.m. to 12:00 p.m. that (Resident 1 named) was having difficulty in walking. Licensed Staff A stated he did a ROM (Range of Motion) assessment on her and saw her "grimacing" in pain. Licensed Staff A stated he gave Resident 1 a pain pill around 12:30 and re-checked her at 1:30 p.m., but noted she was still in pain when he flexed her knee. Licensed Staff A stated he informed the family, who was at the bedside, that he would request an x-ray. Licensed Staff A stated he then faxed a request for an x-ray to the Gerontological Nurse Practitioner at the acute care hospital. Licensed Staff A stated he reported to the on-coming shift he had requested an x-ray via fax from the Gerontological Nurse Practitioner and to monitor Resident 1 for pain. During an interview on 6/4/10 at 12:20 p.m., Licensed Staff B stated there is a protocol that the facility nurses follow for the HMO (Health Maintenance Organization) in which Resident 1 is an enrolled member. It outlines any change of condition/lab reporting process after 5:00 p.m., weekends and holidays. Since 5/31/10 was Memorial Day holiday that was the protocol that would have been used. The facility violated the regulations by failing to inform Resident 1's physician, per the facility's protocol, when Resident 1 suffered a fractured hip and communicated, non-verbally, she was experiencing acute pain. This failure resulted in a delay of treatment for Resident 1's fractured hip and a decrease in the Resident 1's quality of care leaving Resident 1 "grimacing" in pain when she was moved for two days. The facility violated the regulations by failing to inform Resident 1's physician, per the facilities protocol, when Resident 1 suffered a fractured hip, and communicated, non-verbally, she was experiencing acute pain. This failure resulted in a delay of treatment for Resident 1's fractured hip, and a decrease in Resident 1's quality of care, leaving Resident 1 "grimacing" in pain when she was moved, for two days. The above violations had a direct or immediate relationship to resident health, safety or security. |
| 010000949 |
Pine Ridge Care Center |
110007586 |
A |
19-Oct-12 |
HWSE11 |
12943 |
F311 ?483.25(a)(2) TREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a)(1) of this section. The facility violated the regulation by failing to assist and maintain Resident 1's ability to use the toilet, and by failing to provide and maintain Resident 1's ability to bathe and perform peri-care. These failures resulted in Resident 1 wearing a urine soaked adult protective brief for staff convenience and contributed to the development of uremic (caused by the waste products found in urine) burns and skin infections with a multi-drug resistant organism (methicillin resistant staphylococcus aureus, MRSA) and enterococcus (a bacteria found in the bowel). Resident 1 had "stinging" pain on Resident 1's buttocks and perineum (the skin from the scrotum to the anus), and required an admission to an acute care hospital for eleven days.Review of the clinical record on 9/8/10 at 1:15 p.m., revealed an acute care history and physical (H&P) examination, dated 8/15/10, which indicated Resident 1 was transferred from the long term care facility to the acute care hospital on 8/15/10, "Arrived with a foul odor and a soiled diaper," with redness on his sacrum (bony structure that is located at the base of the spine) and maceration (softening of tissue by soaking in liquid) in his gluteal fold (between his buttocks)and perineal area (the area between the anus and scrotum), and along his buttocks. The H&P indicated Resident 1's skin was indurated and tender (Induration is the result of infection). Skin that is indurated is red, inflamed, thickened, and tender along his gluteal fold, around his rectum, and extending to his sacrum (the area at the base of the spine). A discharge summary, dated 8/25/10, indicated Resident 1 was admitted to the acute care facility on 8/15/10 with uremic burns and a skin infection on his sacrum with a multi-drug resistant organism (methicillin resistant staphylococcus aureus, MRSA), and bacteria found in the bowel (enterococcus). The discharge summary indicated Resident 1 required oral medications for bacterial skin infection when he was discharged back to the long term care facility on 8/25/10, eleven days after admission to the acute care facility. During an interview on 9/9/10 at 10:15 a.m., Resident 1 stated he did not have bladder or bowel problems. Resident 1 stated he needed assistance to get to the restroom. Resident 1 stated facility staff gave him a urinal and adult protective briefs for his toileting needs. Resident 1 stated facility staff did not check his skin regularly prior to transfer to the acute care hospital on 8/15/10.A record review was conducted on 9/8/10 and 9/9/10 that revealed the following: Resident 1 was admitted from the acute care hospital to the skilled nursing facility on 6/27/10, for nursing care for left femoral neck fracture repair. The admission Minimum Data Set (MDS) assessment tool, dated 7/4/10, indicated the following: Resident 1 had no long term or short term memory problems nor cognitive impairment. Resident 1 suffered a fall with hip fracture and had skin problems including; abrasions, open lesions, rashes, skin tears or cuts, and surgical wounds. Resident 1 was continent of bowel and had an indwelling urinary catheter. The MDS indicated Resident 1 required moderate assistance from staff for bathing and extensive assistance from staff for toileting, personal hygiene, and moving in his room.During an interview and concurrent record review on 9/9/10 at 11 a.m., Licensed Nurse (LN) D stated she assessed Resident 1 when he was initially admitted to the facility on 6/27/10. LN D stated she completed the document titled, "Patient Data Collection," dated 6/27/10, which indicated Resident 1 required assistance for transferring, walking, and bathing. LN D stated Resident 1 required assistance walking to the restroom and transferring to the toilet. LN D stated Resident 1 had a catheter on admission (6/27/10), but that it was discontinued on the 6/28/10 and Resident 1 was provided with a urinal.Continued interview and concurrent record review on 9/8/10 at 12:20 p.m., revealed a, "Bowel & Bladder Training," assessment tool, dated 6/27/10, completed by LN D, which indicated Resident 1 urinated normally without incontinence (involuntary urination), was continent of stool, had some redness on his genital, perineal area or buttocks but no excoriation. The document indicated Resident 1 was alert, oriented and aware of his toileting needs. LN D stated Resident 1 was continent and able to communicate his need to use the restroom, but facility staff provided him with adult protective briefs, "in case he had an accident."Review of Physician's orders, dated 6/27/10, indicated licensed nurses were to perform head to toe skin checks on, "All" areas of Resident 1's body and document the skin checks on a weekly summary.Review of "Nursing Weekly Summary" and "Change of Condition" notes dated 6/27/10 - 8/15/10, revealed that there was no documented evidence indicating licensed nurses provided head to toe skin checks on, "All" areas of Resident 1's body. The notes had no documented evidence of redness on Resident 1's sacrum or maceration in Resident 1's gluteal fold, perineal area, or buttocks.During an interview and concurrent record review on 9/8/10 at 12:20 p.m., The Treatment Nurse (TN) stated she documented, "Additional Skin Assessment Notes," dated 6/27/10, based on direct, "head to toe" observation of Resident 1's skin. Review of the skin assessment notes, dated 6/27/10, revealed no documented evidence of redness or maceration in Resident 1's gluteal fold or perineal area; or of uremic burns or skin infection on Resident 1's sacrum. The TN stated she did not assess or document the condition of Resident 1's skin on his sacrum, gluteal fold, or perineal area on dates 6/27/10 - 8/15/10.Resident 1's nursing care plan, dated 7/27/10, for Activities of Daily Living (ADL) care: ADLs are self-care tasks such as toileting, bathing, grooming, and ambulating. The ADL care plan identified interventions including: encourage independence with assistance/supervision as needed, provide verbal cues, task segmentation and opportunity for resident to complete activity, monitor any improvement or decline in ADL and inform MD and responsible party, keep resident clean and neatly groomed, allow resident time to accomplish task. The goal of the ADL care plan was, "Resident's ability to perform ADL at highest practicable level will be promoted with interventions." During an interview and concurrent record review on 9/8/10 at 4:30 p.m., the Certified Occupational Therapy Assistant (COTA) stated she assessed Resident 1's ability to bathe himself on three dates, 7/9/10, 7/29/10, and 8/11/10. The COTA stated Resident 1 required assistance to clean the lower part of his body. "Occupational Therapy Progress Status" notes, dated 6/28/10 - 8/16/10, included no documented evidence of that Resident 1 received assistance bathing from occupational therapy staff on any other dates.During an interview on 9/8/10 at 4:15 p.m., the Director of Therapy (DOT) stated the COTA assisted Resident 1 with showering as part of an assessment. The DOT stated showering residents was not a duty of the therapy department. During an interview on 9/9/10 at 4:55 p.m., CNA F stated he asked Resident 1 if he wanted to use adult protective briefs because, "just maybe" Resident 1 would have an accident if staff did not assist Resident 1 to the restroom timely. CNA F stated he did not assist Resident 1 to the restroom and he did not assist Resident 1 with bathing on dates 6/27/10 - 8/15/10.Interview and concurrent document review on 9/8/10 at 1:30 p.m., revealed CNA B cared for Resident 1 seven day shifts during 8/1/10 - 8/15/10. CNA B stated Resident 1 wore adult protective briefs and she did not assist Resident 1 to the toilet or provide assistance with peri-care. The "Resident Functional Performance Record," dated 8/1/10 - 8/15/10, contained no documented evidence that CNA B assisted Resident 1 with bathing. CNA B stated she did not see Resident 1's sacrum, buttocks, between his buttocks, or perineal area.Interview and concurrent document review on 9/14/10 at 12:10 p.m., revealed Certified Nursing Assistant (CNA) G cared for Resident 1 four day shifts during 8/1/10 - 8/15/10. A, "Resident Functional Performance Record," dated 8/1/10 - 8/15/10, indicated CNA G documented Resident 1 was continent to bowel and bladder, but required extensive physical assistance to toilet. CNA G stated he did not assist Resident 1 to the toilet to urinate, but gave Resident 1 adult protective briefs. CNA G stated that he did not assist Resident 1 with peri-care.The "Resident Functional Performance Record," dated 8/1/10 - 8/15/10, also revealed CNA G documented Resident 1 required total assistance for bathing on 8/4/10. When queried, CNA G stated he did not remember assisting Resident 1 with bathing on 8/4/10. The "Resident Functional Performance Record," indicated, that over a 15 day period, Resident 1 received assistance bathing from staff on 8/4/10 and 8/11/10.During an interview on 9/10/10 at 11:50 a.m., Resident 1 stated CNAs provided him with adult protective briefs and told him, "it would be better if I wore them." Resident 1 stated he wore an adult protect brief, "Every day and every night" until the brief became wet with urine. Resident 1 stated he complained to facility staff that his gluteal/perineal area was sore, but staff did not provide help cleaning his gluteal/perineal area every day. Resident 1 stated it was hard to withstand the pain when the adult briefs got wet because it was, "stinging" and he felt the stinging pain, "just about every day."During observation of a dressing change procedure on 9/10/10 at 12:10 p.m., Resident 1 was wearing adult protective briefs, 17 days after his return from the acute care facility on 8/25/11. Pink-bright red, irregularly bordered skin damage was observed on Resident 1's perineum (the skin from the scrotum to the anus), groin, scrotum, folds of thigh, and upper thighs. (see photography report page 1). Excoriated skin (an injury to a surface of the skin that can be caused by irritant body fluids such as urine) was observed on Resident 1's scrotum, between his buttocks, and on his buttocks (see photography report pages 2,3,4,5,6,7,8), maceration of tissue (softening of tissue by soaking in liquid) was observed between Resident 1's buttocks (see photography report pages 6,7,8). Bright red, superficial, wounds with irregular shaped borders were observed in the following locations: sacrum, 11 centimeters (cm) x 12 cm (see photography report pages 4, 7, 8), left buttock, 20 cm x 9 cm (see photography report pages 4, 5, 6), right buttock, 18 cm x 9 cm (see photography report pages 4, 5, 6).The Gray et al. Journal Wound Ostomy Continence Nurse. 2011, revealed prolonged and/or repeated exposure to moisture of any kind (i.e. urine) in addition to containment devices (i.e. adult protective briefs) or stool puts skin at a higher risk for damage and may cause inflammation and erosion of the skin. Skin damage can occur in the perineum (the skin from the scrotum to the anus in men), groin, buttocks, scrotum, perianal, and gluteal fold (between the buttocks) areas, depending upon exposure to urine and/or stool and use of containment devices. Skin damage can extend to the inner and posterior thighs. Gray et al. Journal Wound Ostomy Continence Nurse. 2011; 38(3):233-241. Published by Lippincott Williams & Wilkins. During an interview and concurrent record review on 9/9/10 at 5:30 p.m., the Director of Nursing (DON) reviewed Resident 1's entire clinical record and stated facility staff did not provide Resident 1 with: assistance with ambulation to the toilet, "good" peri-care, or two showers per week and additional showers as needed or requested. The DON stated facility staff did NOT perform and document skin checks with each shower, per facility policy and was not able to provide documented evidence indicating staff performance of skin checks for Resident 1. Therefore the facility violated the regulation by failing to assist and maintain Resident 1's ability to use the toilet and by failing to provide and maintain Resident 1's ability to bathe and perform peri-care, which resulted in Resident 1 wearing a urine soaked adult protective brief for staff convenience that contributed to the development of uremic burns and skin infections with MRSA and enterococcus. Resident 1 had "stinging" pain on Resident 1's buttocks and perineum (the skin from the scrotum to the anus), and required admission to an acute care hospital for eleven days.These failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000949 |
Pine Ridge Care Center |
110007663 |
B |
04-Sep-12 |
NIDL11 |
9715 |
?483.25 Provide Care/Services for Highest Well Being Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility violated the regulation when facility staff failed to assess and recognize, when Resident 1 exhibited signs and symptoms of hyperglycemia and failed to follow Resident 1's nursing plan of care. These failures resulted in elevation of Resident 1's blood sugar (BS) to 839 and required admission to an acute care hospital with altered level of consciousness and diabetic ketoacidosis (DKA-diabetic ketoacidosis is a complication of diabetes characterized by hyperglycemia [high blood sugar]) that could lead to cerebral edema, coma, and death. Resident 1 was admitted to the skilled nursing facility on 8/10/10 from the acute care hospital with diagnoses including Type II, diabetes mellitus. The discharge summary from the acute care hospital, dated 8/10/10, indicated Resident 1 "has adequate control of his blood sugars" and was taking 2.5 milligrams (mgs) of Glipizide (an oral medication used to treat diabetes) once per day and Resident 1 will continue to have check blood sugars twice per day. An admission Minimum Data Set (MDS) assessment tool, dated 8/13/10, indicated Resident 1 had clear speech, was able to understand others, make himself understood, heard adequately, did not suffer delirium, disordered thinking, or behavioral symptoms. The MDS indicated Resident 1 independently performed all of his activities of daily living (ADLs), was awake morning, afternoon, and evening, and spent 1/3 - 2/3 of his time involved in activities.Resident 1's nursing plan dated 8/11/10 revealed that Resident 1 was at risk for hyperglycemia secondary to diabetes mellitus. The licensed nurses were to: 1) Monitor Resident 1 for signs and symptoms of high blood sugar, warm flushed skin, extreme weakness, dimmed vision, confusion, increased thirst, vomiting, and fruity odor to breath. Staff was to report signs and symptoms to the physician; 2) Finger stick blood sugars (FSBS) were discontinued on 8/19/10; and Glipizide 2.5 mg was discontinued on 8/14/10. The goal was that Resident 1's blood sugar level will be within medically acceptable range for the resident and Resident 1's risk of hyperglycemia will be reduced with interventions. Physician's orders dated, 8/10/10-8/31/10: 1. Glipizide 2.5 milligrams (mg) by mouth each day, dated 8/10/10. 2. Accucheck twice per day, dated 8/10/10. 3. Regular diet, dated 8/10/10. 4. D/C Glipizide 2.5 mg by mouth each day, dated 8/14/10.5. D/C Accucheck BID, dated 8/19/10 Resident 1's MAR for the month of August 2010 revealed the following finger stick blood sugars (normal blood sugar range 70-100 mg/dl) twice a day: DateFSBS DaysFSBS PMS 8/10/10140 8/11/10 160227 8/12/10 117262 8/13/12 134228 8/14/12 158181 8/15/12 162202 8/16/12 108112 8/17/12 120130 8/18/12 118128 During an interview on 10/18/10 at 9 a.m., the Nursing Supervisor (NS) stated that the facility standard was residents admitted to the facility taking oral medications to treat diabetes had blood sugar checks, per physician order. The NS stated that nursing staff assessed the Resident's blood sugar for one month and if the resident's blood sugar was within normal range, nursing staff requested a physician order to decrease the blood sugar checks to once per day. The NS stated if the Resident's blood sugar was not within normal range nursing staff continued to check the resident's blood sugar twice per day. The NS further stated the facility standard was to check the Resident's blood sugar once per week. Resident 1 had been at the SNF for only 8 days and Resident 1's blood sugar checks were discontinued before he had been there a month and Resident 1's blood sugars were not within normal range. During interview on 10/15/10 at 4 p.m., Resident 1 stated he had diabetes mellitus for 14 years and Resident 1 normally checked his blood sugar and took oral medication before coming to the SNF. Resident 1 stated facility staff did not always check his BS.During an interview and concurrent record review on 10/18/10 at 10 a.m., Licensed Nurse F stated she was caring for Resident 1 on 9/20/10, and facility staff was monitoring Resident 1's level of consciousness (LOC). LN F stated in the morning on 9/20/10, Resident 1 responded to his name, but was drowsy and confused. LN F stated Resident 1's LOC changed by lunch and Resident 1 was more confused. LN F had to call Resident 1's name 2 -3 times to get the resident to respond.During an interview on 10/18/10 at 3:10 p.m., LN F was asked about the signs and symptoms of high blood sugar, LN F stated a change in LOC, confusion and did not remember the rest of the signs and symptoms. LN F did not assess Resident 1 on 9/20/10 and recognize when Resident 1 exhibited signs and symptoms of hyperglycemia. LN F did not refer to Resident 1's nursing plan of care for guidance and report that Resident 1 exhibited signs and symptoms of hyperglycemia to the physician. A signed statement to California Department of Public Health (CDPH), dated 9/29/10, from Resident 1's case worker, indicated the following: "On Monday, September 20, (2010) I arrived at [facility named] at approximately 1:30 p.m. Client was lying on his back with his eyes closed . I called his named and-no response. I put my hand on his arm and rubbed it to get him to respond. He was able to open his eyes 1/4 of an inch, and make some mumbling sounds...Many times I went back and forth between [Resident 1 named] and [Licensed Nurse F named]...She kept repeating the same thing over and over, [Resident named] is responsive...I saw a man that appeared to be dying in front of me...I told her [SW] that I was frightened for his life and she came with me right away...[Social Worker named] saw the shape [Resident named] was in and immediately went to the front desk. Then things started to happen. A different nurse came in to observe him."During an interview on 10/18/10 at 11:20 a.m., the Social Worker (SW) stated that on 9/20/12, Resident 1's case worker came to her office and asked for help. The SW stated she went to Resident 1's room where SW found Resident 1 lying in bed. The SW stated when she called Resident 1's name and touched Resident 1's arm, Resident 1's, "Eyes rolled and was mumbling, talking gibberish."The SW stated she went to get LN G for help. The SW stated LN G and LN F went to Resident 1's room, assessed Resident 1 and then called the physician. During an interview on 10/18/10 at 11 a.m., LN G stated on 9/20/11 the facility Social Worker (SW) came to her office and requested her LN G to assess Resident 1. LN G stated when she assessed Resident 1, she called Resident 1 name and shook him, but Resident 1 did not open his eyes, move, or speak.A physician's telephone order, dated 9/20/10 at 2:30 p.m., revealed an order signed by LN F to transfer Resident 1 to the acute care facility for further treatment and evaluation. An acute care emergency department admission note, dated 9/20/10, indicated paramedics transported Resident 1 to the acute care facility from the skilled nursing facility due to a four day history of altered mental status that, "significantly" changed on 9/20/10. The note indicated staff at the SNF discontinued administering medications Glipizide and diabetic medications to treat Resident 1's diabetes and stopped checking his blood sugar. Resident 1's blood sugar was 839 on admission to the acute care facility. An acute care laboratory report, dated 9/20/10, confirmed Resident 1's blood sugar was 839 and indicated a normal blood sugar range was 70-100). Resident 1 moved arms and legs in response to painful stimulus, his speech was garbled, and Resident 1 could not follow commands. Resident 1 was started on an insulin infusion at 5 units per hour. Blood glucose levels started to decrease from 800's to 400s Resident 1 was admitted to the intensive care observation and treatment. An acute care History and Physical dated 9/20/10, indicated Resident 1 suffered: 1. "Diabetic ketoacidiosis, likely secondary to lack of medication" 2. Altered level of consciousness, likely to diabetic ketoacidosis. During an interview on 10/19/10 at 4 p.m., Resident 1's physician was asked about the blood sugar of 839, Resident 1's physician responded, "he should have been taken care of at the facility." Resident 1's physician stated he expected that a known diabetic had blood sugar checks twice per day.Lippincott, a professional resource for nurses, cited nursing standards of care guidelines when caring for patients with diabetes mellitus which included:Assess for trends in blood glucose and other laboratory tests, and "Get help immediately for patients presenting with signs including nausea, vomiting, and altered level of consciousness, muscle weakness, seizures, stupor, coma" Lippincott, 2010. Therefore, the facility violated the regulation when facility staff failed to assess and recognize, when Resident 1 exhibited signs and symptoms of hyperglycemia and failed to follow Resident 1's nursing plan of care. These failures resulted in elevation of Resident 1's blood sugar (BS) to 839 and required admission to an acute care hospital with altered level of consciousness and diabetic ketoacidosis (DKA- diabetic ketoacidosisis is a complication of diabetes characterized by hyperglycemia [high blood sugar]) that could lead to cerebral edema, coma, and death. The violation of this regulation/these regulations had a direct relationship to the health, safety, or security of patients. |
| 010000052 |
Petaluma Post-Acute Rehabilitation |
110008387 |
B |
03-Jan-14 |
IPNM11 |
8769 |
Health & Safety Code 1418.91a - 1.01 Health & Safety Code 1418 - 1418.4(d) (d) Family councils shall also be provided adequate space on a prominent bulletin board or other posting area for the display of meeting notices, minutes, newsletters, or other information pertaining to the operation or interest of the family council.Health & Safety Code 1418 - 1418.4(f) (f) The facility shall provide a designated staff person who shall be responsible for providing assistance and responding to written requests that result from family council meetings.Health & Safety Code 1418 - 1418.4(h) (h) The facility shall respond in writing to written requests or concerns of the family council, within 10 working days.Health & Safety Code 1418 - 1418.4(i) (i) When a family council exists, the facility shall include notice of the family council meetings in at least a quarterly mailing, and shall inform family members or representatives of new residents who are identified on the admissions agreement, during the admissions process, or in the resident's records, of the existence of the family council. The notice shall include the time, place, and date of meetings, and the person to contact regarding involvement in the family council.Health & Safety Code 1418 - 1418.4(j) (j) No facility shall willfully interfere with the formation, maintenance, or promotion of a family council. For the purposes of this subdivision, willful interference shall include, but not be limited to, discrimination or retaliation in any way against an individual as a result of his or her participation in a family council, or the willful scheduling of facility events in conflict with a previously scheduled family council meeting.Health & Safety Code 1418 - 1418.4(k)(1) (k) (1) Violation of the provisions of this section shall constitute a violation of the residents' rights.Health & Safety Code 1418 - 1418.4(k)(2) (k) (2) Violation of the provisions of this section shall constitute a class "B" violation, as defined in Section 1424.The facility violated the regulation by failing to support the promotion and function of the Family Council when:1. The facility did not provide a prominent posting space to display meeting notices or other information pertaining to the Family Council; 2. The facility did not provide a designated staff person, who was responsible for providing assistance to the Family Council and who was responsible to provide a written response to Family Council concerns within 10 working days; and 3. The facility did not include notice of the family meetings in at least a quarterly mailing. These failures had the potential to prevent family and friends of residents' families from joining the Family Council and interfered with the formation, maintenance and promotion of the Family Council. The Founder of the Family Council and two Family Council Coordinators (Family Members A, B, and C) submitted a signed document, dated 1/17/11. This document indicated on-going concerns about posting of Family Council meetings, mailings of meetings, and lack of a facility liaison to assist the council. A second signed document, dated 11/23/11, was submitted by Family Members A, B, and C. This complainant letter indicated continued concerns from the first letter including the lack of mailing notifications of Family Council meetings, which "has prevented the family and friends of new residents/patients from joining the Family Council by attending these meetings." Additionally, the withholding of the mailings "continues to impede the progress and promotion of the Family Council." 1. The signed complainant letter, dated 1/17/11, indicated that Council members wanted the return of a prominently placed bulletin board, utilized by the Family Council, which existed in the lobby/entryway prior to renovation in 2008/2009. The board was removed and in late 2009, it had not been replaced. Family Members A, B, and C, stated that during this time frame, information regarding the Family Council meetings and other information was not posted. A smaller, less prominent bulletin board was placed in mid-2010, with "only a small taped designation, "Family Council", posted in the lower right corner.The complainant letter revealed that the notice of upcoming Family Council meetings, dated September 2010, was removed from the board, by the facility, in December 2010. The notice of the Family Council meeting to be held on January 8, 2011 was not posted in a timely manner. It was not posted, even though requested by members of the Family Council, until two days before the meeting. Following multiple observations of postings in the facility, on 1/27/11 at 10:30 a.m., posted Family Council information was not readily or easily discernible. A notice regarding the next Family Council meeting was finally located on a bulletin board on a sidewall of the facility. The second complainant letter, dated 11/23/11, indicated that on 10/31/11, Family Members A and B presented a copy of the announcement for the November 12, 2011 Family Council meeting to the administrator for posting on the bulletin board. The announcement posted on the bulletin board, on 11/12/11, was dated September 20, 2011 and invited family, friends, and guests to the October 8, 2011. As of 11/22/11, the invitation to the October 2011 Family Council meeting was the only notice of Family Council meetings posted on the bulletin board. 2. The letter received from the Family Council, dated 1/17/11, indicated that the person identified to them as being responsible for assisting the Family Council, addressing requests and questions did not fulfill these responsibilities.The letter, dated 1/17/11, indicated members of the Family Council met with the administrator on 7/28/10, to request mailing of the August 2010 meeting and on 1/3/11, to discuss posting of the January 2011 Family Council meeting. During interview on 10/25/11 at 4:25 p.m., Family Member A stated that the facility never provided any written responses to the concerns of the Family Council. During interview, on 3/4/11 at 1 p.m., the administrator stated that there was a designated person to act as liaison for the Family Council, but the liaison did not go to Family Council meetings as they were held outside the facility. The administrator stated he was not sure how requests or questions from the Council were addressed. He had no written evidence of communication with Family Council members regarding their expressed concerns. 3. On 7/28/10, the Family Council requested a mailing of notification of its 8/14/10 meeting. It was accepted but was not received by family members until either the day of the meeting or the week after the meeting. In mid-November 2010, the Council requested a quarterly mailing to include the meeting of 12/11/10. "No mailing occurred." The Administrator was informed of these findings on 3/4/11. During interview, on 3/4/11 at 1 p.m., the Administrator recalled that, in the past (dates unknown) a quarterly notification of Family Council meetings was given to the facility and had not been mailed in a timely manner through oversight.Review of the signed declaration, dated 11/23/11, revealed Family Member B presented an announcement of the fourth quarter meetings (October 2011, November 2011, and December 2011) to the Administrator, on 9/20/11, for mailing, by the facility, to the responsible parties of the residents of the facility. Family Member B "was assured" by the Administrator that the "mailing would go out soon." On 9/30/11, the Administrative Assistant told Family Member B that the quarterly mailing would probably arrive in homes over the next couple of days. At the Family Council meeting, on 10/8/11 and as of 11/23/11, none of the members of the Family Council had received a quarterly mailing to inform them of either the October 8, 2011 meeting or the November 12, 2011 meeting. The facility violated the regulations by failing to support the promotion and function of the Family Council when:1. The facility did not provide a prominent posting space to display meeting notices or other information pertaining to the Family Council; 2. The facility did not provide a designated staff person, who was responsible for providing assistance and for providing assistance and response to the Family Council written concerns within 10 working days; and 3. The facility did not include notice of the family meetings in at least a quarterly mailing. These failures had the potential to prevent family and friends of residents' families from joining the Family Council and interfered with the formation, maintenance and promotion of the Family Council. The violation of this regulation/these regulations had a direct relationship to the health, safety, or security of patients. |
| 010000043 |
Park View Post Acute |
110009098 |
B |
14-Mar-12 |
VLCF11 |
8063 |
72311 (a)(3)(B) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. The facility failed to follow physician orders to notify a physician when Resident 1's oxygen saturation level fell below 90%, which resulted in a delay of treatment for the cause of a low oxygen level, and contributed to Resident 1's death. Resident 1 was 93 years old when admitted to the facility for rehabilitation following a fall in which Resident 1 sustained a fracture of his cervical vertebrae, (neck). A review of the clinical record for Resident 1 was done on 1/4/11 at 1:20 p.m. Emergency Department Progress Notes, from an acute care hospital, dated 12/9/10, indicated Resident had sustained a cervical fracture from a fall. A neurosurgical consult indicated the fracture was stable and would not be improved with surgery. The Record of Admission, to the long term care facility, indicated Resident 1 had been admitted for rehabilitation following a fall. Physician Orders, dated 12/9/10, noted Resident 1 did not have the capacity to make health care decisions. During an interview, on 1/8/11 at 1:40 p.m., Physical Therapist B, (PT B), stated at approximately 2 p.m., on 12/18/10, he found Resident 1 in a reclining chair in his room. PT B stated Resident 1 was slumped to the side with a cervical collar over his mouth. PT B adjusted the collar and found Resident 1 to be lethargic. PT B stated Resident 1 would rouse to noxious stimuli but fall back to sleep. PT B noted that Resident 1's hands were blue. PT B stated he got a pulse oximeter, (a device used to measure oxygen saturation), and measured Resident 1's oxygen saturation in the "80's". PT B stated he returned Resident 1 to his bed and reported his finding to Licensed Nurse A. During an interview, on 1/6/11 at 2 p.m., Licensed Nurse A stated, during afternoon report, approximately 2:30 p.m., on 12/18/10, Physical Therapist B, (PT B), had notified him that Resident 1 had been sleepy during Physical Therapy so PT B had checked Resident 1's vital signs, (heart rate, blood pressure, respirations and oxygen saturation). PT B reported that Resident 1's vital signs were within normal limits except for his oxygen saturation which was 88-89%. Oxygen saturation describes the amount of oxygen carried by red blood cells. An oxygen saturation under 90% is considered too low to provide adequate oxygen to all parts of the body, including the brain. Licensed Nurse A stated he immediately administered oxygen to Resident 1 and Resident 1's oxygen saturation rose above 90%. Licensed Nurse A stated Resident 1 looked stable so the physician was not notified. A review, of Nurse's Notes, dated 12/18/10, indicated that at approximately 3:30 p.m., Resident 1's oxygen saturation had dropped to 83% on room air. Oxygen was begun and Resident 1's saturation level rose to 92%. During an interview, on 1/4/11 at 4:30 p.m., Licensed Nurse D stated she didn't think she had notified the physician when Resident 1's oxygen saturation had dropped below 90% on 12/18/10.Physician Orders, dated 12/9/10, for Resident 1, included the following order: "O 2 (oxygen) @ 2 l(iters)/min(ute) via nasal cannula, (thin tubing that delivered oxygen to the lungs through the nose), prn (as needed) SOB, (shortness of breath), chest pain, O 2 sat(uration)<90% and notify physician."
Review, of Nurse's Notes for 12/18/10, indicated that Resident 1 remained sitting upright, with his head at a 90 degree angle, after drinking a milk shake, with assistance. The notes indicated that at approximately 5:30 p.m., Resident 1's family found him unresponsive. The Nurse's Notes stated Resident 1's oxygen saturation was 83% on 2 liters of oxygen and he was unresponsive. Licensed Nurse D called 911 and Resident 1 was transported to an acute care hospital.
Continuing Care Telephone notes, dated 12/18/10 at 5:57 p.m., documented the facility call to the physician, after 911 had been called. Resident 1's vital signs were noted as: blood pressure 158/72, heart rate 116, respiratory rate 25, and oxygen saturation 83% while receiving 2 liters of oxygen.
Review of acute care emergency department notes, dated 12/18/10, indicated Resident 1 was admitted to the emergency department with acute shortness of breath, and altered mental status.
Review of an emergency department physical exam, dated 12/18/10 at 6:26 p.m., indicated Resident 1 used accessory muscles to aid breathing, and was not responsive to verbal or painful stimuli. Resident 1 had mottled skin and was cool to the touch. Rhonchi, (heard upon auscultation of the chest, caused by an accumulation of mucous or other material), were heard throughout Resident 1's chest. Vital signs were documented: blood pressure 99/61, heart rate 101, respiratory rate 27, oxygen saturation 90%.
Review of the results of a chest X-ray, done at 6:26 p.m. on 12/18/10, indicated,"Since 12/9/10, there is a new area of patchy opacity in the right lower lung which may represent an infiltrative process such as pneumonia".
Arterial Blood Gases were drawn at 6:59 p.m. Blood gases measure how much oxygen and carbon dioxide are in the blood and are an indication of respiratory status. (www.nlm.nih.gov/medlineplus).
Resident 1's blood gases, while receiving 100% oxygen, were as follows:
PH 7.31, (normal 7.35-7.45), PCO2 38, (normal 35-45(mmHg), measures carbon dioxide. PO2 58, (normal 80-95 (mmHg), amount of oxygen.
HCO3 18.6 (normal 23.0-28.0 (mmol/L), measures sodium bicarbonate,
Base Excess -6.7 (normal -2.4-2.3 (mmol/L), SPO2 91.5% saturation, (normal 95.0-99.0 %). The physician's interpretation of the blood gases indicated Resident 1 had metabolic acidosis and carbon dioxide retention due to his difficulty breathing.
Additional blood work was obtained at 7:08 p.m., Resident 1 had an elevated white blood count of 24.8, (normal 3.5-12.5 k/ul), indicative of an infection, and an elevated lactic acid of 7.0 (normal 0.7-1.9 mmol/L). Tissue hypoxia (lack of oxygen) is the most common cause of lactic acidosis, (emedicine.medscape.com/article. Emergent Management of Lactic Acidosis, 6/24/11).
Review, of Physician Notes, ED Course, dated 12/19/10 at 12:47 a.m., indicated that Resident 1's diagnosis was sepsis secondary to aspiration pneumonia, (lung infection caused by breathing foreign matter, food or saliva, into the lungs).
Sepsis is a potentially life-threatening complication of an infection, most dangerous in the elderly. To be diagnosed with sepsis, at least two of the following symptoms must be present: fever above 101.3 F or below 95.0 F, heart rate over 90 beats per minute, respiratory rate over 20 breaths per minute, and probable or confirmed infection. Resident 1 exhibited 3 of the symptoms of sepsis. Resident 1 presented with additional symptoms: areas of mottled skin, abrupt change in mental status, and difficulty breathing, all signs of progression from sepsis to severe sepsis, (mayoclinic.com/health/sepsis, 7/22/11)
Mayoclinic.com/health/sepsis, additionally noted that the mortality rate for severe sepsis was close to 50% and that "early, aggressive treatment" increased chances of survival.
Continuation of physician notes, ED Course, dated 12/19/10 at 12:47 a.m., indicated the physician and Resident 1's family discussed Resident 1's wishes prior to becoming so sick and agreed that aggressive care, (central line, pressors and intubation), was not what Resident would have wished. Resident 1 was transferred to Comfort Care, and died at 9:57 a.m., on 12/19/10.
The facility failed to follow physician orders to notify a physician when Resident 1's oxygen saturation level fell below 90%, which resulted in a delay of treatment for the cause of a low oxygen level, and contributed to Resident 1's death.
This violation had a direct or immediate relationship to the health, safety, or security of the resident. |
| 010000949 |
Pine Ridge Care Center |
110009357 |
B |
20-Nov-12 |
UP8T11 |
2376 |
1418.21 Health & Safety Code (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (A) An area accessible and visible to members of the public. 1418.21 Health & Safety Code (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (B) An area used for employee breaks. 1418.21 Health & Safety Code (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities.1418.21 Health & Safety Code (b) Violation of this section shall constitute a class B violation, as defined in subdivision (e) of Section 1424 and, notwithstanding Section 1290, shall not constitute a crime. Fines from a violation of this section shall be deposited into the State Health Facilities Citation Penalties Account, created pursuant to Section 1417.2.The facility violated the regulation by failing to post their overall Star Rating in three locations throughout the facility where it would have been visible to residents and members of the public as required that resulted in a B Citation. FindingsDuring an observation on 4/16/12 at 9:30 a.m., the posting of the facility's overall Star Rating were absent from any location in facility. There were no Star Rating posted in the lobby area, communal areas such as a dining, or activity room and in the employee break room.During an interview on 4/16/12 at 10:30 Management Staff A acknowledged awareness of regulation requirements for the above posting. |
| 010000043 |
Park View Post Acute |
110009582 |
B |
04-Dec-12 |
9ETU11 |
1444 |
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 resident abuse (Resident 15 to Resident 11) to the State survey and certification agency, with the potential for continuing abuse. Resident 11 was identified by facility documentation, received 10/22/12, as alert and oriented. During interview, on 10/22/12 at 12:10 p.m., the resident stated that another resident (Resident 15) "kicked me very hard, a week ago Friday." Resident 11's clinical records were reviewed on 10/23/12 at 9:20 a.m. Nurses notes, dated 10/13/12, indicated Resident 11 "states she was kicked by another resident on the left leg on 10-12-12." Review of the facility policy (received 10/24/12) "Abuse Prevention," dated February 2008, revealed that all alleged incidents of abuse or mistreatment were to be reported to the State licensing agency "immediately or within twenty-four (24) hours." During concurrent interview with Management Staff N and O, on 10/26/12 at 7:20 a.m., the staff members stated that the kicking incident between Residents 11 and 15 had not been reported to the State licensing and certification agency. |
| 010000949 |
Pine Ridge Care Center |
110009715 |
A |
30-Dec-13 |
2Z5J11 |
10761 |
F323 ?483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility violated the regulation by failing to provide adequate supervision to prevent an elopement from the facility when Resident 1 left the facility, in his car and drove away undetected on 12/15/12. Resident 1 was found by the police down a ravine following a car accident, where he had been ejected from the car and was clinging to a tree. The police estimated that Resident 1 had been clinging to the tree for five hours before a hiker heard Resident 1's cries for help. These failures resulted in Resident 1 sustained left hand fracture that was displaced and required surgical pinning on 12/15/12. Resident 1 continued, after 12/15/12, to go outside the building unsupervised. Review of the clinical record conducted on 12/27/12 revealed the following: A facility report dated 12/17/12 revealed that Resident 1 was admitted to the skilled nursing facility for rehabilitation and nursing services on 11/6/12, following an acute hospital stay with diagnosis including three fractured ribs, and hypoxic ischemic encephalopathy (damage to cells in the central nervous system - the brain and spinal cord). The admission Minimum Data Set (MDS-an assessment tool) revealed that Resident 1 was able to understand and be understood.During an interview, on 1/10/13 at 9 a.m., the psychologist who had been following Resident 1, stated that he had reported to the facility on 12/6/12 that Resident 1 had a history of elopement from a previous skilled nursing facility and showed a lack of judgment and was impulsive.During an interview, on 12/27/12 at 9:30 a.m., Administrative Staff A stated that Resident 1 had been missing on 12/13/12, for three hours, and when he returned to the facility stated he had left to get clothes from home. This was when it was discovered that Resident 1 had a car and he refused to hand over the keys. Administrative Staff A stated that she did not know where Resident 1's car was at that time.A Non-Compliant Care Plan, dated 12/13/12, revealed Resident 1 was non-compliant with following the facility protocol of signing in and out for a pass and refused to turn in his car keys. The facility instituted an every 15 minute visual check on Resident 1's whereabouts. A physician order, dated 12/14/12, discontinued Resident 1's pass privilege due to non-compliance with signing in or out of the facility.During an observation and interview, on 12/27/12 at 1 p.m., Resident 1's left hand was bandaged, the right hand and arm had multiple bruises and skin tears. Resident 1 stated that on 12/15/12, that he was tired of being in the facility, so used his cane to walk to his car, which was parked in the facility parking lot, and left at about 11 a.m., he drove to his old apartment and then went out to lunch. He then stated he wanted to drive out to the beach. Resident 1 did not recall going off the road, but does remember that he was ejected from the car and was pinned to a tree. Resident 1 stated that it was raining and he was extremely cold and that it took hours for a hiker to pass by and provide help.Resident 1 stated that the rescue team had to cut down several trees down the side of the ravine to be able to reach him, put him in a basket type stretcher, and haul him up to the road.Nurses notes, dated 12/15/12, revealed that Resident 1 was not in his room for the 12:15 p.m. visual check. This was an hour and 15 minutes after Resident 1 had left. The facility and facility perimeter were searched. At 1:20 p.m. Licensed Nurse (LN) C called Resident 1's contacts and called Resident 1's cell phone but it went to voice mail, at that time LN C noticed that Resident 1 had signed out on a pass at 12:05 p.m.At 2:50 p.m., 2 1/2 hours later, the facility administrator, the Director of Nurses and the police were notified. At 3:38 p.m., the police arrived at the facility.During an interview, on 12/27/12 at 11:15 p.m., LN C reviewed the sequence of events on 12/15/12. LN C stated that the police were notified around 2:45 p.m. When asked to clarify the procedure for how soon to notify the police of a missing resident, LN C responded immediately. When asked why this was not reported to the police immediately, LN C stated " I didn't want to call them and have him (Resident 1) show up, so I wanted to make sure he was really gone, I didn't want to look stupid."The police Incident Report, Case # SR 12-9677, dated 12/15/12, revealed that the date and time reported was: 12/15/12 at 1607 (4:07 p.m.), approximately four hours after Resident 1 was not found. The Police put out an All-Points Bulletin (APB) for the missing elder. Police were later notified by the California Highway Patrol that they had located Resident 1 at a car crash scene. Resident 1 was down a ravine clinging to a tree after being ejected from the car during the crash. The CHP estimated that Resident 1 had been clinging to the tree for approximately five hours until a passerby found the crash. Resident 1 was transported to a local acute hospital.The local weather report revealed that the temperature for 12/15/12, was a high of 49 degrees and low of 40 degrees, with rain. The acute care hospital's discharge summary, dated 12/21/12, revealed that Resident 1 had been admitted on 12/15/12, following a car accident. Discharge diagnosis included: motor vehicle accident; left thumb metacarpal fracture (broken hand), 100% displaced, with surgical pinning; and multiple contusions (bruises).During an interview, on 1/4/12 at 9:30 a.m., Administrative Staff A stated that the facility had not treated this as an elopement because Resident 1 had signed out on a pass that day. The facility policy titled "Resident on Pass", dated 4/15/01, revealed that "all residents leaving the facility must be signed out and have an appropriate 'out on pass' physician order written." Resident 1's privledges for going "out on pass" were discontinued on 12/14/12. During an interview, on 1/4/13 at 11:35 a.m., and a declaration signed on 1/9/13 at 10:00 a.m., Resident 1 stated that he had not signed out the last 2 times he left the facility and that was why he was in trouble. When the facility sign out record was presented for his review, Resident 1 stated that he had signed the first two entries, dated 12/5/12 and 12/8/12, but had not done the entries for 12/13/12 or 12/15/12; that it was not his handwriting, and that he had not asked staff to sign him out. During an interview, on 1/4/13 at 12:45 p.m., Administrative Staff A concurred that the last two entries on Resident 1's pass sign out sheet did not appear to be Resident 1's handwriting, and did not know who made the entries.An Elopement Risk Review form, dated 12/21/12, indicated that Resident 1 had eloped from the facility in the last 30 days and exhibited behaviors of "wanting to go home." The facility documented that Resident 1 was considered "at risk" for elopement. A physician order dated 12/21/12 revealed "Wanderguard on resident to remind resident not to leave facility unassisted due to poor safety awareness, monitor the placement and function every shift."A wandering and elopement care plan, dated 12/23/12, included "at risk for wandering due to poor safety awareness, to place wanderguard on the resident (monitor function and placement every shift), check resident's whereabouts, redirect resident back to supervised areas, ...call MD for changes in resident's condition."A Non-Compliant Care Plan dated 12/25/12, revealed that Resident 1 was non-compliant with wearing the wanderguard, that it had been offered and refused three times, on 12/26/12, 12/27/12 and 1/3/13. Interventions included "monitor for untoward manifestations resulting from non-compliant and provide intervention, inform family and MD." There were no effective interventions specified for staff to follow to prevent Resident 1 from eloping from the facility. The Interdisciplinary Team Risk meeting notes dated 12/30/12, included "placed on wanderguard for resident at risk for elopement. LN (licensed nurse) and other staff to check on resident from time to time. Will continue to monitor." The IDT note did not indicated specifically what "time to time" or what "continue to monitor" meant. There were no other effective interventions mentioned for staff to follow to provide adequate supervision to prevent accidents. During an observation and interview, on 1/4/13 at 11:05 a.m., and 11:35 a.m., Resident 1 was seated in a wheelchair with no visible wanderguard.When asked, Resident 1 stated that he refused the Wanderguard and had informed the staff that he was not a dog, so refused to wear it and that he had removed the first one. During an observation, on 1/4/13 at 12:35 p.m., Resident 1 was seated in his wheelchair, outside the facility, around the corner from the front door, on the driveway to the parking area to the back of the building, smoking. No staff was present. Resident 1 did not have a visible wanderguard. During an interview, on 1/4/13 at 12:40 p.m., when asked if the facility staff knew Resident 1's whereabouts at that time, both Administrative Staff A and B did not know.At 12:45 p.m., Resident 1 was observed at the front door of the facility, using his feet to propel the wheelchair back inside, with no staff present. During an interview, on 1/4/13 at 1 p.m., Administrative Staff A concurred that the physician should have been notified of the refusal for the wanderguard, and concurred that the driveway on the side of the building was not a safe place for Resident 1 to be alone, smoking. Administrative Staff A stated that the designated smoking area was in the back of the building, where staff could visually monitor the residents.Therefore, facility violated the regulation by failing to provide adequate supervision to prevent an elopement from the facility when Resident 1 left the facility, in his car and drove away undetected on 12/15/12. Resident 1 was found by the police down a ravine following a car accident, where he had been ejected from the car and was clinging to a tree. The police estimated that Resident 1 had been clinging to the tree for five hours before a hiker heard Resident 1's cries for help. These failures resulted in Resident 1 sustained left hand fracture that was displaced and required surgical pinning on 12/15/12. Resident 1 continued, after 12/15/12, to go outside the building unsupervised. This violation presented either imminent danger of death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000949 |
Pine Ridge Care Center |
110009966 |
A |
01-Apr-14 |
LMNO11 |
5654 |
F323 ?483.25(h) Free of Accident Hazards/Supervision/DevicesThe facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility violated the regulation by failing to provide and maintain adequate supervision to prevent accidents and assistance devices when the facility failed to lower the bed and provide assistive devices to prevent accidents, when Resident 19 fell out of bed and sustained a cervical fracture of the second vertebrae. These failures resulted in Resident 19 was not sent to the hospital until 5 days later for an evaluation and stabilization of Resident 19's neck which was a delay in treatment. Resident 19 experienced pain and potential for paralysis of Resident 19's body. During an observation on the initial tour on 5/13/13 at 9:15 a.m., Resident 19 was observed wearing a hard plastic collar around his neck. A physician's order, dated 3/7/13, for two half side rails (side rails extending halfway from the head of the bed to approximately the middle) to be up for assisting the resident's movement in bed. An order, dated 3/7/13, also indicated that a licensed nurse was to check placement and function of the side rails during each shift. Resident 19's Treatment Administration Record (TAR) for April indicated documentation that the side rails were checked each shift that included the night shift of 4/1/13. During an interview on 5/16/13 at 1:20 p.m., Resident 19 stated he had broken his neck on Tuesday 4/2/13 at 2:30 a.m. Resident 19 stated, "No one here has a clue on how to help a patient with a broken neck." The resident stated he supported his own neck while CNAs put him back in bed, and asked, "Isn't it protocol to put on a neck brace? " Resident 19 stated that the CNAs usually move his bed to a position higher off the ground to provide care in the evening and forget to return it to a low position when done. The resident stated that the CNAs did not lower his bed or put the side rails back up and he fell out of the bed. Resident 19 stated, "Now I have to wear this neck brace for six months. This really sets my recovery way back. I came in for my knees." Resident 19 stated an x-ray was taken of his neck on Wednesday 4/3/13. Resident 19 stated he was told by facility staff that his physician would see him on Thursday 4/4/13, but Resident 19 stated he "never saw [the physician]."Resident 19's change of condition notes, dated 4/2/13 at 2:30 a.m., revealed that the resident was found down at bedside with arms folded to knees and complained of pain 7 out of 10 (on a scale where 0 indicates no pain and 10 indicates the worst pain). The note indicated that the resident was placed back in bed and his head supported with pillows. The note indicated an order for an x-ray of the neck was obtained. A note dated 4/2/13 at 5:30 a.m. indicated that Resident 19 was provided with education regarding "C-spine injury" (injury to the bones or portion of the spine that extends from the skull to the base of the neck).During an interview on 5/20/13 at 9:55 a.m., Licensed Nurse Z (LN Z) stated he found Resident 19 sitting on the floor on 4/2/13 at 2:30 a.m. The resident was alert and oriented, in a crouched position with his arms resting on his knees. LN Z stated that Resident 19 told him he awoke from a dream [on the floor]. Resident 19 complained of pain in his neck. LN Z stated he assessed Resident 19 to confirm that the resident could move his arms and legs. LN Z stated Resident 19 supported his own neck while he was assisted back to bed. The Lippincott Manual of Nursing Practice, Ninth Edition, indicates that "Any person with a ...neck...injury should be suspected of having a potential spinal cord injury until proved otherwise" and that the spine should be immediately immobilized while performing the primary assessment (p. 1202). Nurse's Notes dated 4/6/13 at 2 p.m., revealed that "resident assessed for pain in neck. Resident able to move neck side to side very minimally. Able to nod up and down minimally with pain noted. Referred to MD." A subsequent note, dated 4/6/13 at 6 p.m., indicated that a physician order was obtained for a CT (computed tomography) scan (a series of x-rays from different angles that create cross-sectional images) of the cervical spine.A Nurse's Note, dated 4/7/13 at 9 a.m., indicated that Resident 19 was picked up by ambulance for transport to the hospital. A Nurse's Note dated 4/7/13 at 11:30 a.m., reflected a call from one of Resident 19's physicians reporting that the resident would not return to the facility due to a "C-2 fracture," (a break in the second bone in the neck). A hospital admission note, dated 4/7/13, included imaging results documenting a CT scan that indicted fractures at C2 on both sides of the second bone in the neck. The facility violated the regulation by failing to provide and maintain adequate supervision to prevent accidents and assistance devices when the facility failed to lower the bed and provide assistive devices to prevent accidents, when Resident 19 fell out of bed and sustained a cervical fracture of the second vertebrae. These failures resulted in Resident 19 was not sent to the hospital until 5 days later for an evaluation and stabilization of Resident 19's neck which was a delay in treatment. Resident 19 experienced pain and potential for paralysis of Resident 19's body. 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. |
| 010000949 |
Pine Ridge Care Center |
110009967 |
A |
01-Apr-14 |
LMNO11 |
4425 |
F315 ?483.25(d) No Catheter, Prevent UTI, Restore Bladder Based on the resident's comprehensive assessment, the facility must ensure: 483.24(d)(2) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. The facility violated the regulation by failing to treat a urinary tract infection when the licensed nurse failed to obtain timely treatment for a resident with a symptomatic urinary tract infection for 1 of 25 sampled residents (Resident 2). These failures resulted in a delay in treatment for 4 days when Resident 2 experienced lower abdominal pain, pain on urination and low back pain. Findings: During an interview on 5/16/13 at 3:30 p.m., a responsible party for Resident 2 stated the resident had a history of frequent urinary tract infections (UTIs). The responsible party further stated that Resident 2 developed a urinary tract infection in April 2013 which was initially identified on 4/30/2013, and the specific germs causing the infection were identified on 5/2/13. The responsible party stated Resident 2 received no treatment for the infection in the facility, and was sent to the hospital emergency room on 5/3/13 at 5:30 p.m. where antibiotics were prescribed. Resident 2's record revealed a urine test done on 4/30/13 that showed many bacteria, an increased number of white blood cells (cells that fight infection), and positive leukocyte esterase (a protein released into the urine by white blood cells). A notation on the lab results sheet indicated that these results were faxed to the resident's physician on 4/30/13 at 7 p.m. The nurses notes indicated that facility staff was awaiting a reply from the physician. The nurses notes, including a section titled "UTI (signs/symptoms)", reflected the following: Resident 2 had lower back pain, decreased appetite, and painful urination on 4/29/13; lower back pain and painful urination on 4/30/13; lower back pain, painful urination, and decreased appetite on 5/1/13; lower back pain, decreased appetite, and painful urination on 5/2/13. The record revealed that two specific organisms were identified in Resident 2's urine on 5/2/13, Citrobacter freundii (C. freundii) and Providencia stuartii (P. stuartii). A notation on the lab results sheet indicated that it was faxed to Resident 2's physician on 5/2/13 at 4 p.m. Nurses notes reveal that the results were again faxed to Resident 2's physician three times on 5/3/13 and a text message was also sent to the physician with no reply. The nurses notes indicated "Unable to contact MD at this time" on 5/3/13 at 4 p.m. A personal document dated 5/4/13 provided by a responsible party for Resident 2 indicated the responsible party was told by facility staff on 5/3/13 at 4 p.m., that the laboratory results were sent to Resident 2's physician on the morning of 5/2/13 and the facility was awaiting treatment orders from the physician. The responsible party stated that she told facility staff of her intent to report the facility to the state [survey agency]. The responsible party took Resident 2 out of the facility on pass at 5 p.m. on 5/3/13. At 5:20 p.m., the responsible party was contacted by the facility and told to return Resident 2 to the facility so she could be sent to the hospital by ambulance in accordance with physician orders.The personal document indicated that the responsible party called the office of Resident 2's physician and insisted on a return call, after being advised by the facility that the physician wanted Resident 2 seen at the hospital. The responsible party received a return call from the physician. The responsible party was told by the physician, "If we don't like his care and if we don't agree with his treatment plan we can go to another facility." Therefore, the facility violated the regulation by failing to treat a urinary tract infection when the licensed nurse failed to obtain timely treatment for a resident with a symptomatic urinary tract infection for 1 of 25 sampled residents (Resident 2). These failures resulted in a delay in treatment for 4 days when Resident 2 experienced lower abdominal pain, pain on urination and low back pain. The violation of this regulation presented either imminent danger that death or serious harm would result aor a substantial probability that death or serious physical harm would result. |
| 010000949 |
Pine Ridge Care Center |
110009983 |
A |
01-Apr-14 |
LMNO11 |
7451 |
F323 ?483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility violated the regulation by failing to provide and maintain adequate supervision to prevent accidents and assistance devices when the facility failed to provide a safe environment with adequate assessment and supervision for Resident 21 who chose to smoke which resulted in Resident 21 sustaining burns from cigarettes. During an initial tour on 6/10/13 at noon, Resident 21 was sitting in an electric wheelchair in the outside smoking area, wearing a heavy cotton apron over her clothes. Resident 21 shook hands with the left hand, and was noted to have right facial droop, (indication of facial muscle weakness). Resident 21's right hand hung over the wheelchair armrest, when Resident 21 raised her right hand, an unlit partial cigarette was observed in the right hand. Resident 21 then used both hands to open the cigarette package on her lap, extracted a lighter, and lit the cigarette. Resident 21 responded appropriately to questions regarding length of stay and care in the facility. During the conversation, the Director of Nursing reached into Resident 21's lap and removed a cigarette butt. Two facility staff were present in the smoking area. The clinical record for Resident 21 was reviewed on 6/10/13 at 2:15 p.m. The resident admission record dated 7/30/02 indicated Resident 21 had diagnoses that included multiple sclerosis.Resident 21's Smoking Care Plan rewritten on 12/17/12, noted "Non-compliant with recommendation to keep smoking (materials) with nurses. The goals included: "Resident risk of injury to self and others will be minimized with interventions. The care plan included an undated handwritten note, for a smoking apron as an intervention. Another intervention dated 4/30/13, directed: Close monitoring during smoking hours", however "close monitoring" was not defined. A Nursing Care Plan for "Non-Compliant", rewritten 12/17/12 indicated Resident 21 was non-compliant 12/10/10, when she refused to "give smoking (materials) (secondary) to safety issues". An additional issue of non-compliance was in "using smoking apron". The goal of the care plan was the resident would understand the risk associated with being non-compliant. An, undated, handwritten intervention directed: "Provide adequate supervision ...smoking activity". The most recent Minimum Data Set, (MDS), a resident assessment tool, dated 3/13/13, indicated Resident 21 had limited motion in both upper and lower extremities, and required assistance with all activities of daily living. A Change of Condition Note, dated 4/29/13, indicated a CNA had noted fluid filled blisters on Resident 21's abdomen during daily care. A Licensed Nurse assessed and documented the blisters as follows: "...noted as fluid filled blisters. Abdomen site #1-1.5 X 1.8. Abdomen site #2- 2 X 3.5... Abdomen site #3-1 x 1.3. Abdomen site #4-1.8 x 1.8. L(eft) ant(erior) thigh -1 x 1." The Licensed Nurse wrote: "Resident verbalized it happened when she was smoking and refused to wear the smoking apron because its too heavy." The Licensed Nurse documented that the physician was notified and orders were obtained for the care of the blisters.The IDT (Interdisciplinary Team) risk meeting notes, dated 4/30/13, indicated the facility would provide different kinds of aprons for Resident 21 to try until an appropriate one was found to use as a protective device, and that Resident 21 would, "...have supervision during smoking sessions to ensure that resident is safe". There were no subsequent risk meeting notes that evaluated the effectiveness of the care plan. Smoking Nursing Plan of Care dated 4/30/13 noted "resident with episodes of refusing to wear smoking apron", a handwritten intervention, dated 4/30/13, indicated Resident 21 required close monitoring during smoking hours, the day after the burns were noted.During an observation and concurrent interview, on 6/11/13 at 10:35 a.m., Resident 21 had 4 four lesions on her abdomen that were small and covered with scabbed tissue. Multiple circular, dime-sized scarring was visible scattered over the entire abdomen. A fifth lesion, circular and covered with a yellow exudate, was present on the left lower abdomen. The Treatment Nurse stated the fifth lesion was new, he had not seen it before. The Treatment Nurse stated the previous anterior thigh blister was completely healed. Resident 21 stated that the lesions on her abdomen were burns from dropped cigarettes.During an interview on 6/11/13 at 10:35 a.m., Resident 21 stated when she dropped a cigarette she was able to recover it, however it took time to do so. Resident 21 stated the staff would help her if she dropped a cigarette, but the burns happened really quickly. When asked about wearing a smoking apron, Resident 21 stated in the past she had dropped cigarette(s), down the neck of an apron, the cigarette would get trapped between the apron and her body, a heavy apron made the burn even worse. The Safe Smoking Assessment dated 5/20/13-5/21/13, for Resident 21, was signed by the Interdisciplinary Team on 5/20-5/21/13. The Cognitive Assessment indicated Resident 21 was independent in decision making as she demonstrated reasonable, consistent and organized behaviors. Resident 21 was assessed as having impaired vision; she was not able to read regular print. Resident 21 was also found to demonstrate unsafe technique for putting out matches, (lighter), and disposing of ashes. The form directed if all answers were "Yes", the resident would be determined to be a safe smoker, however with one "No." Resident 21 was deemed to be an unsafe smoker that required supervision when smoking. The Safe Smoking Assessment directed if a resident was found to be an unsafe smoker, a care plan would be done "immediately" that included: Smoking Designation, Degree of supervision needed, Protective Device (if needed), where smoking materials will be stored, as well as observation for seizure activity if applicable. During a visit to the smoking area, on 6/11/13 at 11:35 p.m., Resident 21, wearing a cotton apron, manipulated the controls of her electric wheelchair with both hands as she readjusted her position, a lit cigarette dangled from her lips. The Medical Records Director sat at a picnic table, next to Resident 21's wheelchair, with a cell phone. The Medical Records Director did not look up as she manipulated the cell phone, as she also smoked. A second staff member, without a name tag, (later identified as a janitor), stood at the edge of the smoking area. The staff member stated he watched the residents smoke as he gestured toward the smoking area. The janitor was not observed watching the residents out in the smoking area. Therefore, the facility violated the regulation by failing to provide and maintain adequate supervision to prevent accidents and assistance devices when the facility failed to provide a safe environment with adequate assessment and supervision for Resident 21 who chose to smoke which resulted in Resident 21 sustaining burns from cigarettes. The violation of this regulation presented either imminent danger that death or serious harm would result nor a substantial probability that death or serious physical harm would result. |
| 010000949 |
Pine Ridge Care Center |
110010548 |
B |
25-Mar-14 |
IW5W11 |
6592 |
A001 HSC 1429 (a)(1)(A) Health & Safety Code 1429 1429. (a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility. (1) The citation shall be posted in at least the following locations in the facility: (A) An area accessible and visible to members of the public.A002 HSC 1429 (a)(1)(B) Health & Safety Code 1429 (a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility. (1) The citation shall be posted in at least the following locations in the facility: (B) An area used for employee breaks. A003 HSC 1429 (a)(1)(C) Health & Safety Code 1429 a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility. (1) The citation shall be posted in at least the following locations in the facility: (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities.A004 HSC 1429 (a)(2)(A) Health & Safety Code 1429 (a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility. (2) The citation, along with a cover sheet, shall be posted on a white or light-colored sheet of paper, at least 8 1/2 by 11 inches in size that includes all of the following information: (A) The full name of the facility, in a clear and easily readable font in at least 28-point type.A005 HSC 1429 (a)(2)(B) Health & Safety Code 1429 1429. (a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility. (2) The citation, along with a cover sheet, shall be posted on a white or light-colored sheet of paper, at least 8 1/2 by 11 inches in size, that includes all of the following information: (B) The full address of the facility, in a clear and easilyA006 HSC 1429 (a)(2)(C) Health & Safety Code 1429 1429. (a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility. (2) The citation, along with a cover sheet, shall be posted on a white or light-colored sheet of paper, at least 8 1/2 by 11 inches in size that includes all of the following information: (C) Whether the citation is class "AA" or class "A."A011 HSC 1429 (c) Health & Safety Code 1429 (c) A violation of this section shall constitute a class "B" violation, and shall be subject to a civil penalty in the amount of one thousand dollars ($1,000), as provided in subdivision (e) of Section 1424. Notwithstanding Section 1290, a violation of this section shall not constitute a crime. Fines imposed pursuant to this section shall be deposited into the State Health Facilities Citation Penalties Account, created pursuant to Section 1417.2.The facility failed to post Class A Citation # 11-2389-0009715-F that was served to the facility on 12/30/13 for a violation of federal tag F 323 in the locations and manner as specified by the Health and Safety Code. This violation resulted in an automatic "B" Citation. Findings: During an observation and interview on 3/7/14 at 11:25 a.m., there was an off white color binder in a slot on the wall next to the receptionist's desk. The binder indicated "Survey binder" and the Administrator stated that this was where the surveys are kept. In the binder was an "A" citation # 11-2389-0009715-F that was served to the facility on 12/30/13. The Administrator stated that this is the only place it was placed. During an observation on 3/7/14 of the employee break room and dining and Activity rooms, at 2:20 p.m., there was no A citation posted. During an interview on 3/7/14 at 2:30 p.m., The Administrator stated that he was not aware that A citations needed to be posted. The Administrator stated that he used to automatically get the All Facility Letters to long term care facilities from the state, but since he came to this new facility with different ownership, he did not receive them any more. He also stated he did not have a specific policy about what to post, but had a survey readiness checklist, but it did not include the posting of A citations. Review of the AFL 14-04, dated January 8, 2014 on 3/7/13, indicated that long term care facilities must post A citations prominently for 120 days in an area accessible and visible to the public, in an area used for employee breaks and in an area used by residents for communal functions such as the dinning, resident council meetings or activities.The facility failed to post Class A Citation # 11-2389-0009715-F that was served to the facility on 12/30/13 for a violation of federal tag F 323 in the locations and manner as specified by the Health and Safety Code. This violation resulted in an automatic "B" Citation. |
| 010000949 |
Pine Ridge Care Center |
110010572 |
B |
27-Mar-14 |
W7PB11 |
5105 |
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 violated the regulation by failing to provide adequate supervision as indicated in Resident 1's plan of care, when staff were not in close proximity to Resident 1 while on close supervision for a history of abusive behaviors including hitting, grabbing and throwing things.Resident 1 threw a book and hit Resident 2 in the face which resulted in a nosebleed and Resident 2 being afraid. The admission facesheet indicated that Resident 1 was admitted on 10/27/2009 with diagnosis that included dementia.The Minimum Data Set (MDS) an evaluation tool, dated 1/5/12, indicated that Resident 1 exhibited behaviors of hitting, kicking, pushing staff and others and throwing objects and wandering into other resident's rooms.A Psychosocial Care Plan dated 10/10/11 and updated on 4/2012, included a history of physically abusive behavior, which included a history of throwing things and required an intervention of close monitoring and ... "do not sit near other residents if possible to avoid conflict."A Behavior Care Plan dated 8/21/11 and updated 10/5/11, included a problem of an altercation with another resident and included an intervention of 1 to 1 monitoring, (keeping resident within arm's length), a psychiatric consult and medications for anti-anxiety. Nursing notes dated 1/15/12, indicated that Resident 1 was in the dining room and picked up a book and threw it and hit Resident 2 in the nose. During an interview on 1/20/12 at 10:50 a.m., Certified Nursing Assistant (CNA) A stated that while doing close monitoring for Resident 1 they went into the dining room around 7:30 a.m. Resident 1 was seated in a wheelchair by the piano and CNA A decided to place the table cloths on all the dining room tables for breakfast. When CNA A was all the way across the room, loud voices were heard and Resident 1 picked up a book and threw it into Resident 2's face. CNA A could not make it all the way across the room in time to stop it. Resident 2 had a bloody nose. CNA A concurred that she should have been at Resident 1's side and not across the room to prevent aggressive behaviors.During an interview, on 1/20/12 at 11 a.m., Resident 2 (identified by nursing notes as alert and orientated) stated that Resident 1 always wandered around and was hitting staff and throwing things. Resident 2 stated that staff were supposed to be watching Resident 1, but when Resident 1 hit Resident 2 in the face with the book, the CNA was on the other side of the dining room. Resident 2 also stated that he was afraid of Resident 1 and that staff should always be with Resident 1 because Resident 1 could really hurt someone. During an interview, on 2/1/12 at 11:30 a.m., Licensed Nurse C stated that other alert residents had commented that they worry about Resident 1's agitation and behaviors, and were more apprehensive since they witnessed the incident with Resident 2. During an interview, on 2/1/12 at 8:20 a.m., CNA B stated that it sometimes took three or four staff to remove Resident 1 from situations where Resident 1 could hurt others, Resident 1 "gets crazy and throws things, goes into other resident rooms and tries to take things." CNA B also stated that Resident 1 was too aggressive and strong, hurt staff and placed other residents at risk for injury, and that other residents were afraid. During an interview and observation, on 1/20/12 at 10:15 a.m., CNA B was seated beside Resident 1's bed, Resident 1 was sleeping. CNA B stated that she had been assigned to do one to one monitoring for Resident 1 for two months, and thought that "one to one" required remaining within arms reach of the resident. CNA B stated that CNA A covered for breaks and lunch. During an interview, on 1/20/12 at 12 noon, when asked for the policy for close monitoring or one to one observation and the education sessions for staff, the Director of Nursing (DON) stated that the facility did not have a policy. The DON provided an inservice training report, dated 8/22/11, topic: one to one monitoring, which included "never leave residents that are on one to one...". The DON concurred that CNA A and CNA B had not attended this inservice. The DON provided another inservice training report, dated 1/15/12, topic: Abuse, which included..."never leave residents who are on one to one monitoring..." DON concurred that CNA A and CNA B had not attended this inservice either. The facility violated the regulation by failing to provide adequate supervision as indicated in Resident 1's plan of care, when staff were not in close proximity to Resident 1 while on close supervision for a history of abusive behaviors including hitting, grabbing and throwing things.Resident 1 threw a book and hit Resident 2 in the face which resulted in a nosebleed and Resident 2 being afraid. This violation had a direct relationship to the health, safety or security of residents. |
| 110000053 |
Piner's Nursing Home |
110011062 |
A |
15-Oct-14 |
0FLK11 |
10145 |
B820 T22DIV5CH3ART3-72311(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 develop a nursing plan of care to provide adequate supervision when, during a bedside diagnostic test (ultrasound), Resident 1 was moved to the edge of the bed without staff present at the bedside in order to ensure she would not fall off the bed. This lack of supervision resulted in Resident 1 falling from the bed to the floor, sustaining a fracture to her left elbow.Resident 1 was a 73 year-old woman who was initially admitted to the facility on 9/26/11. Her most recent date of admission to the facility was on 2/12/13. Her diagnoses included after-care for fractured bones. According to the Minimal Data Set (MDS) [an assessment tool], dated 10/14/13, Resident 1 had no difficulties with memory recall, and exhibited no symptoms of delirium or psychosis (being out of touch with reality). Resident 1 required limited assistance by one person when moving around in bed or transferring from chair/wheelchair to bed.Review of the "Fall Risk Evaluations," dated 7/10/13, 9/19/13, and 10/10/13, indicated Resident 1 had scores on all three evaluations of "16." The form indicated that scores over "10" meant the individual was at risk for falls. The instructions stated, "When resident's total score is 10 or more, interventions should promptly be put in place." According to the evaluation tools, Resident 1 had two falls in the 90 days prior to the assessments.During an observation and concurrent interview on 12/10/13 at 2:20 p.m., Administrative Staff A measured the height from the top of Resident 1's personal bed (top of mattress) to the floor. The distance was 25.5 inches. A standard facility bed measured 23.5 inches from the top of the mattress to the floor. Administrative Staff A stated Resident 1's bed was "like an electric home bed." During an interview on 12/10/13 at 1:20 p.m., Administrative Staff B stated, at the time of the fall, Resident 1 was lying in her own personal bed which was a "single bed with a high mattress, higher off the floor than a hospital mattress." She also stated that the facility did not have a policy for staff to assist x-ray technicians with residents during diagnostic tests, adding that staff will assist technicians if they ask for help. During an interview on 12/10/13 at 2 p.m., Administrative Staff A stated the facility has "never had staff accompany techs into patient rooms before." During an interview on 12/10/13 at 2:10 p.m., Licensed Staff C stated, following Resident 1's fall the resident was lying in an awkward, uncomfortable position on the floor, so five staff placed Resident 1 onto a sling and put her back into bed while waiting for the ambulance to arrive. During an interview on 12/10/13 at 3:05 p.m., Licensed Staff D stated, on the morning of 11/23/13, she saw Technician E at the front desk following her arrival to the facility. Licensed Staff D stated she gave the technician Resident 1's chart and told her, "You can always ask for help if you need help." Licensed Staff D added that she knew Resident 1 would have to be re-positioned by the technician in order to perform the ultrasound. After the fall, upon finding Resident 1 lying on the floor, Licensed Staff D stated she immobilized both of Resident 1's arms because she was not sure which arm was injured. After that, she stated she assessed the resident, called for help, and five staff placed the resident onto a sling and put her back into her bed. Licensed Staff D stated Resident 1 was at risk for falls because she "was on all this medication and got sleepy." When asked how long Resident 1 had been using her own personal bed, Licensed Staff D stated, "More than a month." During an interview on 12/10/13 at 3:20 p.m., Resident 1, who the facility identified as being alert and oriented, stated a woman came to do "an image of my left flank." The technician had her lying on her right side with her feet facing the head of the bed and her head facing the foot of the bed. She stated the technician "pulled" her to the edge of the bed. "I told the tech that I didn't feel stable because I didn't have anything to hold onto." Resident 1 stated the tech did not respond to her concern, but went over by the bathroom door looking for a plug for the machine. "That's when I fell off. I have no stability. I have very little control...My arms are really bad." Resident 1 added there was no one accompanying the technician at the time of the fall, nor were staff present for past x-rays. Following the fall, Resident 1 stated she went from lying on the floor directly to the ambulance's gurney, then to the Emergency Room. She stated staff did not put her back into her bed after the fall.During an interview on 12/10/13 at 3:40 p.m., Resident 2 (Resident 1's roommate), who the facility identified as alert and oriented, stated the privacy curtain was drawn around Resident 1 during the preparation for her ultrasound so she did not see what happened. Resident 2 stated she heard Resident 1 tell the technician not to leave her on the side of the bed "like that." Resident 2 added that Resident 1 had never fallen out of the bed like that before and that she had never before seen staff accompany a technician into the room while performing a diagnostic test.During an interview on 5/14/14 at 10:05 a.m., Technician E stated she entered Resident 1's room and found her seated in her wheelchair. She told Resident 1 that she needed to get into her bed for the ultrasound. Technician E asked Resident 1 if she needed any help in getting into bed and Resident 1 stated, "No." Resident 1 asked for either the privacy curtain to be pulled or the door to the room shut. Technician E pulled the curtain around Resident 1's bed. She then positioned Resident 1 on her side and asked her to "scoot" over to the left side of the bed (against the wall). Technician E asked Resident 1 if she was comfortable, to which Resident 1 responded, "Yes." Technician E stated she then turned her back on the resident and searched for an outlet so she could plug in the machine. She then heard a "thud" and saw Resident 1 lying on the floor. Technician E stated she then went out of the room looking for help and did not notice if any bedrails on the bed were up or down. She stated staff then put Resident 1 back to bed. When asked if it was usual practice for her to go into a resident's room unaccompanied by staff, she stated, "Yes." Technician E added that, prior to her entering Resident 1's room, no staff asked her if she needed help in positioning the resident.Review of the "Fall" care plan, dated 2/13/13, indicated Resident 1 had six falls from 4/11/12 to 1/16/13 (prior admissions to the facility). Other falls occurred on 2/15/13, 7/10/13 (with facial bone and finger fractures), 11/23/13 (with fractured elbow), and 12/1/13. The care plan's indicated goal was: "[Resident] will have no injuries from falls daily." Interventions included: "Assess ability to use assistive devices safely; Instruct on the use of the call light; Instruct [Resident] to call for assistance before ambulating or transferring; re-explain how to use the call light frequently; refer to activities for diversional activities; notify MD of falls; notify responsible party of falls; and encourage [Resident] to not self-transfer without supervision when sleepy." A Social Services notation, dated 7/5/13, indicated: "Called RP [Responsible Party (Resident 1's daughter)] and informed her that we were concerned about resident's safety. Resident was being non-compliant with safety guidelines we have set forth." A note dated, 8/9/13, indicated: "Resident still not safe." The narrative Nurses' Notes, dated 11/21/13, indicated Resident 1 had a new physician order for a renal (kidney) ultrasound for "flank" pain. A note, dated 11/23/13 at 9 a.m., indicated: "Resident found on the floor lying on her right side. Obtained right lower lip laceration and a bump with bruising in her temporal area. Patient stated she use [sic] her left arm to lean on the floor and left arm bounced back harder. Now patient could not moved [sic] the left arm and [complained of] left arm excruciating pain upon assessment. Assisted back to bed with 5 persons...transferred to ER."Review of the Weekly Nurses' Notes, dated 12/1/13, contained a notation about Resident 1's condition following the fall on 11/23/13: "Personal bed removed and facility bed provided for safety. It also indicated Resident 1 had sustained another fall (from her wheelchair) on 12/1/13 and that the resident's electric wheelchair had now been taken away with the resident having to now use a manual wheelchair. Review of Resident 1's records from the acute care hospital indicated she sustained a fractured left elbow as a result of her fall from her bed on 11/23/13. Review of the policy titled, "Fall Risk Assessment," revised 12/2007, indicated, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.The facility violated the regulation by failing to develop a nursing plan of care to provide adequate supervision when, during a bedside diagnostic test (ultrasound), Resident 1 was moved to the edge of the bed without staff present at the bedside in order to ensure she would not fall off the bed. This lack of supervision resulted in Resident 1 falling from the bed to the floor, sustaining a fracture to her left elbow.This violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 110000863 |
Paradise Valley Estates |
110011827 |
B |
09-Nov-15 |
4FMQ11 |
6031 |
T22 DIV5 CH3 ART3-72311(A)(1)(C) 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: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.The facility violated the regulation by failing to revise Resident 1's nursing plan of care to prevent further falls with effective interventions specific to Resident 1's known behaviors of getting out of bed and the wheelchair unassisted and fell on 8/8/13 and sustained a fractured right hip requiring surgery. Resident 1 was admitted to the skilled nursing facility on 5/10/13 with diagnoses including dementia. Resident 1's fall risk assessment dated 5/10/13 indicated Resident 1 had a score of 20 (A score of 10 or greater is high risk). Resident 1's nursing plan of care for fall risk dated 5/10/13, indicated that Resident 1 had a potential for injury related to unsteady gait, impaired safety awareness, weakness, balance problem. Resident 1 was unable to ambulate without assistance and unable to transfer without assistance. The interventions were to: 1) Make sure that all staff members are aware that resident is a high risk for falls; 2) Provide chair with arms to assist with rising; 3)Low bed; 4) Padded floor; and 5) Bed wheels in the locked position. The goal was that Resident 1 would remain free from significant injury. First Fall Interdisciplinary notes dated 5/29/13 at 9:14 a.m., observed Resident 1 on hand and knees on 5/28/13 at 10:10 a.m. Housekeeper had pushed Resident 1 into the room and direct care staff were unaware. Instructed ancillary staff to ask for assistance or refer care concerns to nurse. The fall risk assessment dated 5/28/13 indicated that Resident 1's fall risk increased from 20 to 22. Resident 1 nursing plan of care for falls risk indicated on 5/28/13 that Resident 1 was to have a pull tab alarm in bed or wheelchair. Second Fall Interdisciplinary notes dated 6/3/13 at 3:30 p.m., Resident 1 was found sitting on 5/31/13, on the floor next to the mat near Resident 1's bed. The interventions were that Resident 1 was frequently monitored and the goal was no injuries to Resident 1. There was no update to Resident 1's fall risk assessment for the fall on 5/31/13. During an interview on 7/21/14 at 3:20 p.m., Licensed Nurse E stated that she provided the resident assessments and develops the residents' nursing care plans. Licensed Nurse E was asked how are direct care staff aware that Resident 1 is high risk for falls, Licensed Nurse E stated that she tells direct care staff to "keep an eye on them." Licensed Nurse E was asked what does "keep an eye on them" mean? Licensed Nurse E replied, residents need assistance and are not to transfer self alone. Licensed Nurse E was asked if Resident 1 made frequent attempts to get up without assistance, Licensed Nurse E replied, that we will add supervision at the nurses station, "She wasn't there yet, didn't think she required that assessment of monitoring." Fall Review dated 6/17/13, indicated that a bed alarm was placed Resident 1's bed after the fall on 5/31/13. Resident 1 stays at nursing station 4, in the den during wake hours. Resident 1's nursing plan of care for fall risk indicated that on 5/31/13 a bed alarm was added. There were no effective interventions added specifying how Resident 1 was going to be "frequently monitored" or how direct care staff were specifically going to keep Resident 1 safe at station 4, in the den to prevent injuries. Third Fall Nurses' notes dated 8/8/13 at 11:45 a.m., indicated Resident 1 fell transferring self from wheelchair to wing chair. Resident complained of right hip pain. During an interview on 7/17/14 at 4:00 p.m., CNA B was asked how you supervise Resident 1 and cover other CNA's at lunch break? CNA B replied, We usually put Resident 1 at the nurses station with one CNA. We put the residents in one place, we can't watch them if they aren't together. We gather them in the TV room. One CNA is supposed to be with them all the time. CNA B stated " I am not sure what had happened that day. We try not to leave them alone."CNA B was at lunch at the time of the fall. During an interview on 7/18/14 at 2:10 p.m., CNA C stated the morning of the fall, CNA C found Resident 1 on the floor. CNA C was not there at the time of the fall. Resident 1 was in the TV room. CNA C stated that frequent monitoring meant "Keep an eye on them most of the time." During an interview on 7/23/14 at 11:40 a.m., Licensed Nurse D stated she was on the phone at the nurses station when Resident 1 got up unassisted and fell. Licensed Nurse D stated that she does this all the time self transfers unassisted. When asked how Licensed Nurse D supervises Resident 1 while one CNA is on break and the other is busy with another resident, Licensed Nurse D replied, "I don ' t know." The demographic record dated 8/12/13, indicated that Resident 1 was admitted to the skilled nursing facility for aftercare of a traumatic fracture hip. The interdisciplinary notes dated 8/13/13 indicated that Resident 1 had the right hip surgically repaired. The facility's policy and procedure for Assessing Falls and their causes revised October 2010 indicated "When a resident falls, the following information should be record in the resident's medical record...6. Appropriate interventions taken to prevent future falls." Therefore, the facility violated the regulation by failing to revise Resident 1's nursing plan of care to prevent further falls with effective interventions specific to Resident 1's known behaviors of getting out of bed and the wheelchair unassisted and fell on 8/8/13 and sustained a fractured right hip requiring surgery. The violation of this regulation had a direct relationship to the health, safety, or security of patients. |
| 110000863 |
Paradise Valley Estates |
110011877 |
A |
23-Dec-15 |
TDG911 |
4581 |
72311(a)(1)(A)Nursing Service -- General(a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission.The facility violated the regulation by failing to develop an individualized plan of care for safe transfers of Resident 1 who had right sided hemiparesis (inability to grasp with the right hand or bear weight with the right leg.) These failures resulted in Resident 1's sustaining a fractured right humerus, during a transfer using a Stand-up lift.Findings: During an observation and interview on 10/07/13 at 11:10 a.m., Resident 1 was in her bed with her right arm propped up on pillows. Resident 1's right arm had marked bruising, yellowish blue fading to purplish red from her right shoulder area to her right biceps area.During a record review on 10/7/13 at 12:15 p.m., Resident 1's demographics sheet, dated 3/25/13, listed Resident 1's admission diagnoses as: "CVA with dominant (right) side weakness, lack of coordination (due to right sided paralysis), abnormal posture (due to right sided paralysis and status post right hip fracture), status post right hemi-artroplasty (right hip repair), personal history of fall." During a concurrent record review, Resident 1's nursing care plans from the date of her admission to the facility, 3/25/13 to 9/19/13 (the date of Resident 1's fall with injury), had no references to the specific type of lifting machine that should be utilized to keep Resident 1 safe during transfers or transport from her bed into her bathroom for activities of daily living (ADL's). During an interview on 10/7/13 at 2:20 p.m., CNA B was asked to explain his role in the incident involving Resident 1 on 9/19/13. CNA B stated that he was helping them [LN A, CNA C and CNA D] move [Resident 1 named] the morning of 9/19/13. They were using the Stand-up lift with [Resident 1 named]. CNA B stated that she [Resident 1] had been using that lift whenever she had to go to the toilet, and then onto her motorized wheelchair. She (Resident 1) could only hold onto the handlebar with one hand because her upper body, one side was paralyzed, but she can stand with the lift. CNA B stated that we need to do her transfers quickly, because she can't stand up too long. That morning she had a large amount of loose stool. So, she was standing with the Stand-up lift to be cleaned up after the loose stool. We cleaned her and we were putting on her brief, so she could go back to her wheelchair. The wheelchair was nearby so it would be a quick, short transfer like usually. CNA B stated that she got tired while standing and she told him that her arm hurt and she let go of her grip. So we assisted her down. The machine [Stand-up lift] would not release for her to go down, so we assisted her to lower her down, so she would have an assisted fall, and not hurt herself more.During a record review on 10/7/13 at 3:45 p.m., the X-ray report for Resident 1, dated 9/20/13 at 10:02 a.m., indicated: "There is a fracture of the right humeral neck (upper end of the long bone of the right upper arm) with modest displacement." Concurrent review of Resident 1's attending physician's (Doctor F's) progress note, dated 9/20/13, indicated: "S/P (status post) fall (with) Fx (fractured) right humerus," signed Doctor F. During a document review on 10/14/13 at 9 a.m., the facility policy, titled, "Lifting Machine, Using a Portable," dated 2001, revised 2010, contained only instructions for the use of a Hoyer lift (full body sling lift). The facility policy in use at the time of Resident 1's fall on 9/19/13, did not include instructions for the proper use of a Stand-up lift (shoulder sling lift).The document titled, User Manual for the Stand-up Patient Lift (Invacare Model 350), used by facility staff to transport Resident 1 into the bathroom on 9/19/13, indicated: "Individuals that use the standing patient sling MUST be able to support the majority of their own body weight, otherwise injury may occur." The facility's failure to follow the instructions in the User Manual for the Stand-up Patient Lift presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 010000968 |
Professional Post Acute Center |
110011954 |
A |
08-Mar-16 |
2YDK11 |
9643 |
F223 ?483.13(b) ?483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to prevent and protect Resident 3 from physical harm, verbal abuse, and mental anguish when there was a history of conflicts between Resident 2 and Resident 3 which led to: 1. Resident 2 grabbed and punched Resident 3 on 7/8/14 at 3:15 p.m. which resulted in 4 scratches and significant bruising to Resident 3's left forearm;2. Resident 2 swore and punched Resident 3 on the shoulder on 7/25/14 at 10:15 a.m., 17 days after the first altercation; and3. Resident 2 verbally abused Resident 3 before, during, and after the two physical altercations noted above. Resident 2 continued to swear out loud and mouth profanities and was "giving him the finger" which led to Resident 3 being anxious and unable to sleep at night. During an interview, on 8/6/14 at 4:20 p.m., Ombudsman G stated that Resident 2 and Resident 3 had a history of antagonizing each other verbally. Ombudsman G had met with both Resident 2 and Resident 3 on several occasions and had met with the Long Term Psychiatry Nurse Practitioner (NP) F to discuss the issues with both Resident 2 and Resident 3. Ombudsman G stated that Resident 2 could escalate to actual physical fighting (hitting, grabbing and throwing objects) as Resident 2 had a prior history of physical fighting at this facility.(The Ombudsman investigates and works to resolve complaints made by, or on behalf of, individual residents in long-term care facilities).A Long Term Care Psychiatry note, dated 6/26/14, by Nurse Practitioner (NP) F, noted that the reason for the visit to Resident 3 that day was management of irritability: "...[Resident 3] has a lot of complaints about another resident who [Resident 3] says harasses him...I am sympathetic to [Resident 3's] complaints about the other resident - I know him [Resident 2] and consider him a bully who amuses himself by picking on other people...[Resident 3] is excitable, and there is a simmering conflict with another resident [Resident 2]...According to [Resident 3's] own values [Resident 3] is showing a very high level of restraint in not attacking the other resident.""Bullying is a form of aggressive behavior in which someone intentionally and repeatedly causes another person injury or discomfort. Bullying can take the form of physical contact, words or more subtle actions...The bullied individual typically has trouble defending him or herself and does nothing to "cause" the bullying." American Psychiatric AssociationResident 2's demographic face sheet, dated 5/27/14, indicated that Resident 2 was admitted to the facility on 3/7/12 with diagnoses that included late effect from a stroke with hemiplegia (paralysis of one side), diabetes type 2 and mood disorder. Mood disorder: a condition impacting mood and related functions. In a mood disorder, moods range from extremely low (depressed) to extremely high or irritable (manic).Gale Encyclopedia of Medicine. (2008).Resident 3's demographic face sheet, dated 6/19/14, indicated that Resident 3 was admitted to the facility on 3/6/14 with diagnoses that included muscle weakness, insulin dependent diabetes, hypertension and dementia without behavior disturbance.During an observation and interview on 7/14/14 at 4:35 p.m., Resident 3 was seated in a wheelchair in the Activity room. Resident 3's left forearm had 4 oval shaped scab's, consistent with fingernail shapes, with scratches leading from these on the underside of the forearm and a large area of bruising on the top of the left forearm. Resident 3 stated he was on blood thinners and the bruises and scratches were from Resident 2's grabbing and scratching. Resident 3 stated that Resident 2 always used foul language and continually "gives me the finger." On 7/8/14 Resident 3 was visiting a friend, who was Resident 2's roommate, when Resident 2 grabbed his arm, smacked his chest, hit him several times in the chest and pushed the over-bed table into him and staff had to break it up and then Resident 2 also hit the staff person. Resident 3 stated: "I can't stand the foul language and having [Resident 2] give me the finger all the time... [Resident 2] antagonizes me...I feel that [Resident 2] is a bully..." Resident 3 agreed to notify staff if Resident 2 antagonized him again.During an observation and interview on 7/14/14 at 4:15 p.m., Resident 2 stated that he promised to meet weekly with Management Staff D and Resident 3 to resolve conflicts between Resident 2 and Resident 3. Resident 2 stated he did not scratch Resident 3's arm, that Resident 3 left the room and returned with the scratches and tried to blame me [Resident 2] for them.A fax, dated 7/8/14 (no time noted), was sent notifying the physician of the incident and requested treatment of Resident 3's scratches which included: wash with normal saline, pat dry, apply antibiotic cream and cover. The Physician responded "OK" and dated 7/8/14.A Physician (MD) E progress note for Resident 2, dated 7/8/14 at 5:45 p.m., noted a chief complaint of "...physical and verbal confrontation with another resident...confrontation, onset this afternoon, intensity: severe, quality: physical punching...verbal confrontation (cursing)...Diagnosis included: ...Assault...Aggressive behavior...1) Assault - resident [Resident 2] physically and verbally assaulted another resident...law enforcement documented incident - Patient education - psychiatric counseling offered (declined), 2) aggressive behavior - hx [history] of inappropriate coping mechanisms...patient education - psychiatric counseling offered (declined)..."Physician E wrote an order, dated 7/8/14, to monitor Resident 2 for physical and verbal aggressive behavior for 72 hours.A Physical and Verbal Aggression Care Plan was initiated on 7/8/13 for Resident 2 with a goal of no physical or verbal aggression towards other residents for 30 days with interventions that included: follow MD order to monitor for aggression every shift for 72 hours, prevent [Resident 3] from entering [Resident 2's] room, do not let [Resident 2] close to [Resident 3's] room or other places of the facility.During an interview on 7/14/14 at 3:10 p.m., Management Staff D stated that a weekly meeting was initiated with both residents to discuss that they needed to be civil to each other and get along. When asked if this had been added to the Care Plans for both residents, Management Staff D said that it had not.During an interview on 7/23/14 at 10 a.m., Management Staff D stated that Resident 2 had admitted to being the instigator on 7/8/14 and that the weekly meetings with Resident 2 and Resident 3 were going well with no further problems.During an interview on 7/23/14 at 1:30 p.m., Resident 3 stated that even though Resident 2 had promised Management Staff D to leave Resident 3 alone, Resident 2 continued "...giving me the finger and mouthing bad words all the time...I am having difficulty sleeping due to being anxious about this...I will try to keep away from him..."Second episode of abuse: During an interview on 7/25/14 at 1:35 p.m., Resident 3 stated "... he punched me today in the right upper arm." (7/25/14 at 10:15 a.m.) Resident 2 bumped wheelchairs while trying to pass Resident 3 in the Activity room. Resident 2 used foul language and insisted that Resident 3 move and then the wheels of both wheelchairs got tangled and Resident 2 punched Resident 3 in the shoulder. Staff took Resident 2 away.During a record review on 7/25/14 at 3 p.m., the Activity Assistant witness statement, dated 7/25/14 at 10:15 a.m., noted that Resident 2 was the aggressor and while passing Resident 3 in the activity room used foul language when Resident 3 did not move his wheelchair out of Resident 2's way fast enough for him, and Resident 2 punched Resident 3's shoulder. Resident 3 remained calm during this episode.Facility Policy titled: "Abuse Prevention Program," dated revised August 2006, indicated: "Our policy is committed to protecting our residents from abuse by anyone, including but not necessarily limited to: facility staff, other residents...Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish...The facility management and staff will institute measures to address the needs of the residents and minimize the possibility of abuse and neglect...the physician and staff will address causes of problematic resident behavior where possible..."The facility failed to prevent and protect Resident 3 from physical harm, verbal abuse, and mental anguish when there was a history of conflicts between Resident 2 and Resident 3 which led to: 1. Resident 2 grabbed and punched Resident 3 on 7/8/14 at 3:15 p.m. which resulted in 4 scratches and significant bruising to Resident 3's left forearm;2. Resident 2 swore and punched Resident 3 on the shoulder on 7/25/14 at 10:15 a.m., 17 days after the first altercation, and3. Resident 2 verbally abused Resident 3 before, during, and after the two physical altercations noted above. Resident 2 continued to swear out loud and mouth profanities and was "giving him the finger" which led to Resident 3 being anxious and unable to sleep at night. These violations presented imminent danger that death or serious harm would result, or a substantial probability that death or serious physical harm would result. |
| 010000968 |
Professional Post Acute Center |
110011956 |
A |
08-Mar-16 |
2YDK11 |
14266 |
F323 ?493.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility failed to provide adequate supervision and develop an effective plan of care to provide adequate supervision for 1 of 7 sampled residents (Resident 4): 1. When Resident 4, who had exhibited mental decompensation and dangerous behaviors, eloped from the facility on 6/23/14 at 4:45 a.m.; on 7/7/14 at 3:45 a.m. and on 7/27/14 at 7:25 p.m., and2. When Resident 4 threw a cigarette and set the hillside behind the facility on fire when not in the designated smoking area on 7/19/14 and Resident 4 burned both thumbs when trying to light a cigarette with a lighter which was treated on 7/24/14.These failures may result in:1. Treatment of second or third degree burns to both thumbs; 2. A fire hazard to other residents in the facility when the hillside was set on fire, and 3. Repeated elopements putting the resident at risk for injury.1. Resident 4's demographic face sheet, dated 7/15/14, indicated that Resident 4 was admitted to the facility on 4/6/11 with diagnosis that included muscle weakness, schizoaffective disorder (a condition in which a person experiences a combination of schizophrenia symptoms - such as hallucinations or delusions - and mood disorder symptoms, such as mania or depression. Mayo Clinic) and abnormal gait (walk).The minimum data set (MDS) an evaluation tool, dated 6/9/14, indicated that Resident 4 could walk with supervision. A physician order, dated 6/21/13, indicated that Resident 4 could go out on pass with the responsible party.The Interdisciplinary Team (IDT) review, dated 6/5/14, indicated that Resident 4 had poor safety awareness and judgement, unsteady gait, attempted to function beyond his capabilities and was impulsive.An Elopement Risk Assessment, dated 6/11/14, noted Resident 4 had an elopement risk score of 4. (score of 4 or greater represents Risk). First episode of elopement: A Change of Condition note, dated 6/23/14 at 6:59 a.m., indicated that at 4:45 a.m. Resident 4 left the facility without signing out, the physician was notified and the police were able to locate Resident 4 at a local grocery store buying cigarettes. Resident 4 was returned to the facility by the police at 6 a.m. Mental status is noted as forgetful, mood as anxious, and behavior as: resists care, threatening, uncooperative and verbally abusive. Additionally, this form included: "Fall Risk Factors: Poor safety judgement, psychotropic medications, cardiac med's [medications], pain med's [medications]."Google Maps: To get to the local grocery store required walking 1.1 miles. This required walking down a steep hill and crossing a traffic light at an intersection, then crossing a heavily trafficked road without a traffic signal at a freeway on-ramp to a foot path leading to a steep staircase. This led to the bridge that crossed over the freeway, then crossing a traffic light at the freeway exit intersection and crossing two additional intersections (four lanes) with traffic lights to the grocery store. Local weather: 48 degrees at 4 a.m.The Care Plan, not dated, included the problem: "Leaving facility without signing out," and included a goal of no further complications for 7 days with goal date of 6/30/14. There were no specific goals. There were no specific interventions indicated as to how the facility was going to keep Resident 4 safe.The Care Plan included the problem: "Potential for injury due to fall risk," not dated, and included a goal of no major injuries from fall for three months with a goal date of 9/9/14. The interventions included: Keep resident in frequently monitored areas, assist with transfers and mobility and provide reminders to use ambulation and transfer assist devices when needed.Nurses notes, dated 6/25/14 at 7:02 a.m., noted that Resident 4 was being monitored for 72 hours because Resident 4 left the facility without signing out.The Long Term Care Psychiatry note by Nurse Practitioner (NP) F, dated 6/26/14, indicated: "...left building without alerting anyone a few days ago - claimed to have walked to the supermarket to buy cigarettes, which seems to be far beyond what he is actually capable of. Dramatic decompensation recently - paranoid delusions, stuck a pen in his anus [May 23, 2014], acutely anxious. Complains of insomnia (difficulty sleeping)... Same complaint about a patient with long red beard ("Alex") who has allegedly been openly freebasing in the courtyard. Also says he has been having sexual relationships with two female residents (one of whom died) and wants Viagra...constant anxiety...staff confirm that there is no such person as "Alex" and that there is no way this patient is having a relationship with any woman in this facility..."During an interview on 8/7/14 at 10:10 a.m., NP F stated that Resident 4 confabulates (confabulation is a memory disturbance, defined as the production of fabricated, distorted or misinterpreted memories about oneself or the world, without the conscious intention to deceive). NP F stated that Resident 4 had been decompensating recently and had relayed stories that could not possibly be true. (decompensating - the appearance or exacerbation of a mental disorder due to failure of coping mechanisms in response to stress, resulting in personality disturbance or psychological imbalance).Additionally, NP F stated he had followed Resident 4 until one month ago, when the facility stated that the family wanted their family psychiatrist to care for Resident 4.During an interview on 8/8/14 at 3 p.m., Management Staff D stated that the family psychiatrist had stated that the visit was a courtesy visit for the family, and no note or recommendations would be submitted.Second Incident of Elopement:A fax, dated 7/7/14 with no time noted, was sent to the physician which indicated: "Resident [Resident 4] was found by staff [name of staff] by the bridge and brought back to the facility around 3:45 a.m. Resident [Resident 4] left without signing out or notifying the nurse."During an interview on 8/7/14 at 11 a.m., when asked about finding Resident 4 on the bridge overpass of the freeway, Management Staff D stated the following: 1) Even though Resident 4 was in the wheelchair when in the facility Resident 4 could walk and had reported going to the store to buy cigarettes, 2) The Director Of Nurses (DON) had tried a Wanderguard (an electronic device attached to a resident that alarms when passed through an alarmed door) but Resident 4 had cut it off, and 3) Resident 4 was told not to walk to the store and Resident 4 seemed to understand. Additionally, Management Staff D stated that the doors to the facility were locked at night and would not allow entrance into the facility, but did not prevent opening the door from the inside and leaving the facility.Third Incident of Elopement:Nurses notes, dated 7/16/15 at 11:43 p.m., noted that Resident 4 was found near the stairs leading to the basement garage and was reminded not to leave without signing out.During an observation on 8/8/14 at 8:55 a.m., the back patio contained the designated smoking area. On the side of the back patio there was a gate which led to stairs going down to the parking garage under the building.Fourth Incident of Elopement:Nurses notes, dated 7/27/14 at 7:24 p.m., noted that Resident 4 left the facility without signing out or notifying nursing staff.During an observation and interview on 8/8/14 at 8:35 a.m., Resident 4 was seated in a wheelchair in the main lobby by the exit door with no staff visible at the nursing station, the reception desk or hallway. When asked why he left the facility Resident 4 stated he needed to get cigarettes at the grocery store. When asked how Resident 4 got to the store, Resident 4 replied "I just walked out through the front door."Fifth Incident of ElopementDuring an observation and interview on 8/8/14 at 10:40 a.m., Resident 4 was seated in a wheelchair and stated that on Sunday 8/3/14 staff caught him walking down the hill and made him return.During an interview on 8/8/14 at 11:05 a.m., LN I relayed the facility process for locating a missing resident and stated that Resident 4 had not ever signed out when leaving the facility. The book to sign out is located at each nursing station and should be completed by the responsible party. Review revealed that there were no entries by Resident 4 or Resident 4's responsible party (mother) for the dates of elopements.During an interview, on 8/8/14 at 1:20 p.m., Management Staff D stated that Resident 4 had agreed to wear the Wanderguard at all times and it was now on Resident 4.During an observation, on 8/8/14 at 1:25 p.m., Resident 4 was observed in the wheelchair going down the hallway, with no Wanderguard visible on the person. When the Director of Nurses (DON) asked Resident 4 about the Wanderguard, Resident 4 stated he left it in his room.During an interview on 8/8/14 at 2:40 p.m., LN J stated that whenever Resident 4 left without signing out the facility would place Resident 4 on every one hour monitoring for 72 hours, which meant that a CNA would document on a log the location of Resident 4 each hour, i.e., in room, in dining room etc.During an interview on 8/8/14 at 3:20 p.m., the facility Medical Director stated that walking to the supermarket and leaving the facility in the middle of the night represented very dangerous behaviors and Resident 4 had been escalating and increasing these dangerous behaviors recently. Additionally, the Medical Director stated that the facility would need to immediately "beef up" an Unsafe Behaviors Care Plan and they needed to make sure that the Wanderguard was not taken off.2. Resident 4's Smoking Assessment, dated 7/19/14 at 11:57 a.m., indicated that Resident 4 could light a cigarette and did not need adaptive equipment (smoking apron, cigarette holder, supervision or one-on-one assistance) and noted that the facility would hold Resident 4's lighter and cigarettes, and that a plan of care was implemented to ensure that Resident 4 was safe with smoking.Resident 4's Smoking Care Plan, not dated, indicated a goal of smoking in designated areas and included the following interventions: explain facility smoking policy; monitor and report smoking non compliance to supervisor. Monitor need for smoking materials and remove materials as needed for safe keeping at nursing station. The nursing care plan did not specify what specific behaviors were non compliant and what non compliant behaviors should the staff monitor.First incident of unsafe smoking behaviors:Nurses notes, dated 7/19/14 at 2:37 a.m., indicated that Resident 4 was seen outside of the smoking area by the biohazard waste area at 1:30 a.m. and was reminded to stay in the designated smoking area.During an observation on 8/8/14 at 8:55 a.m., the back patio contained the designated smoking area. At the end of the smoking area there was a large red gate, which was open, and led to the facility main electrical panel and the biohazard waste storage area.Second incident of unsafe smoking behaviors:Social Service notes, dated 7/19/14 at 2 p.m., indicated: "[Resident 4] was involved in an incident while smoking outside the smoking area. [Resident 4] admitted he threw a cigarette into the grass area behind the building which caused a fire...[Resident 4] was again educated about smoking only in the smoking area. [Resident 4] acknowledged understanding the risks and agreed not to smoke outside the smoking area."The Smoking Care Plan was updated on 7/21/14 with : "...resident was re-educated to the smoking policies and procedures and acknowledged understanding."Third incident of unsafe smoking behaviors:A fax dated 7/24/14, with no time noted, was sent to the physician requesting an order for treatment for bilateral thumb burns from the cigarette lighter. This fax did not include the date, time or a description of the burns.A Physician order dated 7/24/14 at 1:47 p.m. re: Bilateral thumb burn, indicated: "Apply Silvadine cream to bilateral thumb burn bid (twice a day), wrap with a dry sterile dressing and re-assess in 14 days."(Silvadine cream: Silver sulfadiazine, a sulfa drug, is used to prevent and treat infections of second and third-degree burns. Second degree burn: causes blistering on the skin but does not damage the deeper layers. Third degree burn: A severe burn in which the skin and underlying tissues are destroyed and nerve endings are exposed. MedLine Plus)During an interview on 8/8/14 at 1:35 p.m. LN J, the wound care nurse, stated that Resident 4 had broken blisters on the tips of both thumbs that had healed well after two weeks of treatment. LN J was unable to indicate the date of the burns, just when Resident 4 had requested treatment for the burns.During observation and interviews on 8/7/14 at 4 p.m. and 8/8/14 at 10:40 a.m. Resident 4 was seated in a wheelchair on the back patio smoking with staff present. When asked how the thumbs were injured Resident 4 reported that both thumbs were burned while lighting a cigarette and demonstrated by holding both thumbs up to a lighter at the same time. Both thumbs had dry peeling skin from tip of thumb down to the first joint, with visible red/pink new skin underneath. Resident 4 stated both thumbs had blisters from the burn and staff used creams and bandages to cure them.Therefore the facility failed to provide adequate supervision and develop an effective plan of care to provide adequate supervision for 1 of 7 sampled residents (Resident 4): 1. When Resident 4, who had exhibited mental decompensation and dangerous behaviors, eloped from the facility on 6/23/14 at 4:45 a.m.; on 7/7/14 at 3:45 a.m. and on 7/27/14 at 7:25 p.m., and 2. When Resident 4 threw a cigarette and set the hillside behind the facility on fire when not in the designated smoking area on 7/19/14 and Resident 4 burned both thumbs when trying to light a cigarette with a lighter.These violations presented imminent danger that death or serious harm would result, or a substantial probability that death or serious physical harm would result. |
| 010000043 |
Park View Post Acute |
110012028 |
A |
30-Mar-16 |
QKN411 |
10385 |
F323 ?483.25(h) Free of accident Hazards/Supervision/devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure the resident environment was as free from accident hazards as possible by failing to ensure residents were properly secured when transporting two residents, Resident 1 and Resident 2, by wheelchair in a van owned and operated by Sister Facility D. While riding in the van on the way back to the facility after an outing on 10/22/15, Resident 1 fell out of her wheelchair and sustained a fracture of the right femur, (thigh bone), and the right tibia, one of the bones in the lower leg, which required surgical repair. At the same time, Resident 2 fell out of her wheelchair and injured her right knee without a fracture. The injuries compromised the residents' ability to maintain an optimum level of physical function and well-being.During an interview, on 11/10/15 at 2:15 p.m., Resident 1 stated she was seated in her wheelchair in the back of the van on the way back to the facility from an outing on 10/22/15. Resident 1 stated there was a seat belt across her lap but not across her chest. Resident 1 stated she did not think the seat belt was buckled. Resident 1 stated when the van braked suddenly, she fell forward from the wheelchair onto the floor of the van. During a review of Resident 1's medical record, on 10/30/15, the resident's Minimum Data Set (MDS), dated 10/13/15, indicated Resident 1 was able to understand and be understood and scored 15 out of 15 possible points on the Brief Interview for Mental Status test (BIMS). The MDS is a comprehensive assessment of a resident's physical, mental, and emotional status. The BIMS test evaluates the resident's memory, awareness of surroundings, and understanding of current situation.The note of the Fall Committee of the IDT (Interdisciplinary Team), dated 10/23/15 at 3:47 p.m., written by the Director of Nursing (DON), indicated Resident 1 sustained a fracture of the right distal fibula (one of the bones in the lower leg) and right femur after a fall from her wheelchair while riding in the van on 10/22/15. The Discharge Summary from the acute care hospital, dated 10/26/15, documented Resident 1 was admitted to the acute care hospital from 10/23/15 to 10/26/15. The discharge summary documented Resident 1 had sustained a right fracture of the femur with displacement (the lower third portion of the long bone of the right thigh was broken and not in alignment with the rest of the bone) from a fall out of a wheelchair which required surgery. The surgery to fix the femur fracture, was a post intramedullary nail fixation (a metal rod placed inside the long bone of the femur to hold it in alignment). The Discharge Summary indicated Resident 1 also sustained a nondisplaced right tibial shaft fracture (the lower portion of one of the bones of the lower leg, the tibia, was broken but not out of alignment). The surgery to fix the tibia fracture was to ensure the upper and lower portions of the bone were lined up correctly and to apply a splint to hold the bone in place while it healed. The surgery to repair both bones occurred on 10/23/15. During an interview, on 10/30/15 at 2:30 p.m., Resident 2 stated she sat in her wheelchair in the back of the van on the way back to the facility from an outing on 10/22/15. Resident 2 stated the wheelchair was attached to the floor of the van but she did not remember anything about the seat belt. Resident 2 stated the driver had to brake suddenly, very hard, and she fell forward out of her wheelchair onto the floor of the van. Resident 2 stated she did not remember being buckled into the wheelchair and did not think she had a seat belt on. During a review of Resident 2's medical record, on 1/11/16, the resident's MDS indicated Resident 2 was able to understand and be understood, and scored 14 points out of 15 possible points on the BIMS.The report of the evaluation by the orthopedist on 11/2/15 indicated Resident 2 sustained a diffuse (spread over a large area) bone bruise involving the right medial femoral condyle (a bone in the knee) with no fractures when she fell out of her wheelchair while riding in a van during an outing on 10/22/15. During an interview, on 11/5/15 at 2:30 p.m., Staff A, the Activity Director, stated she accompanied the residents in the van on the way back to the facility from the outing on 10/22/15. Staff A stated the residents who were seated in their wheelchairs in the back of the van had seat belts that went across their chests from the floor. Staff A stated the driver of the van secured the wheelchairs to the floor of the van and the seat belts to the floor of the van. Staff A stated she buckled Resident 1's seat belt and Resident 2's seat belt. Staff A stated she was turned around facing the back talking to Resident 1 and 2, not buckled into her seat which faced forward, when the driver braked suddenly. Staff A stated she was able to move toward Resident 1 and Resident 2 to break their falls. Staff A stated the seat belts for both wheelchairs popped open and both residents fell out of their wheelchairs on top of her. Staff A stated she did not have any formal training by the facility in the use of or buckling of the van seat belts. During an interview, on 11/20/15 at 12 noon, the Administrator stated the facility did not have a policy and procedure that addressed transporting residents in a facility van because the facility did not own a van. The Administrator stated the facility did not provide training to staff in how to secure residents for transportation in a van or bus or personal vehicle. During an interview, on 10/30/15 at 1 p.m., Staff B, the driver from Sister Facility D, stated she showed Staff A, the Activity Director, how to buckle the seat belts for the residents who were in wheelchairs in the back of the van in preparation for the outing on 10/22/15. Staff B stated the seat belt for residents in wheelchairs had a part that goes across the resident's chest as well as a part that goes across the lap. Staff B stated on the return trip from the outing she did not assist Staff A and the other staff with the two residents in wheelchairs. Staff B stated she did not secure the wheelchairs to the floor and did not buckle the wheelchair residents' seat belts in preparation for the return trip to the facility after the outing. Staff B stated she only handled the lift to transfer the residents who were in wheelchairs into the van in preparation for the return trip back to the facility from the outing.During a document review, on 12/3/15, the document from Sister Facility D titled, "Bus/Van Pre Trip Inspection", dated 10/22/15, and completed by Staff B indicated the following task was completed: "Check seat belts, in good working order, not frayed, cut or torn." Under the section, "Notify Maintenance Director of any issues found", the document indicated the following: "When leaving Petaluma Pumpkin Patch asked staff if residents were all in seats and if seat belts were on and secure. Staff responded yes." The document was signed by Staff B. During a document review, on 12/18/15, a document from Sister Facility D titled "Fleet Safety Program SNF/ALF", (undated), indicated the following: "The driver and all occupants are required to wear safety belts at all times when the vehicle is in operation or while riding in the vehicle. The driver is responsible for ensuring all passengers, including residents, wear their safety belts and are properly secured in the vehicle at all times using the exiting harnesses and restraints." During an interview, on 10/30/15 at 11:30 a.m., Staff E, the Activity Assistant, stated all residents were loaded into the van via the lift while sitting in their wheelchairs to go to the outing and on the return trip from the outing on 10/22/15. Staff E stated most residents were transferred from their wheelchairs to regular seats and their wheelchairs were placed in the back of the van. Two residents remained in their wheelchairs in the back of the van and their wheelchairs were attached to the floor. Staff E stated she only buckled the seat belts of the residents who were seated in regular seats and did not buckle in the residents who remained in their wheelchairs. Staff E stated she assisted with buckling in the regular seat residents going to the outing and on the return trip from the outing. Staff E stated she did not ride in the van with the residents, but rode in a private car to and from the outing. During an interview, on 11/12/15 at 12:30 p.m., Staff F stated she was in the van on the return trip from the outing on 10/22/15. Staff F stated she helped buckle in the residents who sat in regular seats for the return trip but did not buckle in the residents who sat in their wheelchairs in the back of the van. Staff F stated she sat in the last seat on the right side of the van. Staff F stated when the van braked suddenly, she looked back and saw both of the residents, Resident 1 and Resident 2, completely on the floor out of their wheelchairs. Staff F stated she and the Activity Director got the residents back in their wheelchairs. Staff F stated she did not buckle the residents' seat belts after they were back in their wheelchairs but thought another staff member did. The facility failed to ensure the resident environment was as free from accident hazards as possible by failing to ensure residents were properly secured when transporting two residents, Resident 1 and Resident 2, by wheelchair in a van owned and operated by Sister Facility D. While riding in the van on the way back to the facility after an outing on 10/22/15, Resident 1 fell out of her wheelchair and sustained a fracture of the right femur, (thigh bone), and the right tibia, one of the bones in the lower leg, which required surgical repair. At the same time, Resident 2 fell out of her wheelchair and injured her right knee without a fracture. The injuries compromised the residents' ability to maintain an optimum level of physical function and well-being. The above failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000968 |
Professional Post Acute Center |
110012316 |
B |
16-Sep-16 |
X36711 |
5653 |
72311(a)(1)(A) Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. 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 failed to accurately assess staff's ability to transport a resident, Resident 1 who weighed 354 pounds, and develop a nursing plan of care to safely transport Resident 1 from the wheelchair into the transport van when the wheelchair tipped forward and Resident 1 landed on her tailbone. This resulted in an acute fracture of the lower sacrum just above the sacrococcygeal joint. The sacral region (sacrum) is at the bottom of the spine and lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone). Resident 1's admission demographic sheet, dated 1/13/16, indicated Resident 1 was admitted to the facility on 7/6/15. The physician's admission history and physical, dated 7/7/15, indicated Resident 1 was admitted for skin ulcers of the ankles, cellulitis (infection of the cells) with diabetes and obesity, and the wound would be monitored by a wound specialist at a hospital (approximately 20 miles from the facility). A physician note, dated 6/30/15, from the [name of the advanced wound care facility] indicated that Resident 1 was able to be transported to appointments via a bariatric wheelchair (heavy duty wheelchairs intended to safely transport larger individuals) with her legs outstretched and raised. Resident 1's Minimum Data Set (MDS) an assessment tool, dated 7/13/15, indicated that she had a Brief Interview of Mental Status (BIMS) score of 15, scores of 13 - 15 mean cognitively intact and that Resident 1 required extensive assistance of one person for physical transfers and ambulation. Resident 1 did not have an individualized nursing care plan for transport to the wound care specialist in a bariatric wheelchair with both legs outstretched on the leg rests which included how Resident 1 would be transported and the number of required staff. During an observation and concurrent interview on 8/3/15 at 10:40 a.m., Resident 1 was seated in a wide wheelchair, with both legs elevated, in the hallway. Resident 1 stated on 7/7/15 the regular van driver for the facility hurt his knee so he could not drive the van. Resident 1 stated Activity Director immediately started to push her wheelchair and had a hard time getting the wheelchair, with legs elevated, through the facility and into the elevator to go down to the garage level, and never asked staff for assistance. When Activity Director tried to push the wheelchair up onto the van's mechanical lift by herself, the wheelchair wheels got stuck on the edge of the mechanical lift and the wheelchair leaned forward and she fell out of the wheelchair onto the cement floor on her buttocks. Activity Director asked Resident 1 to get up off the floor, but Resident 1 stated she could not do it by herself due to problems with her knees. Activity Director ran to get assistance and came back with 6 men and a mechanical lift to return her to the wheelchair, which was very humiliating. Resident 1 stated the pain to her tailbone was a 5 out of 10 (pain scale used where 0 is no pain and 10 is worst excruciating pain). Resident 1's x-ray report from a local hospital, dated 7/10/15, for examination of a fall with coccyx (tailbone) pain indicated: "Acute fracture of the lower sacrum just above the sacrococcygeal joint." During an interview on 8/3/15 at 1:20 p.m., the Activity Director stated that in hindsight she should have asked for help transferring Resident 1 into the van and that staff usually had 2 staff members assist this resident. She stated she had a license to drive the van and frequently assisted residents in wheelchairs onto the van's mechanical lift and into the van, to be transported for special activities outside of the facility. Activity Director also stated that she knew that it was critical for Resident 1 to go to the wound specialist so wanted to hurry. She stated it was difficult to get the wheelchair onto the lift, due to the positioning of legs up on the leg rests, the front wheels caught on the edge of the mechanical van lift and Resident 1 slid forward and fell out of the wheelchair onto the left side of her body. Therefore the facility failed to accurately assess staff's ability to transport a resident, Resident 1 who weighed 354 pounds, and develop a nursing plan of care to safely transport Resident 1 from the wheelchair into the transport van when the wheelchair tipped forward and Resident 1 landed on her tailbone. This resulted in an acute fracture of the lower sacrum just above the sacrococcygeal joint. The sacral region (sacrum) is at the bottom of the spine and lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone). These violations had a direct relationship to the health, safety, or security of patients. |
| 010000949 |
Pine Ridge Care Center |
110012502 |
B |
17-Aug-16 |
LSSS11 |
6057 |
T22 DIV5 CH3 ART5-72527(a)(10) 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: (10) To be free from mental and physical abuse. The facility violated the regulation by failing to keep two residents (Residents 1 and 2) free from abuse and failed to implement the facility's abuse policy and procedure, when Resident 1 tapped on the wall at 1:00 a.m., 2:00 a.m. and 4:00 a.m., harassing Resident 2, and when Resident 1 made derogatory remarks by calling Resident 2 a "Chink". These failures caused Resident 2 to become upset and hit Resident 1, leaving red marks on the resident's right arm. During a concurrent observation and interview on 2/12/15 at 11:25 a.m., Resident 1 stated that Resident 2 came into Resident 1's room via wheelchair and struck Resident 1, "with a grabber" (a device used to assist residents who have reduced reaching abilities) about "five to ten" times, early in the morning on 2/6/15. Resident 1 had several marks on the right arm and head, which the resident alleged to have received during the attack. Resident 1 stated, "I bang on walls," as the reason why Resident 2 attacked. Resident 1 demonstrated this: The resident reached behind the head of the bed; with fingers, repetitively tapped the wall behind the bed; stopped; reached to the side of the bed, toward the window; with fingers, repetitively tapped on the glass of the window. Resident 1 stated Resident 2's room is right behind Resident 1's head of bed. Resident 1 knew Resident 2 did not like "the banging". During a concurrent observation and interview on 2/12/15, at 12:10 p.m., Resident 2 stated that Resident 1 was "harassing." Resident 2 stated Resident 1 had been bothering Resident 2, day and night, for "weeks." Resident 2 stated Resident 1 had been "calling me names," like "Chink". Also, Resident 2 stated Resident 1 banged on the wall at, "1:00 a.m., 2:00 a.m. and 4:00 a.m.--every night!" Resident 2 stated this behavior kept him awake because the two shared a wall, at the head of the bed. Resident 2 stated "[Staff B]" and "[Staff C]" were aware of Resident 2's behavior prior to 2/6/15. In regard to the incident on 2/6/15, Resident 2 admitted to have "slugged" Resident 1, but only after Resident 1 "threw water on me." During an interview on 3/25/15, at 1:20 p.m., Staff B first became aware of adverse behaviors between Residents 1 and 2 on 2/6/15. In the "late morning" that day, Resident 2 stopped her in a hallway to inform her that Resident 1 had thrown water. Staff B did not inquire more. She left Resident 2 to find Resident 1, and she asked: "Why is [Resident 2] wet?" Resident 1 did not respond. Instead, the resident changed the subject to a missing "cellphone". Staff B promptly ended her inquiry for the moment. Staff B did not recommence inquiries until "the late afternoon," when Resident 1's mother called the facility to inquire how "another resident hit [Resident 1] with a [toilet] plunger". Staff B did not recall if Resident 2 admitted to assaulting Resident 1 on 2/6/15, as alleged by Resident 1. During an interview on 4/22/15, at 1:15 p.m., Staff C stated she observed "several" instances when Resident 1 "antagonized" Resident 2. Staff C stated these instances started after Resident 1's admission to the facility, in January 2015. Staff C believed Resident 1 "especially picked on" Resident 2. She observed Resident 1 use a wheelchair as a weapon to charge into Resident 2. Additionally, Staff C observed Resident 1 laugh "to [Resident 2's] face" after whispering something in close proximity, on three occasions at least. Staff C never deciphered what was said, but observed Resident 2's face appear "upset" after each comment. Staff C, personally, did not inform the facility administrator about what she witnessed. She stated facility staff were well aware of Resident 1's inappropriate behavior, as "Everyone would complain about [Resident 1] in morning meetings." During an interview on 4/22/15, at 1:35 p.m., Administrator A stated that the facility investigated the incident. Administrator A stated that the facility did not substantiate abuse, as neither Resident 1 nor Resident 2 expressed "purposeful" behavior. Administrator A stated the facility did not investigate any incident witnessed by Staff C, as Staff C had not reported the incidents. The facility policy and procedure titled "Abuse & Neglect Prohibition ... California Facility Addendum," undated, indicated the "facility's code of conduct requires any employee to report the facts of known or suspected instance of abuse to the Director of Nursing immediately." The facility policy and procedure titled "Abuse & Neglect Prohibition," dated 10/2004, indicated the facility "must conduct an investigation of any alleged abuse ... in accordance with state law." It defined "abuse" as "the willful inflection of injury ... intimidation ... with resulting harm, pain or mental anguish". It defined "verbal abuse" as the "oral, written or gestured ... disparaging and derogatory terms to residents ..., or within the hearing distance, regardless of their age, ability to comprehend, or disability." Therefore, the facility failed to keep two residents (Residents 1 and 2) free from abuse and failed to implement the facility's abuse policy and procedure, when Resident 1 tapped on the wall at 1:00 a.m., 2:00 a.m. and 4:00 a.m., harassing Resident 2, and when Resident 1 made derogatory remarks by calling Resident 2 a "Chink". These failures caused Resident 2 to become upset and hit Resident 1, leaving red marks on the resident's right arm. The violation of the regulation had a direct relationship to the health, safety, or security of patients at the facility. |
| 010000968 |
Professional Post Acute Center |
110012609 |
A |
31-Jan-17 |
PCMM11 |
15362 |
T22 DIV5 CH3 ART3-72311(a)(3)(B)
(a) Nursing service shall include, but not be limited to, the following:
(3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of:
(B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.
The facility failed to notify the attending physician of Resident 1's fevers of 100.4 degrees F (Fahrenheit) orally on 7/8/15 and 100.5 F orally on 7/10/15, and failed to identify a sudden change of condition for Resident 1 and notify the attending physician promptly of that change of condition, when on 7/19/15 at 7:30 a.m., a family member found Resident 1 on oxygen, pale, diaphoretic (sweating profusely) and complaining of the inability to breathe. The family member insisted on transferring Resident 1 to the hospital. Resident 1 was admitted to the hospital with a diagnosis of severe sepsis, with acute organ dysfunction, most likely secondary to pneumonia. Resident 1 died from pneumonia on XXXXXXX15.
(Sepsis is a complication caused by the body's overwhelming and life-threatening response to an infection, which can lead to tissue damage, organ failure, and death. Sepsis occurs most often in people aged 65 years or older, or less than 1 year, have weakened immune systems, or have chronic medical conditions. Sepsis is often associated with infections of the lungs (e.g., pneumonia), urinary tract (e.g., kidney), skin, and gut. Since sepsis is the result of an infection, symptoms can include infection signs (diarrhea, vomiting, sore throat, etc.), as well as ANY of the symptoms: shivering, fever, or very cold, extreme pain or discomfort, clammy or sweaty skin, confusion or disorientation, short of breath, and high heart rate.)
Resident 1's demographic facesheet, printed on 9/2/15, indicated that Resident 1 was transferred to the facility on XXXXXXX15 with diagnosis that included a recent gastrointestinal bleed, rheumatoid arthritis (Chronic progressive autoimmune disease causing inflammation in the joints and resulting in painful deformity and immobility) with difficulty walking and muscle weakness.
An "Order Summary Report", dated 7/8/15, included medications ordered upon admission which included: 1) Flovent HFA aresol 220 MCG/ACT (microgram [mcg] Aerosol Cloud Enhancer [ACE] Inhalation Aerosol, a steroid) 2 puffs twice a day for shortness of breath and 2) Tylenol 500 milligrams (mg) every six hours as needed for pain.
The Medication Administration Record (MAR), dated 7/16/15, for Resident 1 included notations by nursing staff that Resident 1 received Tylenol 500 milligrams (mg) on 7/8/15 at 9 p.m. for a temperature of 100.4 degrees F and on 7/10/15 at 2 p.m. for a fever of 100.5 degrees F. Nurses notes, dated 7/10/15 at 3:04 p.m., noted: "Resident with fever 100.5, gave Tylenol 650 mg, monitor." Nurse's notes did not include a notation that the physician was notified of the temperatures on 7/8/15 or 7/10/15. A review of Physician orders revealed they did not include an order for Tylenol for fever.
Physician orders, dated 7/13/15, included DuoNeb (bronchodilators that relax muscles in the airways and increase air flow to the lungs) single vial dose, inhaled every four hours as needed for cough, shortness of breath, or wheezing. There was no lung condition or lung disease noted.
Rheumatologist (Physician who specializes in the treatment of rheumatic diseases) orders, dated 7/15/15, included: Tylenol 500 mg, two pills, three times a day (3,000 mg daily) for pain.
The MAR included one notation that on 7/19/15 at 7:30 a.m., a DuoNeb nebulizer treatment was given for shortness of breath. This was the only entry for DuoNeb nebulizer treatments on the July 2015 MAR.
Nurses notes, dated 7/18/15 at 5:20 p.m., indicate breathing treatment per physician order (not noted on MAR) lungs clear. Nurses notes, dated 7/19/15 at 2:53 a.m., for the night shift (11 p.m. on 7/18/15 to 7 a.m. on 7/19/15), noted clear lungs, feels tired, client asked head of bed to be elevated, breathing treatment given as ordered (not noted on MAR).
During an interview, on 2/4/16 at 8:10 a.m., the night shift (11 p.m. on 7/18/15 to 7 a.m. on 7/19/15) nurse, Licensed Nurse C (LN), stated Certified Nursing Assistant B (CNA) was a great CNA and had worked there for over 12 years and knew what symptoms to report to the nursing staff. LN C even stated that CNA B provided great care to Resident 1 and even sat in a chair outside Resident 1's door. LN C stated Resident 1 was producing "whitish sputum" and after the nebulizer treatments Resident 1 would fall asleep. LN C reported that Resident 1 was able to sleep well all night after the nebulizer treatment for shortness of breath. When asked what the symptoms of infection would be for Resident 1, LN C stated they would include a fever over 100 degrees F and shortness of breath.
During an interview, on 2/11/16 at 9 a.m., CNA B stated that the evening shift (3 p.m. to 11 p.m., on 7/18/15) had not reported any problems with Resident 1. CNA B went into Resident 1's room at the beginning of the night shift (11 p.m. on 7/18/15 to 7 a.m. on 7/19/15) and found Resident 1 to be very agitated, in distress, asking for changes in position, and stated she couldn't breathe, and this was reported to LN C. Resident 1 was upset because she had asked for fluids "hours ago" and did not get them. Resident 1 complained of being very, very thirsty and continued with that complaint during the entire night shift. CNA B stated Resident 1 complained about not being able to breathe and was coughing very hard, and that respirations increased as the night went on. Resident 1 kept asking for the bedpan, but was incontinent frequently due to coughing so hard. Resident 1 used a lot of tissues when coughing; so many that CNA B had to empty the trash bag for the used tissues several times during the night. CNA B did not note the color of the secretions on the tissues. CNA B kept reporting Resident 1's complaints to LN C and stated if other nurses had been assigned to Resident 1 they would have called 911 during the night shift. Resident 1 appeared to be very, very uncomfortable and kept complaining of the inability to breathe. CNA B kept asking the night nurse, LN C, to "get in here right now" and evaluate Resident 1. Resident 1 would fall asleep for short periods and wake up like she was having a nightmare and complain of the inability to breathe and extreme thirst loudly. CNA B sat in a chair in the hallway in order to respond quickly to Resident 1. CNA B stated all of Resident 1's complaints of thirst and inability to breathe were referred to the night (11 p.m. to 7 a.m.) nurse, LN C.
During an interview, on 1/14/16 at 2:15 p.m., with the day shift (7 a.m. to 3 p.m.) nurse on duty on 7/19/15, LN D, when asked what the night shift staff had reported at the change of shift at 7 a.m., LN D stated it was reported that Resident 1 had shortness of breath. LN D stated that he remembered checking on Resident 1 that morning and found shortness of breath so provided a breathing treatment which helped bring up her oxygen levels. During the interview, documentation was reviewed consisting of faxed correspondence LN D sent to Physician A at 9:52 a.m., on 7/19/15, noting Resident 1's oxygen levels were 84% (normal is 95 to 100%) with tachycardia (rapid heart rate - rate not noted), and that Resident 1 and her daughter had requested transfer to the hospital. Upon questioning LN D about the vital signs listed on the faxed correspondence to Physician A, LN D stated he could not remember the vital signs he had recorded on the fax and did not record them in Resident 1's nursing notes. LN D stated that because Resident 1 went to the hospital, documentation in the nursing notes was not required. When asked how evaluation would be done to determine symptoms of infection for Resident 1, LN D stated there would be confusion, dehydration, and change in behavior. When asked if vital signs would be checked, LN D stated yes, to see if the temperature was "more than 100 something." When asked if any other vital sign would be evaluated, LN D stated "sometimes the blood pressure." When asked if pulse or respirations would be symptoms, LN D responded "not so much."
During an interview with Physician A, on 3/3/16, at 10:15 a.m., when symptoms reported by CNA B were discussed such as, Resident 1 ' s extreme thirst, coughing so hard Resident 1 was incontinent, Resident 1 using so many tissues for secretions that the garbage bag had to be changed frequently, and Resident 1's complaints of inability to breath, Physician A stated a physician should have been notified and the physician would have requested that nursing staff do a full assessment of the resident with a report back as soon as possible. Physician A further stated staff need physician orders for Tylenol for fevers and the DuoNeb treatments should have been noted on the MAR. Physician A stated the Care Plan should have included nursing assessments for symptoms of infection, what to assess, and when to notify to the physician. Physician A also stated that she frequently had to prompt staff to do a nursing assessment of the residents at this facility. Physician A stated Resident 1 did not have symptoms of infection upon admission on XXXXXXX15. When asked why the respiratory medications were ordered, Physician A further stated she did not remember a respiratory diagnosis for this resident, but ordered respiratory medications when staff reported Resident 1's shortness of breath and wheezing. Physician A also stated, for this resident, with a compromised immune system, and the medications that Resident 1 was taking, a low grade fever would be more profound and should have been reported to the physician. When asked if staff had reported the temperatures on 7/8/15 and 7/10/15, Physician A said they did not. When asked how staff should monitor Resident 1 for potential infections, Physician A stated for Resident 1, if there was a low grade fever of 99 degrees Fahrenheit (F), she would think it was a problem and staff should have notified the physician and completed a full nursing assessment of Resident 1.
A handwritten witness statement, dated 9/2/15, from Resident 1's daughter, a critical care nurse, included the following: I went to visit her [Resident 1] early on the morning of 7/19/15 and when I arrived was horrified to see the condition she was in. She was on oxygen, pale, diaphoretic (sweating profusely) with sweat literally dripping off her hair and face. Her respirations were approximately 50 per minute [normal rate is 12 to 18 breaths per minute] and she stated she had felt bad all night. Her hair and gown was very wet and appeared to have been that way for quite some time. I immediately recognized that she was in acute distress. I went to the nurse's station to seek help. [LN D] was my mother's nurse and after informing him of her current condition he came to her room to assess her. [LN D] needed prompting to check her vital signs [temperature, pulse, respirations, blood pressure and oxygen levels]. He checked her oxygen saturations [a measure of how much oxygen the blood is carrying] and she had desaturated [decreased] to 85% [normal saturation is 95 to 100%], with heart rates in the 160 to 170 range [normal heart rate is 60 to 100 beats per minute]. I asked him to call her physician and he complied. The doctor ordered a chest x-ray, but hours would pass before an x-ray order could be executed. I was offended that her nurse did not see the urgency in this dire situation. A CNA [certified nursing assistant] noticed how upset I was and offered to call 911 for a higher level of care. Within minutes an ambulance arrived to take her to the hospital. My mother was frail and bedbound and could not advocate for herself. She felt helpless and in despair. My mother expired a few days later in the hospital with a diagnosis of bilateral pneumonia [both lungs].
The Emergency Room (ER) report, dated 7/19/15 at 11:53 a.m., indicated the Medical Transport staff noted on transfer [7/19/15], that Resident 1's oxygen saturations were initially in the 80's on room air and Resident 1 received bronchodilators and oxygen during the ride to the Emergency room. The ER report indicated the initial vital signs, upon exam in the ER, were noted as pulse 130, respirations 33, temperature of 98.1 degrees F and blood pressure 115/78. The chief complaint was noted as shortness of breath, chills and fever. The report indicated that Resident 1 complained of feeling sick starting the night of 7/18/15 consisting of fever with chills, cough with green sputum, and mild chest pain with coughing. The Chest x-ray dated 7/19/15, read as left upper lobe and right lower lobe consolidation with a left effusion, which most likely represented pneumonia. Laboratory data included a lactate level of 2.1 (range 0.7 - 1.9). Sepsis screening indicated: A. Heart rate greater than 90 and respiratory rate greater then 20, and B. Lactate level greater than 2.0. The emergency report further noted that: "Patient meets criteria A and B. Patient has severe sepsis." Admit on sepsis protocol.
The hospital discharge summary, dated XXXXXXX15, indicated Resident 1 expired 10 days after admission to the hospital with diagnosis of pneumonia and acute respiratory failure. Resident 1's death certificate, dated issued 8/7/15, listed the immediate cause of death on XXXXXXX15 as pneumonia.
Facility policy and procedure titled "Change in a Resident's Condition or Status", revised February 2014, included: "Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care...1. The Nurse Supervisor/Charge nurse will notify the resident's Attending Physician or On-call Physician when there has been:...d. A significant change in the resident's physical/emotional/mental condition;...g. A need to transfer the resident to a hospital/treatment center...2. A "Significant change" of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff...4. Except in medical emergencies, notifications will be made within twenty-four hours of a change..."
The facility failed to notify the attending physician of Resident 1's fevers of 100.4 degrees F (Fahrenheit) orally on 7/8/15 and 100.5 F orally on 7/10/15, and failed to identify a sudden change of condition for Resident 1 and notify the attending physician promptly, when on 7/19/15 at 7:30 a.m., a family member found Resident 1 on oxygen, pale, diaphoretic (sweating profusely) and complaining of the inability to breathe and the family member insisted on transferring Resident 1 to the hospital. Resident 1 was admitted to the hospital with a diagnosis of severe sepsis, with acute organ dysfunction, most likely secondary to pneumonia. Resident 1 died from pneumonia on XXXXXXX15.
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. |
| 010000949 |
Pine Ridge Care Center |
110012731 |
A |
29-Nov-16 |
1G5R11 |
15227 |
T22 DIV5 CH3 ART3-72311(a)(1)(A) Nursing Service General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. T22 DIV5 CH3 ART3-72311(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. T22 DIV5 CH3 ART3-72313(a)(2) Nursing Service-Administrative of Medication (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed The facility failed to follow physician orders for Licensed Nurses to assess Resident 1's skin from head to toe weekly after Resident 1 was readmitted to the facility following a procedure for inadequate blood supply to the left leg, and to follow the care plans for Resident 1 after an appointment with a vascular surgeon on 2/5/14. The Vascular Surgeon noted dry eschar (scab) on the left foot that measured 4 centimeters (cm). No skin problems were identified until 3/18/14, when a left heel wound that measured 7 cm by 5 cm. was noted as a diabetic ulcer by the treatment nurse. This failure resulted in Resident 1 being admitted to the acute care hospital with sepsis and gangrene on the left foot requiring a below the knee amputation. Resident 1's admission demographic record, not dated, indicated Resident 1 was re-admitted to the facility on 12/12/12 after an admission to an acute care hospital. The acute care hospital operative report indicated a procedure on 12/11/12 for a non-healing left leg wound and rest pain (a continuous unrelenting pain due to ischemia [inadequate blood supply] of the lower leg). Resident 1's admission, dated 9/18/12, to the hospital indicated left heel osteomyelitis (bone infection) with a diabetic foot ulcer and occlusion (blockage) left superficial femoral artery (an artery in the thigh). A Braden Scale assessment, for predicting Pressure Sore Risk, indicated on 12/7/13 and 3/9/14 a score 16. (Total score of 10 to 12 indicates high risk; score of 15 to 18 indicates mild risk). Physician orders included: Order dated 12/12/12, included perform head to toe skin check to all areas of skin, this check should be completed every week on weekly summary by LN [licensed nurse]; Order, dated 12/26/12, included "float heels" (keep pressure/weight off heels); and Order, dated 1/23/13, included: Foot cradle for skin management, licensed nurse to check placement every shift. (Foot cradle to keep sheets/blankets off lower extremities). A Peripheral Vascular Disease (PVD, a disorder of the circulatory system) Care Plan, dated 12/12/13, included the problem as alteration in peripheral tissue perfusion due to PVD. The Interventions included: check lower extremities for shiny skin, loss of hair, change in skin texture and report to MD, skin check as needed. Appointment with vascular surgeon [name] Wednesday [2/5/14], and float heels at all times. A Pressure Ulcer Risk Care Plan, dated 12/12/13, included the problem: Resident at risk for development of pressure ulcer due to left femoral artery stenosis, PVD, Hypertension, fragile skin, and history of non-healing wounds. The Interventions included: weekly skin checks, provide skin care, and foot cradle for skin management (to keep sheets and blankets off the feet). A Fragile Skin Care Plan, dated 12/12/13, indicated a history of PVD and left femoral artery stenosis (narrowing). The Interventions included: monitor skin during care for irritation and breakdown, inform MD for interventions, weekly skin checks, and off load heels while in bed (keep pressure/weight off). A vascular surgeon outpatient visit, dated 2/5/14, included: History of seeing him for peripheral arterial disease (PAD - refers to the condition of progressive atherosclerosis in the arteries of lower extremities, which prevents oxygen-rich blood from reaching the muscles and other tissues), treated with left leg angiogram and recanalization (surgical unblocking of an obstructed vessel within the body) of long segment occlusions of the superficial femoral and popliteal artery (artery in knee and back of leg) in December 2012 for non-healing wounds and rest pain. Dry eschar on the left heel measuring at 4 cm. "...I was concerned about the right heel stage II decubitus. He clearly has impaired blood flow on this leg and I am anxious to avoid the complications he suffered on the left. We talked about floating the heel and avoiding pressure in this area of trauma...I told him this wound was starting because he is spending too much time in bed. He has promised to get out of bed to a chair more often...has significant leg contractures at this point...he also needs to be using skin moisturizer to prevent skin cracking, which could lead to cellulitis and ulceration...". A vascular surgeon verbal order, dated 2/5/14, included: physical therapy to help with increased mobilization, patient needs to move and change position at least every 2 hours, float heels at nighttime, use moisturizer on skin of legs every day. The Fragile Skin nursing care plan, dated 12/12/13, was updated on 2/5/14 with another intervention to apply spa lotion on both legs every day and when necessary for skin management. Resident 1's shower records dated: 2/4/14, 2/7/14, 2/11/14, 2/18/14 and 2/25/14, completed by Certified Nursing Assistant's (CNA's), which included a total body skin assessment, did not note the Stage 2 pressure ulcer to the right foot or the 4 cm eschar to the left foot, as noted by the vascular surgeon on 2/5/14. All shower records were co-signed by Licensed Nursing staff. The Minimum Data Set (MDS), an evaluation tool, dated 3/10/14, noted no pressure ulcers greater then Stage 1. Nursing weekly summary notes dated: 2/1/14, 2/8/14, 2/15/14, 2/22/14, 3/1/14, 3/8/14, and 3/15/14 did not note the Stage 2 pressure ulcer to the right foot or the 4 cm eschar to the left foot, as noted by the vascular surgeon on 2/5/14. A "Weekly Non-Pressure Ulcer Record," dated 3/18/14, noted a left heel wound, size: length 7 cm, width 5 cm and depth 0 cm. Included on this form: "Diabetic foot ulcer, moderate serosanguinous (blood and serum), no odor, no necrosis (cell injury which results in the premature death of cells), or eschar surrounding skin intact, notified MD 3/18/14. Notes dated 4/8/14 included: "length 5 cm, width 4.3 cm and depth 0, with odor, 60 % granulation (material formed in repair of wounds of soft tissue) and notified MD 4/8/14." A Physician order, dated 3/18/14, included: "Left heel diabetic ulcer - cleanse with normal saline [sterile mixture of salt and water], pat dry, apply chlorhexidine 4% [antibacterial used as an antiseptic], let air dry, apply medi honey [possesses antiseptic and antibacterial properties], cover with calcium alginate [A wound dressing used to manage exudates, leaking fluids, in partial to full-thickness wounds, providing a moist environment for healing], secure with kerlix [gauze dressing] once a day and prn [whenever necessary] for 21 days and then re-assess." During an interview on 4/29/14 at 1:20 p.m., Treatment Nurse A stated the facility standard was the CNA's conducted a complete body check during showers to look for any skin issues and if found, the CNA's would report to the Licensed Nursing staff, and record the findings on the shower record. Licensed Nursing staff co-sign the shower records to indicate skin checks were completed by the CNA's. Licensed Nursing staff report all skin findings to the charge nurse, who notifies the physician. If a pressure or diabetic ulcer is found, Treatment Nurse A evaluates the wound and obtains orders from the physicians for wound care. Staff did not report a wound until 3/18/14. Treatment Nurse A stated that a physician called the wound a diabetic ulcer and ordered wound treatments. During an interview on 5/7/14 at 10:45 a.m. Licensed Nurse (LN) B stated the CNA's who assisted Resident 1 with showers did not report or note any skin issues for Resident 1 until 3/18/14. The CNA's are responsible for checking the condition of the skin during showers, and if a skin issue is found, the CNA's report to the Licensed Nurse, who then evaluates the skin issue and co-signs the shower record. During an interview on 5/7/14 at 2:30 p.m. CNA C stated when the CNA's do the body checks during showers they look at all body surfaces, which includes the bottom of the feet and between the toes. If the CNA's find an issue the CNA's create a "Stop and Watch" form to document the findings and provide this form to the Licensed Nurse. CNA's did not note any skin issues for Resident 1. No Stop and Watch forms noted skin issues as the CNA's noted intact skin until 3/18/14 for Resident 1. During an interview on 5/7/14 at 11:15 a.m. and 1 p.m., Director of Nurses (DON) stated the Licensed Nurse assigned to the resident document the weekly nursing summary reports, and would include findings reported by the CNA's from the shower records. When asked how the facility obtains information following physician office visits, DON stated a blank order sheet and blank progress note was sent with the resident on the visit and that the physician [vascular surgeon] may or may not send a report back to the facility and might call the attending physician. The facility did not request the specific office visit note from the vascular surgeon. Additionally, DON stated physicians can call with telephone orders for care and treatment, if needed. During an interview on 5/7/14 at 1:00 p.m., DON stated the wound care physician comes to the facility on Mondays. When the wound changed on 4/8/14 (a Tuesday) the next visit by the wound care physician was scheduled for 4/14/14, and Resident 1 had been transferred to the hospital on 4/10/14. The facility practice is to refer to the wound care physician when there is a significant change. During an interview on 5/28/14 at 8:15 a.m., Administrator D stated the facility did not have a policy for when to refer a resident to the wound care physician, and would do this when there was a change of condition. A Situation, Background, Assessment and Background form (SBAR), dated 4/10/14 at 12 noon, indicated an episode of low blood pressure, with blood pressure of 77/40, resident [Resident 1] appeared lethargic, but follows commands, Physician informed, hold hypertensive (high blood pressure) medications and raise legs. At 12:30 p.m. the blood pressure is noted as 90/50 with temperature 38 degrees Centigrade (100.4 degrees Fahrenheit). Noted at 1:10 p.m.: "new order to send Resident 1 to the hospital for further evaluation." The acute care hospital internal medicine physician note, dated 4/11/14, noted Resident 1 was not able to respond to commands but moaned when the left foot was touched. The left foot had a deep left heel ulcer that had the foul odor of gangrene. The assessment and plan for Resident 1 was noted as currently with evidence of rhabdomyolysis [potentially fatal syndrome caused by the breakdown of skeletal muscle fibers. Mosby's Medical Dictionary, 9th edition. (c) 2009, Elsevier], probably secondary to tissue necrosis [death], this suggests sepsis probably secondary to the gangrenous left heel ulcer. The vascular surgeon progress note, dated 4/12/14, indicated: " ...He returns with sepsis, acute renal insufficiency and worsening gangrenous changes to the left heel. I last saw him in the office 2 1/2 months ago at which time mentation clear, no rest pain, left heel ulcer was dry and measured about 4 cm in greatest diameter and he had a minor stage II decubitus in the right heel...foul odor emanating from the left foot, large eschar over the heel measuring as much as 6 cm, it is boggy (abnormal texture of tissues characterized by a feeling of sponginess, usually because of high fluid content), no obvious discharge. The heel pad is completely gone and the bone is palpated to be just millimeters beneath the eschar ...no significant cellulitis ...Patient has left heel gangrene and also is admitted with sepsis, acute renal insufficiency, and altered mental status. I favor a below the knee amputation...he has had too much tissue loss to make limb salvage a viable option." The facility document titled: Physician Orders, dated 12/18/02 indicated: Purpose: Physician orders are obtained to provide clear direction in the care of the resident. The facility document titled Skin Management, not dated included: " ...Residents who are admitted with pressure sores or other skin condition, such as stasis ulcers, excoriation, etc., will have a "Wound Risk Worksheet" completed. This worksheet will also be completed for every acquired pressure ulcer and quarterly...The Licensed nurses, with each Weekly Summary, will complete "Weekly Skin Checks" . CNA's on each bath day will inspect their patient's skin for any new skin issues, and report to the Charge Nurse, if identified. Licensed Nurses will complete a follow-up of all skin areas identified; 1. MD notification; 2. Family notification; 3. RD [registered dietician] notification of pressure ulcer; 4. Obtain treatment orders as indicated; 5. Check skin "At-Risk score" on the Braden Scale [measures risk of skin breakdown] to see if current and preventive measures are in place; 6. Care plan updates (prevention and for current skin conditions;...Establish a day of the week to measure all pressure ulcers and complete the Pressure Ulcer and Non Pressure Ulcer Logs; Pressure ulcers and non-Pressure ulcers are measured and assessed every week, by the Treatment Nurse or Designated Licensed Nurse; The treatment nurse documents these assessments on the Pressure Ulcer and Non-Pressure Ulcer Logs ..." The facility failed to follow physician orders for Licensed Nurses to assess Resident 1's skin from head to toe weekly after Resident 1 was readmitted to the facility following a procedure for inadequate blood supply to the left leg, and to follow the care plans for Resident 1 after an appointment with a vascular surgeon on 2/5/14. The Vascular Surgeon noted dry eschar (scab) on the left foot that measured 4 centimeters (cm). No skin problems were identified until 3/18/14, when a left heel wound that measured 7 cm by 5 cm. was noted as a diabetic ulcer by the treatment nurse. This failure resulted in Resident 1 being admitted to the acute care hospital with sepsis and gangrene on the left foot requiring a below the knee amputation. Therefore, this presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000377 |
Parkview Healthcare Center |
120007933 |
B |
16-Sep-13 |
DDFT11 |
4153 |
F223 483.13(b), 483.13(c)(1)(i) - 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.On 9/15/09 at 10:45 AM, an unannounced visit was made to the facility to investigate a facility reported incident regarding an allegation of staff to resident verbal abuse.Based on interview and record review, the facility failed to protect Resident A from being subjected to verbal abuse.Resident A is a 58 year old female, who was admitted to the facility on August 27, 2009. She had diagnoses that included: aftercare following, surgery musculoskeletal system, rehabilitation procedures, osteoarthritis, and abnormal gait. She was described in the Weekly Nursing Summary dated 9/7/09, as alert and oriented to person, place, and time. It further described her as continent of bowel and bladder, needing assistance with dressing, grooming, toilet use, transfers, bed mobility, and dependent in locomotion and bathing. Page 3 of the MDS dated 9/7/09 indicates that Resident A is responsible for self, and has no memory problems. On 9/8/09 the facility reported that Resident A alleged abuse from CNA 1. During an observation and interview with Resident A on 9/15/09 at 12 PM, she was sitting in her room in a wheelchair, neat and clean in appearance. The resident described the following events. She stated she had complained to the nurse supervisor about her call light not being answered at night when she needed assistance going to the bathroom. Resident A stated she was not attended to until the morning staff came on and had to clean her. This was reported to the night shift nursing supervisor.Resident A further stated that the next night (9/6/09) the lights in her room suddenly came on and CNA 1 was standing at the foot of her bed yelling at her. She stated, CNA 1 said "you quit accusing me of things, I'm sick and tired of it, and you better shut up." Resident A stated that CNA 1 was displaying a very "threatening" manner and thought she was coming to the side of the bed when the Night Supervisor 1 (NOC 1) entered the room. NOC 1 then took CNA 1 by the arm and escorted her out of the room. NOC 1 returned to make sure Resident A was okay. Resident A stated she was afraid and called her son.During an interview with Resident A's room-mate on 9/15/09, at 12:30 PM, she stated "I was woke up suddenly that night with lights being turned on and yelling". She turned and saw CNA 1 yelling at Resident A. She stated CNA 1 had a threatening look on her face when she was yelling at Resident A.During a phone interview with CNA 2 on 9/16/09, at 8:20 AM, she stated she heard CNA 1 yelling at Resident A. She heard CNA 1 yell "stop making accusations against me."During a phone interview with NOC 1, on 9/16/09, at 9:05 AM, she stated she had been informed of the problem with CNA 1's performance and had just spoken with her about it. NOC 1 stated "CNA 1 then proceeded down the hall to Resident A's room. She followed after CNA 1 but was unable to stop her before she went into Resident A's room. When she arrived at the room she heard CNA 1 say "you're making false accusation against me and lying. Your lies are getting me in trouble." NOC1 stated she removed CNA 1 from the room, escorted her down to the time clock and instructed her to clock out."The clinical record for Resident 1 was reviewed on 9/15/09. Nurse's notes under the heading of "STATUS CHANGE" dated 9/6/09, and untimed, stated the resident was "upset" and had complained of a CNA yelling at herThe Social Workers progress notes dated 9/8/09, untimed, stated Resident A told her that CNA 1 had come into her room and told her (Resident A) to stop making false allegations and lying about her (CNA 1) because she was getting her into trouble.Therefore the facility failed to protect one resident from verbal and mental abuse.The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to resident. |
| 120000377 |
Parkview Healthcare Center |
120009509 |
B |
16-Sep-13 |
PKO111 |
4622 |
Health and Safety Code Section 1418.91 (a) A long term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of the section shall be a class "B" violation. On 6/11/12 at 6 AM, an unannounced recertification survey was initiated at the facility. During the course of the survey, an incident of alleged resident to resident abuse was identified and investigated. Based on observation, interview, and record review, the facility failed to report an allegation of physical abuse of a resident to the California Department of Public Health within 24 hours. Resident 8 was a 59 year old male with diagnoses of urinary tract infection, senile dementia (an illness that affects a person's memory, attention span, social skills and problem solving abilities) with delirium, Parkinson's Disease, and a history of cerebrovascular accident (CVA - stroke). He used a wheelchair for mobility and was moderately impaired with decision making abilities. He had unclear speech and only sometimes understood others. A concurrent observation and attempted interview with Resident 8 was conducted on 6/11/12, at 1:20 PM. The resident was dressed, sitting up in a wheelchair at his bedside watching television and sorting through a stack of DVDs. The resident did not respond to greetings or attempted interview questions. He looked up when his name was called, then returned to watching television without indication of comprehension. The clinical record for Resident 8 was reviewed on 6/14/12. The physician's history and physical examination, dated 11/22/11, indicated the resident did not have the capacity to understand and make medical decisions, was alert but could not communicate verbally. The "Nurse's Notes," dated 1/23/12, at 2:30 PM, indicated the resident had been observed touching a female resident's thigh. No further notations were found in the clinical record regarding the incident. There was no information in the record indicating the Department had been notified of the incident.During an interview with the Social Service Coordinator (SSC), on 6/14/12, at 3 PM, he stated, "I wasn't here at that time (1/23/11), but I can help you. I can't see any note from social services about the incident, but I will as the Medical Record Staff if it's in the overflow files." During an interview with the Director of Nursing Services (DON), on 6/14/12, at 4:30 PM, she stated she would review the record and follow-up with investigation information. At 4:45 PM, she stated she was unable to locate an investigative report about the incident in "our files." She did not find any documentation indicating the incident had been reported to the required agencies. No explanation was offered as to why the incident was not reported to the State Agency within 24 hours. During an interview with the DON on 6/18/12, at 2:15 PM, regarding the details of the nurse's notes documentation of 1/23/12, she stated the Director of Staff Development (DSD) contacted the nurse who made the nurse's note entry on 1/23/12 (Licensed Vocational Nurse, LVN 11) to report to the facility for an interview on 6/15/12. LVN 11 informed the DSD she did remember the incident but could not recall the female resident's name. When asked if LVN 11 was aware of the reporting requirement for possible abuse, the DSD shrugged and stated "she should be." The personnel file for LVN 11 was reviewed on 6/18/12. A signed document in her file indicated she had received "Reporting Elder Abuse" training on 12/22/11. During an interview with the DON, on 6/18/12, at 3 PM, she stated she and the facility administrator had concerns about incident or abuse reporting as they were unable to determine the facility's process for reporting.The facility policy and procedure titled "Abuse Training and Reporting Policy," undated, read in part, "5. ...Staff members will be trained to report anything that may cause injury to a resident." "6. ...If the abuse is between residents, they will be kept apart with an IDT (interdisciplinary team) assessment and permanent interventions implemented." In the policy and procedure titled "Resident-to Resident Abuse," undated, read, "Facility staff will monitor residents...inappropriate behavior towards other residents...such incidents must be promptly reported..." The allegation of abuse had not been reported to the California Department of Public Health by survey exit on 6/19/12. In accordance with Health and Safety Code section 1418.91, this is a class B violation. |
| 120000662 |
POSITIVE DIRECTIONS, INC. #4 |
120010126 |
A |
18-Dec-13 |
0LTF11 |
7732 |
CFR W120 483.410(d)(3) (3) The facility must assure that outside services meet the needs of each client. On 9/13/12 at 11:14 AM an unannounced visit was made to the facility to investigate a fall resulting in a fracture. Based on observation, interview, and record review, the facility failed to ensure the day program staff acted responsibly when putting Client A in physical therapy equipment, and failed to adequately monitor the client while in the equipment, which resulted in the client sustaining a fracture to the upper right leg. Client A is a 64-year-old male admitted to the facility with a history of profound intellectual impairment and seizure disorder (a medical condition that is characterized by episodes of uncontrolled electrical activity in the brain).The facility reported that on 9/6/12, at 10:00 AM, Client A fell from his physical therapy equipment (an "easy lift stander" that enabled the client, normally wheelchair-bound, to stand) while at the day program. Later in the afternoon the client's leg looked compromised. X-rays determined the client's upper right leg was fractured. The Day program had three standers, two smaller ones fit Client A well and one was too large for him. At the time of the incident, Client A was placed in the larger stander because the smaller ones were being used. When a client was placed in a stander, the client needed to be strapped in to prevent repositioning such as leaning forward or to the side. Leaning can cause a client fall while standing on the stander.During an interview with the Day Program Executive Director (DPED) on 9/13/12, at 2:40 PM, he stated, "My conclusion is that (Client A) shouldn't have been put in that stander. It was the wrong stander but (Day Program Staff 1-DPS 1) said (Client A) had been in it before. But (DPS 1) had absolute reason to suspect it was wrong for (Client A). (Client A) was able to reposition himself and he shouldn't have been able to, and (DPS 1) was able to reposition (Client A) without adjusting any straps, without doing any modifications. So I feel (Client A) could have repositioned himself again, which he did. (DPS 1) left the area and had a partner watch him and when (DPS 1) returned she wasn't right next to (Client A). But it shouldn't have gone that far. If they are able to reposition themselves, it is common sense not to leave them in that position. But (the easy lift stander) is too large for (Client A)."When asked what position the client was in when he first repositioned himself, the DPED replied, "Not slipping down but in a position to be able to." DPED added there were other standers available, but DPS 1 told him she used that stander because she hadn't had a problem using that stander with Client A before. "Our procedure is if the correct stander is not available, they wait until it is. (DPS 1) was not doing what was expected... (DPS 1) had plenty of information to know it was the wrong stander." When describing the incident, DPED indicated the client's "upper body slid but his legs stayed in the stander. (Client A's) upper body fell over." During an interview with the Program Coordinator (PC) on 9/13/12, at 3:10 PM, she stated Client A's shoulder was on the ground at the time of the accident. The DPED also stated DPS 2 noticed Client A repositioning himself in the stander, "which shouldn't happen," before the injury. During an interview with DPS 2 on 9/13/12, at 3:25 PM, she stated Client A "was leaning over before he got hurt. (Client A) isn't supposed to be leaning...I waved to (DPS 1), she got my message and repositioned (Client A)...If a client is in the right equipment (stander) there is no need to reposition them...It wasn't adequate to leave (Client A) in (the easy lift stander)." During an interview with DPS 3 on 9/13/12, at 3:35 PM, she stated she had put Client A in the larger stander two or three times before when the two other smaller standers that fit Client A were in use. "We should have waited." Regarding monitoring the client, DPS 3 stated DPS 1 was in charge of Client A. As she saw DPS 1 came out of bathroom, she left Client A and went to talk to the program coordinator. DPS 1, instead of going toward Client A, DPS 1 walked away from the client to a group activity. DPS 1 left Client A alone and out of her reach. DPS 3 stated, "(Client A) needs to be supervised." During an interview with the PC on 10/23/12, at 3:25 PM, she stated, "Someone should have been in reach of (Client A)." During an interview with DPS 1 on 10/23/12, at 3:30 PM, she stated: "The stander didn't fall over...When I came out of the restroom, (Client A's) shoulder was touching the floor and his head was down there also. (Client A) was bent at the waist...No one was right next to him." When asked how she determined what stander to use, DPS 1 replied "It's the bigger one but I've put (Client A) in it before." When asked why she didn't remove the client once he got out of position, DPS 1 answered that none of her clients had ever repositioned themselves in the equipment before. When asked if she was trained to know the clients aren't supposed to be able to reposition themselves in the equipment, DPS 1 indicated, "I don't remember being trained about that beforehand. They trained me after the fact." During an interview with the Physical Therapist (PT) on 10/24/12, at 10:19 AM, he stated he marks the settings on the equipment for each client and indicates on a form which stander to use. The PT stated Client A was not in the stander indicated for his use the day he was injured. The correct stander was determined by the client's weight, size, and height. The PT indicated DPS 1 was trained to put safety straps on the client, and stated that 99 out of 100 times it would have been ok to use the bigger stander if all the supports and safety straps had been applied, but the chest plate was too loose and the hip strap was not applied. "All straps and plates should be applied every time the client is in the equipment." During an interview with DPS 1 on 10/24/12, at 10:35 AM, she stated there was no seatbelt on the stander she used on the day of the accident. "There was Nylex (type of fabric) strap I could have put on around his waist/hip area and I didn't." When asked if she'd previously used the stander without the strap, DPS 1 replied "Yes." DPS 1 also stated she didn't use the strap because the stander didn't have the strap, so she felt it was safe to use the stander without the strap. The PC stated at this time the strap to that stander wasn't attached but was available. Review of the Day Program "EasyStand" instructions for Client A dated 6/21/01 specified which stander to use. The instructions also specified to use a seat belt, and to check that the hips and shoulders were in the center of the stand and lined up with each other. Review of the acute care hospital history and physical report dated 9/7/12 for Client A indicated the client suffered a comminuted fracture of the proximal femur (the nearest part of the long bone running through the thigh has broken into a number of pieces). The acute care hospital discharge summary dated 9/24/12 specified the client underwent an open reduction and internal fixation (a method of surgically repairing a fractured bone, generally involving the use of plates and screws) operation and then was discharged to a nursing home. Therefore the facility failed to ensure the Day Program staff acted responsibly when putting Client A in physical therapy equipment, and failed to adequately monitor the client while in the equipment, which resulted in the client sustaining a fracture of the upper right leg. The above violation presented imminent danger that death or serious harm would result. |
| 120000377 |
Parkview Healthcare Center |
120010167 |
A |
11-Feb-14 |
WZUZ11 |
6727 |
72415 (a) Each occupational therapy service unit shall have written policies and procedures for the management of the occupational therapy service. (b) The policies and procedures shall be established and implemented buy the patient care policy committee in consultation with an occupational therapist. On 4/8/11, at 3:10 PM, an unannounced visit was made to the facility to investigate a complaint of resident injury. Based on interview, and record review, the facility staff failed to follow their policy when staff applied moist heat to Resident 1's shoulder without the required amount of padding wrapped around the heat source. This failure resulted in a burn injury to the resident's shoulder requiring specialty dermatology care and specialized wound care. Resident 1 was an 86 year old female with diagnosis of shoulder joint pain, and insulin dependent diabetes. She was alert and oriented. During an interview with Occupational Therapist 1 (OT 1) on 4/8/11, at 3:20 PM, she stated Resident 1 received therapy services for weakness and assistance with activities of daily living (ADL). She stated the resident had pain on her left side and shoulder when she evaluated and treated her on 3/14/11. She stated another OT saw her on 3/18/11 and applied moist heat to her right shoulder for five minutes. When OT 1 treated the resident after 3/18/11, she stated she noted a dressing on the resident's right shoulder and no further moist heat was applied. When asked if there was a physician's order for the moist heat, OT 1 stated moist heat is a modality used by occupational therapy (OT) and did not require a specific physician's order.The clinical record for Resident 1 was reviewed. The history and physical for Resident 1 from the acute care hospital dated 3/7/11, indicated the resident was admitted for abdominal pain and right shoulder pain. The admitting nursing assessment form, dated 3/13/11, indicated the resident had no open wounds to her shoulders.The OT Evaluation and Plan of Treatment form, dated 3/14/11, indicated Resident 1 was referred to OT for "...decrease in functional mobility, decrease in strength...increased need for assistance from others and reduced ADL participation..." The resident's skin integrity was documented as intact.The "Occupational Therapy Weekly Progress" form for 3/18/11 indicated OT 2 "applied moist heat pad on Rt (right) shoulder for 5 min" (minutes), and "Pt (patient/resident) tolerated moist heat pad for 5 min on her Rt. shoulder to ease the stiffness prior to active exercises. Heat pad was wrapped twice with a towel...." The facility policy and procedure titled "Hot Pack", undated, read "Check the water temperature with thermometer should be maintained at approximately 150-170 degrees. Remove the hot pack from the hydro collator unit, place pack in cloth cover or wrap in 6-8 towels. Skin must be checked every 5-10 minutes or to the patient's tolerance...continue to supervise the patient during treatment."The progress notes by Dr. A, Resident 1's physician, dated 3/23/11, indicated the resident was evaluated with the facility treatment nurse regarding "the right shoulder burn." Silvadene (a topical medication used to treat burns) cream was ordered by Dr. A on 3/23/11. The physician's progress note by Dr. A dated 4/4/11, read "The wound has been healing and is going to be referred to a dermatology consult..."A dictated note titled "Patient Plan" from the resident's managed care network, dated 4/5/11, indicated the burn on her shoulder was worse, had very thick necrosis and was very sensitive. The managed care network document read "...expedite a referral to general surgery as this appears to need surgical debridement and possible skin graft closure. I feel it would be unsafe to attempt outpatient debridement."During an interview with the Director of Nurses (DON) on 4/8/11 at 3:25 PM, she stated the resident's physician and the facility treatment nurse assessed the shoulder injury. The physician then ordered treatment for the injury. She stated the treatment nurse described the injury as a necrotic (death of tissue caused by inadequate blood supply) area. At 4:08 PM, the DON stated she initially received information about the injury via a facility incident report and that the resident stated she was burned during therapy. During a telephone interview with Resident 1's Family Member (FM), on 8/15/11, at 1:35 PM, she stated Resident 1's burn caused her constant pain. The FM stated she had to take Resident 1 to a burn treatment center weekly and change the dressings on the burn two times a day. She stated Resident 1 could not lift her right arm due to the burn and the pain. During a telephone interview with the Risk Manager (RM) for the general acute hospital wound treatment center, on 8/15/11, at 2:35 PM, the RM stated Resident 1 received treatment for a third degree burn to her right shoulder weekly for 5 weeks from 4/14/11 to 5/12/11, then every two weeks from 5/12/11 to 6/9/11, with a return appointment scheduled for four weeks. During a telephone interview with Dr. A, on 8/16/11, at 12:48 PM, he stated Resident 1 had "complained that she was burned during PT (Physical Therapy)" at the facility. He stated when he examined the wound he did not see a blister, he "...just saw a wound." The facility gave "local care" to the wound and he referred the resident to a dermatologist for further care.The Wound Care records from the general acute care hospital wound treatment center, for Resident 1, were reviewed. The wound treatment visit dated 4/14/11, read "(Resident 1) third-degree burn on her right posterior shoulder after a heating pad was placed on her shoulder at the nursing facility. The heating pad was placed and was left on for a significant time and ultimately had an area of a burn on her right posterior shoulder." The wound measured 6x4x0.1 centimeters (cm) and Resident 1 indicated a pain measurement of eight, with one being the least pain and 10 being most pain. The wound treatment visit dated 4/21/11, indicated the resident's pain level was eight out of 10. Debridement (removal) of the necrotic skin was conducted. The wound treatment visit dated 4/28/11, indicated the shoulder burn was debrided again.The wound treatment visit dated 5/5/11, indicated a plan to include the use of a wound vacuum (a mechanical device used to remove secretions and promote healing of wounds), with the possibility of a skin graft.Therefore, the facility failed to take appropriate precautions to prevent injury to Resident 1's shoulder when moist heat therapy was applied, which resulted in a third-degree burn to the resident's shoulder. This violation presented imminent danger that serious harm would result. |
| 120000559 |
POSITIVE DIRECTIONS #6 |
120010370 |
B |
24-Feb-14 |
JDS511 |
3377 |
CALIFORNIA WELFARE AND INSTITUTIONS CODE - 4502(h)Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following:(h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.On 8/1/13 at 2:20 PM, an unannounced visit was made to the facility to investigate an entity reported incident of alleged staff to client abuse. Based on interview and record review, the facility failed to ensure one client (1) was free of abuse. This had the potential to cause physical and/or emotional trauma. Findings: During an interview with the Qualified Individual Intellectual Disability Professional (QIIDP), on 8/1/13, at 2:40 PM, she stated Direct Care Professional (DCP) 2, reported to the Chief Executive Officer (CEO), the incident that happened on 7/23/13. DCP 2 took Client 1 in the room after a shower and was changing Client 1's adult brief, while he (Client 1) was sitting on the edge of the bed with both hands behind him supporting his body and both feet on the floor. While DCP 2 was changing his (Client 1) adult brief he slid and fell to the floor. DCP 2 called DCP 1 to assist Client 1 back to the wheelchair, but Client 1 was "dead weight." While he (Client 1) was on the floor DCP 1 allegedly kicked and slapped Client 1.During an interview with the Chief Executive Officer (CEO), on 8/1/13, at 2:50 PM, she stated DCP 1 confirmed calling Client 1 an "Old man." CEO also stated she asked DCP 1 if she kicked or slapped anyone, DCP 1 did not say "Yes or No" but showed CEO how she put her hands on Client 1's face, demonstrating a slapping gesture. CEO also stated DCP 1 verbalized being tired and frustrated. A review of the facility's investigative report on 8/2/13, indicated the facility had terminated DCP 1. During an interview with DCP 2, on 8/12/13, at 2:56 PM, she stated she was trying to change Client 1's adult brief on the day of the incident, while the client was standing and he slid to the floor. She called DCP 1 to help get the client up. She also stated she could not help DCP 1 in getting the client up to the wheelchair because she was pregnant. DCP 1 had a hard time getting the client up and while the client was on the floor, DCP 1 slapped Client 1 multiple times and kicked him on his left leg while saying "Get up old man." She also stated DCP 1 slapped Client 1 again while he was already sitting in the wheelchair. The undated facility policy and procedure titled "SPECIAL INCIDENTS POLICY: PREVENTION OF ABUSE, NEGLECT, AND MISTREATMENT indicated under Policy: "Individual shall not be subjected to physical, verbal, sexual, or psychological abuse, or neglect." Therefore the facility failed to protect one client from physical abuse.The above violation has a direct or immediate relationship to the patient health, safety, or security. |
| 120000365 |
PARKVIEW JULIAN CONVALESCENT |
120010422 |
B |
11-Feb-14 |
KTS911 |
2067 |
Health and Safety Code 1418.91 (a)(b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 6/7/12 at 10:22 AM, a record review was done on Resident 4 during a recertification survey. The licensed nurses progress note dated 5/13/12, read "This nurse (Licensed Nurse 1-LN 1) responded to arguing in the hall near room 5, while doing medication pass. Upon arrival, this nurse witnessed this resident (Resident 4) throw water on other resident involved in the altercation." Based on interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health within 24 hours of the abusive altercation. Resident 4 was a 79 year old male with the diagnosis of Alzheimer's disease (a progressive, degenerative disorder that attacks the brain's nerve cells, resulting in loss of memory, thinking and language skills, and behavioral changes). During an interview with the Administrator on 6/7/12, at 2:13 PM, he stated LN 1 called him on 5/13/12 to report the altercation involving Resident 4. He verified he did not report the incident to the Department. During an interview with LN 1 on 6/7/12, at 2:23 PM, she stated when Resident 4 threw water on another resident, she immediately rushed to them, separated them, and took them to their rooms. She stated she called the Administrator within approximately 30 minutes of the incident occurring. During an interview with the Director of Staff Development (DSD) on 6/11/12, at 2:54 PM, she state she felt one resident throwing water on another resident as abuse. The facility policy and procedure titled "Policy and Procedure For Reporting Resident Abuse" revised 11/18/11, read "All cases of alleged or suspected resident abuse, neglect and mistreatment....shall be: Investigated and reported....in accordance to Title 22, California State Law...." |
| 120000377 |
Parkview Healthcare Center |
120010482 |
A |
26-Mar-14 |
XTRD11 |
7879 |
F323 (G) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 10/4/12, an unannounced visit was made to the facility to investigate a self-reported incident involving a resident who fell and sustained a fracture.Based on observation, interview, and record review, the facility failed to implement a revised plan of care for one resident (Resident A) who had experienced multiple falls including a fall which resulted in a fractured left hip. This failure resulted in Resident A falling and sustaining another fracture involving the left hip which required a second surgery. Resident A is a 91-year-old female. Her diagnoses included Alzheimer's disease (a form of dementia), dementia (deterioration of intellectual functions), anxiety disorder and depression. During an observation on 10/4/12, at 11:24 AM, Resident A was asleep in her bed. Her bed was of the same standard height as the other two beds in the room. Resident A's room was five rooms away from the nurses' station.The Minimum Data Set (MDS, a structured approach for assessing resident capabilities and needs that results in a care plan), dated 6/22/12, indicated Resident A usually understood others and others usually understood her. Resident A was not able to recall the correct year, month, or day of the week. She needed supervision and set-up assistance in bed mobility, transfers (to or from bed, chair, wheelchair, or standing position), walking in her room or in the corridor, dressing, eating, toilet use, and personal hygiene. She needed one-person physical assistance during bathing. Her balance during transitions from seated to standing position, from bed to chair or wheelchair, from moving on and off the toilet, from turning around and facing the opposite direction while walking was not steady but she was able to stabilize without staff assistance. She had no limitations in her range of motion in her upper or lower extremities. One of the care areas assessed for Resident A was a problem of falls and the facility staff developed a care plan to prevent her from falling. The admission "FALL RISK EVALUATION" form completed on 6/11/12 indicated Resident A was at risk for falls.The "FALL PREVENTION AND SAFETY" care plan, dated 6/22/12, included the following interventions: frequent staff monitoring at night, checking Resident A's whereabouts every half hour, assisting with toilet use as needed, and offering "diversional activities." During subsequent record review, it was identified that Resident A had a total of five fall incidents between 8/15/12 and 9/24/12. Each fall was documented on a "CHANGE OF CONDITION REPORT - FALLS/TRAUMA" form. The summary of these fall incidents were as follows:1. On 8/15/12, at 2:30 PM, Resident A was walking back to her room. She tripped over something and fell in her left knee. She rated the pain at "3" on a 10-point scale with 10 being the most severe.A care plan for her actual fall was developed on 8/15/12 with several approaches that included a "low bed in place." 2. On 8/15/12, two hours after the first fall, at 4:30 PM, a certified nursing assistant found Resident A on the bathroom floor in her room. Resident A was not able to bear weight on her left leg or move it. Resident A was sent to an emergency department at a general acute care hospital for evaluation.A left hip X-Ray performed at the general acute care hospital showed Resident A had a fractured hip. She underwent a left hip replacement surgery the following day. Resident A returned to the facility, to the same room on 8/21/12. A bed and chair alarm was ordered by the physician on 8/23/12. The MDS, dated 9/5/12, indicated Resident A was by this time totally dependent with one-person assistance in bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. She needed extensive one-person assistance in eating and walking. Resident A's range of motion on her left lower extremity was impaired. The "FALL PREVENTION AND SAFETY" care plan, dated 8/21/12, included checking the resident's whereabouts every half hour, not leaving the resident alone in bathroom, frequent monitoring at night, assisting with toileting as needed, offering diversional (sic) activities, and providing a low bed.3. On 9/14/12, at 12 midnight, Resident A was found sitting on the floor in her room beside her bed. "THE INTERDISCIPLINARY PROGRESS NOTES," dated 9/14/12, at 4:40 PM, indicated: "Resident will be moved to a room closer to the nurses' station. Staff will often check Res (resident) if Res need assistance going to the bathroom."During an interview with the licensed nurse (LN 1), on 10/23/12, at 8:10 AM, he stated he was doing initial rounds for his shift when he found Resident A on the floor beside her bed. He stated he did not hear the bed alarm. He stated the alarms were usually loud. LN 1 stated Resident A was in room 43 which was the last room at the end of the hall.4. On 9/17/12, at 10:35 PM, Resident A was found sitting on the floor with her knees bent outside her bathroom door in her room by another licensed nurse (LN 2) who responded to the bed alarm. The "INTERDISCIPLINARY NOTES," dated 9/18/12, at 3 PM, indicated the staff was to continue the use of bed alarms and offer more frequent toileting; and Resident A's room was changed to a location closer to the nurses' station.During an interview with a medical records staff (MR 1), on 10/23/12, at 8:30 AM, she stated Resident A was in room 43 since admission and remained in the same room until she was transferred to room 47 on 9/18/12. The facility did not move Resident A closer to nurses' station as planned for four days, until she had another fall incident. 5. On 9/24/12, at 1:40 PM, Resident A was found lying on her bathroom floor again. She was complaining of left hip pain but was unable to extend her left leg. She was sent to an emergency department for evaluation at a general acute care hospital. She, later, had a surgery. The Operation/Procedure Report from the hospital, dated 9/25/12, indicated Resident A sustained a second fracture of her left hip which started below the stem of the previous surgically replaced artificial left hip. Resident A underwent another surgical procedure on 9/25/12.During an interview with Resident A's roommate (Resident B), on 10/4/12, at 1:30 PM, she stated she saw Resident A got out of bed by herself. She stated no alarms went off at that time. Resident A walked towards the bathroom by holding onto the back of the wheel chair. When she pushed the wheel chair to the bathroom door, she left it there and walked into the bathroom unassisted. Resident B stated she pressed the call button for help when Resident A got out of bed but no one came.During an interview with the Director of Nursing (DON), on 10/4/12, at 2 PM, she stated during the facility's investigation of this incident, the certified nursing assistant who was assigned to Resident A could not remember if she had turned on the pad alarm on Resident A's wheelchair. When asked about the pad alarm on the bed not going off when Resident A got out of bed, she stated it was also not turned on. She explained the reason for the alarms not being turned on was because none of the staff had assisted Resident A back to bed before the incident.The facility staff failed to implement Resident A's plan of care to turn on bed or chair alarm when in use; failed to use a low bed; and failed to move her closer to nurses' station. These failures caused Resident A to fall repeatedly and sustained a second hip fracture. 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. |
| 120001474 |
Providence Sun Villa |
120011037 |
A |
02-Mar-15 |
5CS411 |
5978 |
42CFR 483.25(h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Based on observation, interview and record review, the facility failed to ensure a hot beverage was served at a safe temperature and failed to supervise Resident A and Resident B which resulted in Resident B suffering burns from Resident A's hot beverage. Findings:An unannounced visit was made to the facility on 7/16/14, at 11 AM, to investigate an allegation of resident to resident altercation. The clinical record for Resident A indicated she was a 93 year old female admitted to the facility on 1/7/09 with diagnoses of Alzheimer's disease.Resident A's care plan dated 11/10/13 indicated she was "at potential risk for injuries due to behaviors of wandering and no regard of safety...secondary to late effects of CVA (stroke), Alzheimer's." The goal for this care plan indicated she would "be assisted and monitored by staff to minimize any injuries r/t wandering and behavioral symptoms daily...." The clinical record for Resident B indicated he was a 32 year old male admitted to the facility on 2/4/13 with diagnoses of profound intellectual disabilities and bipolar disorder. The American Academy of Family Physician's defined profound intellectual disability as: "intelligence quotient of less than 20; marked delays in all areas; need close supervision and attendant care; not capable of self-care."Resident B's care plan for bipolar disorder dated 6/6/13 indicated: "(Resident B) is showing increase behaviors; throwing objects at staff, continuous crying and screaming, attempting to strike at staff and other resident-goal is to keep resident stable and reduce/prevent resident from danger to self and others." Resident B had a care plan for impaired cognitive functions related to a diagnosis of intellectual disabilities which had interventions including: Staff please attempt to keep others from approaching resident." Resident B was prescribed an antipsychotic (Abilify) starting 6/6/13 for behaviors listed as: "throwing objects towards staff, continuous screaming and yelling, attempting to strike staff and resident." During an interview on 7/16/14 at 11:15 AM, the Director of Nursing (DON) stated Resident A had a diagnosis of dementia and had thrown a cup of hot cocoa at Resident B on 7/12/14 at 9 AM. The cup of hot cocoa had been prepared by Activities Director (AD) 1. During an observation on 7/16/14 at 11:35 AM, Resident A was seated in the dining room. She was alert and confused and her speech was garbled. During an observation on 7/16/14 at 11:30 AM, at the request of the surveyor, Food Server (FS) 1 poured water from the container used for hot cocoa into a styrofoam cup and placed a thermometer in the water. The water registered 184 degrees F.During a record review on 7/16/14, nurses' notes dated 7/12/14 indicated Resident B suffered burns on bilateral inner thighs. The physician was notified and ordered treatment with silvadene ointment which is an antibacterial cream. During an interview on 7/31/14 at 11 AM, Licensed Vocational Nurse (LVN) 1 stated she observed Resident A throw her hot cocoa at Resident B's lap. LVN 1 stated Resident B was immediately taken for a cool shower and "his skin was peeling off as soon as we got him in the shower." LVN 1 stated Resident A was "not coherent enough to know what's going on." LVN 1 stated she was not aware of any policy about supervising demented residents with hot drinks but stated "There's a policy that drinks have a certain temperature when leaving the kitchen" but did not know the correct temperature. During an interview on 7/31/14 at 11:50, AD 1 stated Resident A was drinking a hot beverage and "(Resident A) freaks out if anyone touches her. (Resident B) touches everybody. No staff was in there; we went in when we heard yelling." AD 1 stated she was not aware of any facility policy regarding safe temperatures of hot beverages and "We just serve what the kitchen fixes." During an interview on 8/13/14 at 12:35 PM, Day Program Staff (DPS) stated the day after the incident she observed bandages on Resident B's thighs; removed the bandages and observed blisters "in more than one area. It's hard to tell if he is in pain; he's always tense. But he looked more uncomfortable than usual."The facility policy and procedure titled, "Food Preparation", dated 2012, indicated in part, "12. Prepared food will be stored at proper temperature until serving time. B. Hot beverages 140 degrees F and < ( below)160 F." An article, "Scalds: A Burn Issue," published in 2000 by American Burn Association has identified older adults and people with any type of disability are at high risk to be scalded by hot water. The severity of injury with scalds depends on two factors - the temperature to which the skin is exposed and the length of time that the hot liquid is in contact with the skin. At 120 degrees Fahrenheit / 48 degrees Celsius, skin requires five minutes of exposure for a full thickness burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 degrees Fahrenheit, resulting in almost instantaneous burns that require surgery to heal. The same article also described people with disabilities or special needs may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. The disability may be permanent or temporary due to illness or injury and vary in severity from minor to total dependency on others Therefore, the facility failed to supervise Resident A which resulted in Resident B suffering burns from Resident A's hot beverage. 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. |
| 120000377 |
Parkview Healthcare Center |
120011224 |
A |
04-Feb-15 |
IS6W11 |
8042 |
A 880 - 72527(a)(9) - Patients' Rights 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: To be free from mental and physical abuse. On 9/11/14, at 1PM, an unannounced visit was made to the facility to investigate an entity reported incident for an alleged verbal and physical abuse of a patient (2) by another patient (1). Based on observation, interview, and record review, the facility failed to follow a care plan for providing close supervision for patient (1) resulting to verbal and physical abuse to patient (2). This adversely affected patient (2) resulting in injuries to the right side of his face, and bleeding to his upper lip. Findings: Patient 1 was a 58 year-old male re-admitted to the facility on 4/25/11, with a diagnosis of depression, high blood pressure, peripheral vascular disease (a common circulatory problem in which narrowed arteries reduce blood flow to your limbs), and hypothyroidism (deficient activity of the thyroid gland). Patient 2 was a 90 year-old male admitted to the facility on 10/10/13, with diagnoses of dementia (general loss of cognitive abilities including impairment in memory) with behavior disturbances, depression, and Parkinsonism (disorder of the brain that affects movement). During an interview with the Director of Nursing (DON), on 9/11/14, at 2:30 PM, she stated, "The facility reported a resident to resident altercation that happened 9/5/14. (Patient 1) was in the dining room watching television when (Patient 2) came in and turned off the fan. (Patient 1) got very angry asking (Patient 2) to plug it in but he did not follow him. (Patient 1) then hit (Patient 2) on his face."During a concurrent interview and clinical record review, with the Assistant Director of Nursing (ADON), on 9/11/14, at 2:45 PM, she was informed that one of the approaches/intervention in the care plan for behavior problems r/t disruptive behavior, combativeness, verbally abusive and inappropriate behavior, was to provide close supervision and watch for early signs of agitation. She verified the findings and stated, "I don't know how it happened but yes, it's in the care plan." No further information was provided. During an interview with the Maintenance Lead (ML), on 9/11/14, at 3:15 PM, he stated, "I heard two residents arguing really loud. I told them to calm down. (Patient 2) told (Patient 1) to turn off the fan. They calmed down so I went to my office. I heard again somebody yelling. I came out and saw (Patient 1) was at the back of (Patient 2) holding his wheelchair. I saw (Patient 1) strike (Patient 2) five times...I saw (Patient 2's) lip with a little blood on it, his face was red. By that time the DON saw the last strike." During a concurrent observation and interview, with Patient 2, on 9/11/14, at 3:40 PM, he was in his room sitting in his wheelchair. He had a cut on his lip, fading bruise on the right eye and skin tear (ST) on his left forearm. He stated, "Still sore but getting better." He also stated, "I turned the fan off because my dining table is right on the fan. He (Patient 1) told me, 'It's hot in here, turn on the fan' and suddenly he hit me, started cursing and said bad words. My eyes, arms, and lips still sore." During an interview with Patient 1, on 9/11/14, at 4 PM, he stated, "That old man (Patient 2) put the fan off. He kicked, hit on me first through the cheek so I hit him. The staff saw me hit him but did not see him hit me." The clinical record for Patient 1 was reviewed. The Minimum Data Set (MDS assessment tool) dated 8/21/14, indicated the "Brief Interview for Mental Status (BIMS-a brief screener that aids in detecting cognitive impairment)" score was 15/15 (cognitively intact). Patient 1 had episodes of being short tempered, easily annoyed, threatening, screaming and cursing others (occurred several days) and daily episodes of rejecting care during this assessment period. The long term care plan for Behavior Problems, dated 6/4/14, indicated Patient 1 manifested verbal disruptive behavior, combativeness, verbally abusive and inappropriate behavior. The approaches to address these problems read "...provide close supervision and watch for early signs of agitation or increasing anxiety and report." The nurses notes dated 8/29/14, at 8:35 AM, read, "...Pt. (patient) states "I'm on fire"...Pt. became very angry and started cursing vulgar obscenities...Pt. refused treatment..." The nurses notes dated 8/29/14, at 9AM, read, "Resident c/o (complaining of) being hot...Was next door with other resident when I heard tx (treatment) nurse suggest resident take a cool shower. Resident then became upset cursing at tx nurse. Resident next door (Patient 2) told Patient 1 to shut up then he (Patient 1) started cursing and threating resident next door (Patient 2)." The nurses notes dated 9/5/14 indicated there was one documented incident of resident to resident altercation on 9/5/14 between Patient 1 and 2. The Nurses Notes on that day, read, "Heard screaming coming from main dining room. Noted Resident (1) involved in altercation with another Resident (2)...Resident 1 stated, "He hit me first so I punched him in the face, I have the right to defend myself." The Social Services Director (SSD) Notes on behavior dated 9/7/14, 3:43 PM, read, "Late entry: 9/5/14, res. (resident) to res. altercation...Res. admitted to punching other resident on his face." The SSD Progress Notes on behavior dated 9/9/14, 2:54 PM, read, "Res. cont. (continue) to have angry outburst with other res...Had to move other res. to another nurses station due to constant name calling and arguing with next door neighbor, which they also share restroom." The clinical record for Patient 2 was reviewed. The Minimum Data Set (MDS assessment tool) dated 8/1/14, indicated Patient 2's "BIMS" score was 14/15 (cognitively intact).The Nurses Notes dated 9/5/14, 10 AM, read, "Heard screaming come out of the dining room, noted resident involved in altercation with another resident. Resident stated, "He punched me in my face for no reason. C/O pain 6/10 with some bleeding noted from upper lip, noted small tear to right side of upper lip." The Change of Condition Report dated 9/5/14, read, "Reported by staff resident has (sic) altercation with another resident. Sustained injuries to right side of his face...Received order to sent (sic) resident out for further eval (evaluation) and tx (treatment) (S/P physical assault resulting to facial injuries and oral bleeding). C/O facial pain." The Interdisciplinary Progress Note dated 9/8/14, 10 AM, read, "Resident obtained S/T (skin tear) about 2.5 cm x 1.5 cm in size to left posterior forearm with dry black discoloration noted around area...Resident stated that he obtained S/T from altercation with another resident on 9/5/14." The undated facility policy and procedure titled "Resident to Resident Abuse" read, "1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Develop a care plan that includes interventions to prevent recurrence of such incidents, including the appropriate management of an underlying condition. Document in the resident's clinical record all interventions and their effectiveness." The facility failed to ensure Patient 2 was free from physical and verbal abuse which adversely affected his physical and emotional well-being. The facility also failed to adequately supervise Patient 1 which resulted physical injury to Patient 2. Therefore 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. |
| 120001421 |
Providence Valley Care Center |
120011440 |
A |
15-Jun-15 |
88R711 |
10227 |
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. On 1/13/2015, at 9:15 AM, an unannounced visit was made to the facility to investigate an entity reported incident of alleged resident abuse. The facility failed to protect one resident (Resident 1) from verbal and physical abuse when he was cursed at, held down and forced to take a shower against his will. This failure resulted in mental anguish and physical harm. Resident 1 was an 81 year old male who was admitted to the facility on 9/13/13. Resident 1 had a history of heart disease, cancer, and a stroke, which left the right side of his body weakened and dependent on others for activities of daily living. Resident 1 had difficulty communicating related to the stroke; he was aware of what he wanted to say however, at times he had trouble speaking the words. During an interview with the Certified Nursing Assistant 1 (CNA 1) on 1/14/15, at 1 PM, she stated she was sitting at the nurses station on the evening of 1/1/15, when she heard Resident 1"...screaming at the top of his lungs..." from the shower room. She stated when she went to the shower room to check on Resident 1, there were three other CNAs (CNA 2, 3 and 4) already in the room and they "twisted his arm and slammed it down..." as they held him down in the shower chair (a special plastic chair used while showering a resident). CNA 1 also stated she heard CNA 3 yell at the resident 'Shut the (expletive) up, Resident 1!" CNA 1 stated "They were holding him down...they forced him. She stated the same incident happened the night before, on 12/31/14, with Resident 1, CNA 2, and CNA 3. I know I should've told someone about it the first night".CNA 1 stated after the shower, she assisted Resident 1 to his room, where he held out his arms and stated to her "Look what they did to my arms." CNA 1 then noticed Resident 1's arms had purple and blue marks on the forearms, wrists and hands.During an interview with CNA 2 on 1/22/15, at 11:24 AM, she recalled the incident with Resident 1. She stated on 12/31/14, she had helped CNA 3 shower Resident 1; he didn't want to have a shower and was very upset during the shower. CNA 2 stated she did not document the incident on 12/31/14..."I should have. I was taught to leave them (residents) alone if they are uncooperative and to come back later." CNA 2 stated on 1/1/14, she was supposed to shower Resident 1..."He refused (his shower)...I went back to convince him...He started yelling...CNA 3 was in there (shower room), then CNA 4 came in to help...I didn't think about it, I just grabbed him instead of just stepping away. We weren't thinking...I was holding him down while CNA 3 was showering him..." CNA 2 stated she did not report the incident on 12/31/15. During an interview with LN 1 on 1/22/15, at 1:40 PM, she recalled the incident with Resident 1 on 1/1/15. "I was in the nurse's station doing charting. CNA 1 and CNA 5 were there too. CNA 2 and CNA 3 were bathing Resident 1. They called out for help. CNA 5 went to check on them, but he came right back. Then I could hear CNA 2 and CNA 3 laughing, so I figured everything was okay. CNA 1 went to check on Resident 1 and she came back right away and told me I needed to check on Resident 1 right now. I went to Resident 1's room and found him in bed naked, no brief on...he was very upset. I asked him what was wrong. He pointed to the bruises on his wrists and said to me 'I just can't do it. I don't know what to do.' He was crying. I noticed he had bruises that were purple on both his wrists and arms. They (bruises) were new. I called CNA 2 and CNA 3 over and asked what had happened. They said the bruises were old...I told them they were not old and they had never been reported to me. I wasn't told about any incidents with Resident 1 the night before (12/31/14)." During an interview with CNA 4 on 1/28/15, at 11:40 AM, she recalled the incidents with Resident 1 on 12/31/14 and 1/1/15. She stated on 12/31/14, CNA 2 and CNA 3 were showering Resident 1. "CNA 2 was holding him down." She stated on 1/1/15, CNA 2 and CNA 3 were again showering Resident 1..."I told them he was showered yesterday so he didn't need a shower today. I held the door open (to the shower room) and Resident 1 started yelling as soon as he got into the shower room. I told CNA 2 he didn't want a shower...he doesn't normally act like that...I've showered him before. CNA 2 held his arms down while CNA 3 showered him. He was really upset. It was obvious he didn't want a shower. CNA 3 flicked him with the towel on his chest. CNA 2 kept yelling at him to be quiet. They kept showering him. CNA 5 came in but was unable to calm him down either. CNA 1 was in the shower room too. She helped me transfer Resident 1 to his bed. He was so upset we couldn't dress him. He held out his arms and said to us 'Look what they did to my arms'.During an interview with CNA 5 on 2/2/15, at 8:30 AM, he recalled the incident with Resident 1 on 1/1/15. He stated he did not work on 12/31/14, so he was unable to provide any information about the incident on that night. CNA 5 stated on 1/1/15, he was at the nurse's station. CNA 3 went to bathe Resident 1. "I was paged overhead (to the shower room). When I got there, CNA 2 was holding his good arm while CNA 3 was holding his bad arm. CNA 3 sprayed Resident 1 in the face (with water)...she never checked the water temperature...when CNA 3 sprayed him, Resident 1 started yelling." CNA 5 stated "It's common sense...if he (Resident 1) doesn't want to shower, don't make him."During a concurrent observation and interview with Resident 1 on 1/13/15, at 11:15 AM, when asked about the shower incident, he put his head down and began to cry; he held both arms out and began to rub his wrists. When asked if someone had hurt him in the shower, he stated, "Oh yes". Resident 1 was able to speak the words; however, it took a few moments for him to be able to articulate them.During a review of the clinical record for Resident 1, the "Skin Assessment Tool", dated 1/2/15, had a drawing outline of the front and back of the human body. Handwritten around the body was the word "Bruising", with lines drawn to indicate the bruising was on the back of the right hand and wrist, as well as the left hand, wrist and forearm.During a review of the clinical record for Resident 1, the "Progress Notes", dated 1/1/15, at 11:55 PM, indicated "Will monitor for any abnormal changes to bruise to right hand and left hand and delayed injury r/t(related to) incident this evening...reassured him staff will be more gentle with him..." The "Progress Notes", dated 1/2/15, at 12:44 AM, indicated "The DON (Director of Nursing) was notified regarding incident of bruising to (Resident 1's) left wrist and top of left hand and also top of his right hand. The bruises are dark purple in color, tender to touch...able to move his left hand and wrist...his right hand is the affected hand from his previous CVA (cerebrovascular accident: condition where lack of oxygen effects the brain) so he has limited movement of the hand and wrist... (Resident) to [sic] upset at this time to do full body assessment..." The "Progress Notes", dated 1/2/15, at 2:03 AM, indicated "When asked if he (Resident 1) was in pain he stated that his hands hurt, his arms hurt and his feet and legs hurt. Said he would like something for pain and was medicated..." The "Progress Notes", dated 1/4/15, at 4:27 PM, indicated "Resident refused a bed bath and that he would attempt a shower. Resident noted to be slightly anxious but was noted to calm down when he was testing the warmth of the water...This nurse noted a fading yellow bruise to L) [sic] (left) upper chest. Unsure if bruise noted to L) upper chest was added to prior full head to toe assessment completed." The "Progress Notes", dated 1/7/15, at 2:45 PM, indicated "Res (resident) is observed this shift with withdrawal, and flat affect. Res. Has very poor appetite this shift for both meals...Res. Enc. (encouraged) to voice any concerns but just drops head and nods "oh no, oh no." The "Progress Notes", dated 1/8/15, at 2:13 PM, indicated "Res. (resident) does not wish to go for meals to main dining room as he usually did." During an interview with the DON, on 1/13/15, at 9:40 AM, when asked what the facility policy is regarding a resident who refuses a shower, she stated the facility policy is to stop the shower immediately and get the resident to a safe area tell the nurse. The DON stated Resident 1 had a history of refusing showers. He had previously had a stroke, so he had difficulty communicating; Sometimes he can form sentences without a problem, other times he can't. The facility policy and procedure titled "Resident Rights Guidelines for All Nursing Procedures" dated April 2013, indicated in part, "Ask permission to implement the procedure. If the resident refuses, notify your supervisor." The facility policy and procedure titled "Reporting Abuse to Facility Management" dated April 2013, indicated in part, "It is the responsibility of our employees...to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source...to facility management...Our facility does not condone resident abuse by anyone, including staff members...Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish...." The facility policy and procedure titled "Shower/Tub Bath", dated October 2010, indicated in part, "Handle the resident as gentle as possible. Do not rush the procedure. Allow the resident to take rest breaks as needed. Should the resident become...uncooperative during the procedure, turn off the shower...Cover the resident and summon the supervisor by using the emergency call system..." Therefore, the facility failed to protect one resident (Resident 1) from verbal and physical abuse, which resulted in mental anguish and physical harm to the resident. This violation had a direct or immediate relationship to the health, safety, or security of residents. |
| 120001421 |
Providence Valley Care Center |
120011441 |
B |
15-Jun-15 |
88R711 |
2292 |
Health and Safety Code Section 1418.91 (a) A long term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of the section shall be a class "B" violation. On 1/13/2015, at 9:15 AM, an unannounced visit was made to the facility to investigate an entity reported incident of alleged resident abuse. The facility failed to report an allegation of abuse to the Department of Public Health within 24 hours. On 1/2/15, at 5:26 PM, the facility reported an allegation of abuse against Resident 1. The incident first occurred on 12/31/14 and again on 1/1/15.Resident 1 was an 81 year old male who was admitted to the facility on 9/13/13. Resident 1 had a history of heart disease, cancer, and a stroke, which left the right side of his body weakened and dependent on others for activities of daily living. Resident 1 had difficulty communicating related to the stroke; he was aware of what he wanted to say, however, at times he had trouble speaking the words. During an interview with the Certified Nursing Assistant 1 (CNA 1) on 1/14/15, at 1 PM, she stated she observed the incident of abuse on 12/31/14 between CNA 2, CNA 3, CNA 4 and Resident 1.CNA 1 stated on 1/1/15, she was sitting at the nurses' station when she heard Resident 1"...screaming at the top of his lungs..." from the shower room. She stated when she went to the shower room to check on Resident 1, there were three other CNAs (CNA 2, 3 and 4) already in the room and they "twisted his arm and slammed it down..." as they held him down in the shower chair (a special plastic chair used while showering a resident). CNA 1 also stated she heard CNA 3 yell at the resident 'Shut the (expletive) up, Resident 1!" CNA 1 stated "They were holding him down...they forced him. I know I should've told someone about it the first night". During an interview with the Director of Nursing (DON) on 1/13/15, at 9:25 AM, she stated CNA 1 was suspended for failure to report the abuse which occurred on 12/31/14. The DON verified the allegations of abuse occurred on 12/31/14 and 1/1/15. Therefore, the facility failed to notify the Department of an allegation of abuse within 24 hours. |
| 120000377 |
Parkview Healthcare Center |
120011478 |
A |
22-Jun-15 |
0P7Y11 |
4322 |
F 323-483.25(h) Accidents The facility must ensure that the resident environment remains as free from accident hazards as is possible, and each resident receives adequate supervision and assistance devices to prevent accidents. On 3/25/15, at 1:45 PM, an unannounced visit was made to the facility to investigate an entity reported incident and complaint of a resident's (Resident 1) fall with injury. Based on interview and record review, the facility failed to use a non-skid pad, as per the plan of care, in Resident 1's wheelchair after a prior fall, resulting in the recurrence of a fall with injury. The clinical record for Resident 1 was reviewed. On 5/31/14, Resident 1 slid off her wheel chair and fell to the floor. The "Change of Condition Report" for the fall, dated 5/31/14, indicated the facility would place a non-skid pad (a pad placed in a wheel chair to help prevent the resident from sliding out onto the floor) on her wheelchair to prevent further falls. The Fall Risk Evaluation for 5/31/14, read. "Non-skid pad on the (sic) wc (wheelchair) when up in w/c." The Interdisciplinary Progress Notes dated 7/18/14, at 10:05 AM, read: "Resident's fall incident on 7/17/14 at 2015 (8:15 PM) hours. CNA reported to Charge Nurse while they were transferring the resident (1) from shower chair to bed and slid from the chair and they assisted her to the floor..." The Change of Condition Report dated 3/11/15, 13:00 (1 PM ), read, "Went to room 30 C found resident (Resident 1) slid down from w/c while she move (sic) wheelchair...Asked resident what happen (sic). She said CNA (1) pushed my w/c that's reason (sic) I slid down..." The radiology results dated 3/11/15 indicated Resident 1 sustained a right hip fracture on 3/11/15, as a result of her fall from the wheel chair on that day.The Certified Nursing Assistant's (CNA 1) written statement dated 3/11/15, read: "When I was coming out from restroom Resident 1 was turning around by herself then I was trying to help her and she slide (sic) down from w/c sitting down on the floor." The Interdisciplinary Progress Notes dated 3/12/15, 10:30 AM, read, "After further investigation resident (1) slid down from w/c...As per CNA (1), resident asked her to push w/c and take her out of the room. As soon as she touched the w/c, resident slid down. CNA touched the resident and trying to stopped (sic) her from sliding down but CNA said she was not able to stop it. Resident was on the floor...Resident reported that she fell/slid down because CNA pushed her w/c..." During an interview with the Licensed Vocational Nurse 1 (LVN 1), on 3/25/15, at 3:15 PM, she stated, "The CNA (1) called me saying Resident (1) fell...Resident (1) was sitting on the floor...she complained her leg was hurting...Found out she had hip fracture...At the time of the fall (3/11/15) there was no non-skid pad on her wheelchair." During an interview with Resident 1, on 4/13/15, at 4:25 PM, she stated, "The CNA (1) pushed me around so fast. She pushed me a little hard. I fell over the w/c inside my room near my bed and broke my hip bone." During a concurrent review of the clinical record for Resident 1 and interview with the Assistant Director of Nursing (ADON), on 4/17/15, at 3 PM, it was noted the recommended intervention for a fall on 5/31/14, titled 'Fall Risk Evaluation' included using a non- skid pad on the wheel chair. The ADON confirmed the finding.The facility policy and procedure titled "Fall Prevention and Incident Management", undated, read, "The intent of this policy is that the community identifies residents who are at risk for accidents or falls, and adequately assesses and plans care to reduce the injuries associated with the resident's risk to the extent possible....The Licensed Nurse will complete an evaluation of the resident on admission, quarterly, annually and with significant change in status. The Interdisciplinary Team, based on the identified potential risk factors, develops and implements an individualized plan of care as necessary." The facility failed to use a non-skid pad, as per the plan of care, in Resident 1's wheel chair, after a prior fall which resulted in the recurrence of falls and a right hip fracture. Therefore, the above violation presented a substantial probability that death or serious physical harm would result. |
| 120000365 |
PARKVIEW JULIAN CONVALESCENT |
120011581 |
A |
03-Aug-15 |
25RO11 |
9693 |
F 309 - Provide Care/Services for Highest Well Being - 483.25 Each resident must receive and the facility must provide the necessary care and service to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On 4/30/15, at 2:10 PM, an unannounced visit was made to the facility to investigate an entity reported incident of a fall with injury. Based on interview and record review, the facility failed to ensure licensed nurse assessments resulted in appropriate interventions being implemented for one of one sampled resident (1) who had a fall. This failure resulted in Resident 1 experiencing worsening hip pain from an undetected hip fracture and a delay in medical treatment for his hip fracture. Resident 1 was a 73 year old male with diagnoses of generalized muscle weakness, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes (a serious disease in which the body cannot properly control the amount of sugar in the blood), hypertension (high blood pressure), cardiac pacemaker (A system that sends electrical impulses to the heart in order to set the heart rhythm), generalized pain, and paralysis agitans (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination). During an interview with the Registered Nurse 1 (RN 1), on 4/30/15, at 2:40 PM, she stated Certified Nursing Assistant 1 (CNA 1) told her on 4/4/15, that Resident 1 was on the floor next to his wheelchair. RN 1 stated, "We were assuming he was trying to get out of his wheelchair (wc) when he fell. Nobody witnessed the fall." During an interview with the Licensed Vocational Nurse 1 (LVN 1), on 4/30/15, at 3:20 PM, she stated, "A CNA called that (Resident 1) fell (on 4/4/15). I saw the resident on the floor, one leg on top of the other kind [sic], a sitting position." During a review of the clinical record for Resident 1, the Minimum Data Set (MDS, assessment tool) dated 2/21/15, indicated he had a Brief Interview for Mental Status (BIMS - a brief screener that aids in detecting cognitive impairment) score of 14/15 (cognitively intact). The MDS indicated Resident 1's balance in moving from seated to standing position, walking, and surface to surface transfer were not steady and he was only able to stabilize with staff assistance. He had no impairment in his functional range of motion. The Physicians Order dated 6/2/14, read, "Tylenol (for pain) tablet 325 mg (milligram) (Acetaminophen) Give 2 tablet (sic)...by mouth every 6 hours as needed for pain." The nurse's notes dated 4/5/15 at 5:36 PM, indicated Resident 1 was complaining of pain and was given Tylenol. The Nurses progress Notes dated 4/6/15, at 16:28 (4:28 PM), read, "...assessed the Resident verbalized pain in the right hip. Resident stated that he is unable to move his right hip....new order received for an X-ray of the right hip." The X-ray report dated 4/6/15, indicated Resident 1 did not have an acute fracture but had an old healed hip fracture.The nurses notes dated 4/7/15, at 6:48 AM, indicated Resident 1 received Tylenol because he was complaining of right hip and thigh pain. The Restorative Nursing Assistant (RNA) note dated 4/7/15 at 4:44 PM, indicated Resident 1 refused to ambulate because of pain and the licensed nurse was notified. The RNA note dated 4/8/15 at 4:22 PM, indicated Resident 1 could not ambulate because of pain and the licensed nurse was notified. The RNA note dated 4/9/15 at 6:17 PM, indicated Resident 1's therapy was withheld due to him complaining of pain and the licensed nurse was notified. There was no indication during the above dates, the licensed nurses notified the attending physician of Resident 1's refusal to ambulate because of right hip and leg pain following his fall on 4/4/15. During an interview with the family member, on 6/8/15, at 8:40 AM, she stated, "My daughter picked him (Resident 1) up on Easter (4/5/15)...I noticed his leg was swollen when he got here. So I called, they said he fell the day before. I asked for an X-ray, they said no. No need for one. I said well the leg is really swollen. So that didn't occur (the X-ray) until Monday 4/6/15. (X-ray) Showed no fracture. But for the next two weeks, he (Resident 1) complained of pain and no weight bearing on that leg (right leg). The only treatment was Tylenol 325 mg. I told them it's not working. They increased to Tylenol # 3 with Codeine. Finally, he could only transfer via Hoyer lift equipment used to aid a person getting from one spot to another). Red flag to me. So I took him to (name of hospital), X-ray there was fracture." The Physician's Order dated 4/10/15 read, "Tylenol with Codeine # 3 Tablet 300-30 MG (Acetaminophen-Codeine use to treat moderate to severe pain) Give 1 tablet by mouth every 8 hours as needed for pain for 30 days." There were no indications in Resident 1's record that the nursing staff requested any further X-rays or interventions from the treating physician or that the nursing staff informed the treating physician of Resident 1's decline in ambulation. The RNA note dated 4/11/15 at 3:33 PM, read "Res (resident) AMB (ambulation) was withheld twice this week due to res complaining of pain. Nurse notified." The RNA note dated 4/19/15 at 5:51 PM, read "Resident has refused all food today, encouraged by RNA to eat and (he) refused all food including desserts." The RNA note dated 4/22/15 at 2:55 PM, read "Resident is unable to hold up weight and take steps due to hip pain. Nurse has been notified of pain." There were no indications the treating physician was notified of Resident 1's continued right leg pain and decline in ambulation due to pain for the above timeframe. The nurse's notes dated 4/26/15 at 6:36 AM, indicated Resident 1 was given pain medication for his complaint of right hip pain with a 9/10 level of pain (an objective value of subjective pain value between 0 and 10 ascribed by the patient to the pain experience, where 0 equals no pain at all, and 10 equals the worst pain experienced or imaginable). There was no indication the treating physician was notified of Resident 1's hip pain. The nurse's notes dated 4/26/15 at 12:52 PM, indicated a telephone call was received from Resident 1's wife informing the facility she had taken the resident to the hospital where he was diagnosed with a right hip fracture (broken leg bone). The care plan for Resident 1 titled "Pain" dated 6/2/14, read "Evaluate for decline in physical functioning. Pain assessment on admission, and Q (every) quarter, and /or with change in condition. Notify MD of change in condition pain." The History and Physical from the hospital dated 4/26/15, read, "Admitting Diagnoses: Right femoral Neck fracture with impaction...Chief Complaint: Right hip pain since the 4th of this month (April) after a fall happened at that time...History of Present Illness:...The pain started on the 4th of this month after a fall...he had an X-ray that was negative. The X-ray was done at the skilled nursing facility where he resides. The pain continued to worsen and now he is unable to walk because of it....he had CT (Computed Tomography-a radiological imaging that uses computer processing to generate an image of tissue density in slices through the patient's body) of the right femur that showed the presence of fracture with impaction...PHYSICAL EXAMINATION:...EXTREMITIES: Unable to move the right hip because of the pain. DIAGNOSTIC WORKUP AND LABORATORY TEST: CT of the pelvis without contrast shows acute fracture of the right femoral neck with associated impaction and posterior angulation. During a concurrent review of the clinical record for Resident 1 and interview with the Director of Nursing (DON), on 6/1/15, at 3:45 PM, the DON verified the above documentation. She stated, "With that issue (pain not relieved by medication) I should have done a new intervention like calling the doctor for a new order." During an interview with the RNA, on 6/1/15, at 4 PM, she stated, "I told her (charge nurse) that Resident 1 was having pain and not able to ambulate...Yes, we were two staff assisting him but he couldn't do steps, like he was doing before (the fall)." During an interview with the LVN 2, on 6/1/15, at 4:10 PM, she stated, "If a Resident's X-ray was negative for fracture but he is still complaining of pain and unable to walk, I'll inform the doctor of the continuing pain so he can do something further like imaging or CT." During an interview with the DON, on 6/3/15, at 9:35 AM, she stated, "We did not have IDT (Interdisciplinary Team) meeting for him (Resident 1-concerning his continued pain and refusal to ambulate). Actually, we don't have formal meetings where we sit down and discuss. We do this informally but it's not documented. I'm working on this for improvement." The facility policy and procedure titled "Change in a Resident's Condition or Status" under Policy Interpretation and Implementation read, 1. The charge nurse will notify the resident's attending physician when:...b. There is a significant change in the resident's physical, mental or psychosocial status, c. There is a need to alter the resident's treatment significantly. 6. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted by the resident assessment nurse and the IDT team." Therefore 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. |
| 120000377 |
Parkview Healthcare Center |
120011664 |
A |
14-Sep-15 |
7Z7V11 |
8375 |
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: To be free from mental and physical abuse. Based on interview and record review, the facility failed to protect one of one sampled resident (2) from abuse by Resident 1, who was cognitively intact and had a known history of striking another resident (5) causing harm, which resulted in Resident 2 being slapped with an open hand, then hit with a closed fist and sustaining a hematoma (a localized swelling which was filled with blood caused by a break in the wall of a blood vessel) to her head.An unannounced visit was made to the facility on 6/8/15 at 10:20 AM, to investigate an allegation of resident to resident abuse. Resident 1 was a 58 year old male with a history of hypertension, diabetes, depressive disorder, and below the knee amputation. Resident 1's clinical record indicated he was cognitively intact. Resident 2 was an 84 year old female with a history of dementia, hypertension, and generalized muscle weakness. Resident 2's clinical record indicated she was severely cognitively impaired. The Department received a report from the facility indicating that on 5/27/15 at 6 PM, witnesses reported Resident 1 struck Resident 2 on the head causing a hematoma to the right side of her head.During an interview with the Administrator on 6/8/15 at 10:20 AM, he stated Resident 1 had a psychological evaluation after the altercation with Resident 2. The Administrator stated Resident 1 told the psychological evaluator he would do it again.During an interview with Certified Nursing Assistant (CNA) 1 on 6/8/15 at 10:30 AM, CNA 1 stated Resident 1 was often a 1:1 (one staff member assigned to care for 1 resident) because of his behavior. CNA 1 stated when the staff member who was doing the 1:1 with Resident 1 has to go to lunch, she has to cover for the staff and watch Resident 1 and also takes care of her assigned residents. She stated, "So, I still have those other residents, plus watch him 1:1, until the 1:1 CNA gets back."During an interview with Resident 1 on 6/8/15 at 11:55 AM, he stated he remembered hitting a woman and a man in the face. Resident 1 was able to recall Resident 2's and Resident 5's names. Resident 1 stated he hit both of them because they hit him first.During an interview with the Social Service Director (SSD) on 6/8/15 at 12:10 PM, the SSD stated Resident 2 was very protective of her purse. The SSD stated, "She holds purse (sic) dear to her."The clinical record for Resident 1 was reviewed. Resident 1's admission record indicated he was 58 years old. The Minimum Data Set (MDS-an assessment tool) dated 5/8/15, indicated Resident 1 was cognitively intact with a BIMS (Brief Interview for Mental Status: is a brief screener that aids in detecting cognitive impairment. It does not assess all possible aspects of cognitive impairment) score of 15 points out of a possible 15 points. The Interdisciplinary (IDT) Progress Notes dated 5/28/15, read "Res (Resident 1) was involved in a res to res altercation. Res (Resident 1) hit another res (Resident 2) on her forehead. He was trying to search her purse for a doll that did not belong to either res. Other res hit him trying to get him away from her purse. He (Resident 1) hit her back on her forehead.... This is his second altercation which he hits (sic) a res this year."Resident 1's progress note regarding the previous altercation with Resident 5 dated 9/7/14, read "Res (resident) to res altercation... Res admitted to punching other res (Resident 5) on his face. He stated in the lobby to everyone that he was a boxer... Res gets easily upset and is not redirectable. Res is very rude and mean to staff. Cont (continues) to be non compliant."Resident 1's care plan dated 9/7/14, read "Provide close supervision and watch for early signs of agitation or increasing anxiety and report. Keep close to nurse station."The clinical record for Resident 2 was reviewed. Resident 2's admission record indicated she was 84 years old with a history of dementia without behavioral disturbance (Dementia is a gradual and progressive decline in mental processing ability that affects short-term memory, communication, language, judgment, reasoning, and abstract thinking) and generalized muscle weakness. The MDS dated 4/5/15, indicated Resident 2 had a BIMS score of 3 which indicates she was severely cognitively impaired.The progress notes for Resident 2 dated 5/28/15, indicated Resident 1 was trying to remove a doll from Resident 2's purse and Resident 2 tried to get him away from her purse. During the altercation, Resident 1 hit Resident 2 on the head. The nurse's notes dated 5/29/15, read "Monitoring d/t (do to) altercation... resident has a hematoma on R (right) side of forehead on R eyebrow."During an interview with Resident 3 and 4 on 7/10/15 at 1 PM, Resident 3 stated she and Resident 4 were in the dining room after lunch. Resident 3 stated facility staff was not in the dining room during the altercation. Resident 3 stated Resident 1 was trying to get into Resident 2's purse and Resident 2 was resisting by pulling back the purse. She stated Resident 1 slapped and then hit Resident 2 with a closed fist to the side of Resident 2's face. When asked if they had seen Resident 2 hit Resident 1 during the altercation, Resident 3 and Resident 4 stated no, Resident 2 did not hit Resident 1 at any time during the altercation. Resident 4 agreed with Resident 3's account of the altercation and stated, "I yelled at (Resident 1) to stop hitting her (Resident 2) and I tried to go to protect (Resident 2) but when I stood up, he stopped. Resident 3 stated, "We were yelling for staff to come and when the nurse came in, she (the nurse) said 'I didn't see anything'." When asked if the facility staff had interviewed them about the incident, Resident 3 and Resident 4 stated the facility staff did not interview them regarding the incident.The clinical record for Resident 3 was reviewed. The MDS dated 5/21/15, indicated Resident 3 had a BIMS score of 14, which indicates she was cognitively intact.The clinical record for Resident 4 was reviewed. The MDS dated 5/9/15, indicated Resident 4 had a BIMS score of 10, moderately impaired.During an interview with the MDS nurse and the Assistant Director of Nursing (ADON) on 7/10/15 at 1:20 PM, the MDS nurse stated Resident 4 was "very with it". The ADON stated Resident 4 was able to remember and verbalize without problems. The clinical record for Resident 5 was reviewed. Resident 5's admission record indicated he was 90 years old at the time of the altercation with Resident 1 on 9/5/14. The facility investigation document, undated, read "On 9/5/14 there was a physical altercation between resident (Resident 1) and (Resident 5). The incident occurred in the A wing dining room where (Resident 1) was watching TV. (Resident 5) came into the dining room and turned off the fan. (Resident 1) then proceeded to strike (Resident 5) on the face approximately 5 times. (Resident 5) sustained a cut right upper lip and had swelling and discoloration around his right eye."The facility policy and procedure titled "Abuse and Neglect Prevention Standard" dated 2013, read "The community staff will identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur."The facility policy and procedure titled "Resident-to-Resident Abuse", undated, read "Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents... develop a care plan that includes interventions to prevent the recurrence of such incidents, including the appropriate management of any underlying conditions... inform all staff involved in the care of the resident of the care plan... " Therefore, the facility failed to prevent the abuse of Patient 2 by Patient 1 which presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000377 |
Parkview Healthcare Center |
120011779 |
A |
09-Nov-15 |
4O5611 |
16421 |
T22 72527(a)(10) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 5/11/15, an unannounced visit was made to the facility to investigate a complaint regarding the abuse of a resident. The entity reported incident received on 5/13/15 regarding this same incident was also investigated during the third day of this investigation. Based on observation, interview, and record review, the facility failed: 1. To ensure two sampled patients (Patient D and Patient E) were free from physical and verbal abuse from another patient (Patient A). This failure resulted in actual physical harm (skin tears) and an environment of fear through verbal abuse to Patient D and Patient E from Patient A. 2. To ensure three sampled patients (Patients F, Patient G, and Patient H) were free from verbal abuse from a second patient (Patient B). This failure resulted in an environment of fear through verbal abuse to Patient F, Patient G, and Patient H from Patient B. Findings: 1. Patient A was a 78 year old male with diagnoses of dementia with behavioral disturbances (behavioral pattern with subjective distress, functional disability, or impaired interactions with others or the environment), and a BIMS (Basic Interview for Mental Status, a scoring system to indicate a patient's orientation, understanding, reasoning and recollection. A score of 13-15 means a resident is cognitively intact; 8-12 means a patient is moderately impaired; 0-7 means severe impairment) score of 3. A. Patient A to Patient D: Patient D was a 73 year old male with history of muscle weakness, diabetes (high blood sugar), chronic pain, atrial fibrillation (abnormal heart rate), and a BIMS score of 3. During a review of the "Change of Condition Report" dated 5/5/15 indicated this altercation with Patient A caused three skin tears to Patient D's left arm, and were measured to be: a. 1.0 by 1.0 centimeters b. 4.5 by 3.5 centimeters c. 5.0 by 3.5 centimeters. During a review of the clinical record for Patient D, the "Interdisciplinary Progress Notes" dated 5/6/15 indicated "[Patient D] involved in Res [resident/patient] to res altercation. Res reported new roommate [Patient A] 'flip him off & called him inappropriate names.' [Patient A] also stood up on side of the bed & grabbed [Patient D's] hand & started hitting it to the side rail, which caused skin tear. Both res were separated immediately. [Patient A] moved to different room." During an interview with the Social Services Director (SSD), on 5/11/15, at 4:30 PM, she stated Patient A was admitted to the facility, on 5/5/15. She stated Patient A had "an altercation" with Patient D, on 5/5/15. Patient A was then moved to the room where Patient E lived. SSD stated Patient A and Patient E were roommates for six days until Patient A was moved, again, to another room earlier today. During a concurrent observation and interview with Patient D, on 5/14/15, at 3:20 PM, a large white gauze bandage was noted covering the entire left forearm, from wrist to elbow. Patient D stated there were injuries under the bandages, from a recent altercation with a former roommate. Patient D recalled the incident with Patient A, and became tearful over his overall state of health, looked at his left arm, and stated, "And now this." B. Patient A to Patient E: Patient E was a 91 year old male with history of hypertension (high blood pressure), depressive disorder (a syndrome that reflects a sad and/or irritable mood exceeding normal sadness or grief), Parkinsonism (a nervous disorder marked by muscular rigidity, tremor, and impaired motor control), cardiac pacemaker (an implanted device that sends electrical impulses to the heart in order to set the heart rhythm), and gout (a form of acute arthritis that causes severe pain and swelling in the joints). Patient E had a BIMS score of 14. During an interview with Patient E's family member (Family 1), on 5/11/15, at 9:10 AM, she stated Patient E was her father who is 91 years old, frail, and had been a patient of this facility for seven years. Family 1 stated the facility moved Patient A into her father's room after Patient A had an altercation with Patient D. Family 1 stated Patient A immediately started to use foul language toward her father, and pushed a bedside table toward him, which caused injury to her father's hand. Family 1 stated her father did not go into his room during the day because he did not like the "verbal abuse" from Patient A. Family 1 stated Patient A seemed very confused and thought his roommates were trying to steal his belongings. She stated she had spoken with the Director of Nursing (DON) and the SSD about these issues, but nothing was done about the abuse situation. Family 1 further stated, "Even the nurses told me that the (DON) should have not put (Patient A) in that room." During an interview with Patient E, on 5/11/15, at 4:12 PM, he stated, "[Patient A] started shoving the [bedside] dining table at me. The table hit my left hand which caused this (bruise and about an inch long scab). [Patient A] cusses me out. I felt threatened and not safe in my own room. All this had happened on the same day [5/5/15] that Patient A was moved into my room. I had told my daughter on the same day it happened. Staff was aware about what happened that day. Staff should have done something on that first day. I went to Social Services on that day and informed them Patient A had abused me. When I went to Social Services Office to tell them, the SSD said they will try to get Patient A out of my room. Meanwhile, Patient A kept causing trouble. I stayed out of my room during the day so Patient A didn't cause any problems for me. The staff would give Patient A a sleeping pill around nine to ten at night. Then I would go to sleep after that. Patient A wasn't moved out of my room until today [5/11/15, 6-days duration]. I feel safe now." During an interview with SSD, on 5/11/15, at 4:30 PM, she stated Family 1 came in this morning feeling very upset because her father told her Patient A used foul language toward him; and Family 1 had told the DON. SSD stated the DON approached her to do a room change for Patient A. During a concurrent observation and interview with a Registered Nurse Supervisor (RNS), on 5/11/15, at 5:15 PM, she observed Patient E's left hand and stated, "That is a bruise on his hand. It's red, purple, and yellow. The scab is about one to one and a half inches long." RNS asked Patient E about the bruise and scab, and he stated Patient A had pushed the bedside dinner table into his hand, causing the scab and bruise to his left hand. During a concurrent record review and interview with RNS, on 5/11/15, at 5:20 PM, she reviewed Patient E's clinical record and was unable to find documentation of Patient E's scab and bruise on his left hand. She stated, "I don't see any order treatment to his hand. There is no skin sheet in his chart. No change of condition documentation was completed regarding his left hand. I'm unable to locate in the nurses' notes any information about Patient E's bruise and scab on his left hand." During an interview with the Administrator, on 5/12/15, at 11:15 AM, he stated CNA 2 had learned of a skin tear to the left thumb of Patient during an altercation with Patient A, on 5/5/15. The Administrator stated CNA 2 did not report this to the other staff. The Administrator stated licensed nursing staff assessed Patient E after the altercation, but did not see the skin tear. CNA 2 informed them he did. 2. During a review of the clinical record for Patient B: Patient B was a 79 year old male with diagnoses of dementia with behavioral disturbances, hypertension, chronic kidney disease, legal blindness, and BIMS score of 3. The "Nurses' Notes" dated 5/6/15 indicated Patient B told a CNA to get out of his room, "...and shut up. Resident pulled his hand back and threatened to punch the CNA in the face." The "Nurses' Notes" dated 5/6/15 indicated Patient B "yelled at 'A" bed's wife, told her to get out. (DON's name) aware." The "CNA Notes" dated 5/6/15 indicated "[Patient B] was going through all the belongings of his two other roommates, when I tried to explain to resident and redirect him, resident became aggressive and threatened to smash my face and made a fist. Told me to get out of the room." The "Nurses' Notes" dated 5/7/15 indicated Patient B was "...up in wheelchair propelling self around facility all night...offered to go to his room to sleep and resident becomes agitated...seemed upset, using profanity." The "Nurses' Notes" dated 5/10/15 indicated Patient B "refused to let CNA change his clothes, he became verbally abusive...." A. Patient B to Patient F: Patient F was a 47 year old male with a history to quadriplegia (no movement of all four limbs or the entire body from the neck down), diabetes, acute kidney failure, muscle spasms, chronic pain, and had a BIMS score of 15. During a concurrent observation and interview of Patient F in his room (3-bed occupancy with one yard of space in between the beds) on 5/11/15, at 11:25 AM, he occupied the bed by the window. He had limited use of his arms; could not reach to manipulate the bed controls to raise the head of the bed. Staff had to be summoned to perform this task for him. It was noted he did not have a push-button type of call light, instead, he had a pressure pad placed on the pillow next to his cheek. He would move his head to one side to activate the call light. If the pressure pad call light activator moved only a few inches, Patient F would not be able to use it. Patient F stated there had been several residents admitted to this facility recently. He stated one of these new residents (Patient B) was now his roommate, and was assigned to the second (middle) bed. Patient F stated whenever staff tried to re-direct or provide care to the resident, "he becomes aggressive." Patient F stated this second bed resident "goes through my clothes and belongings." When staff attempts to re-direct him, he "becomes aggressive" with the staff. Patient F stated, "I'm afraid of a man like that. I can't defend myself." During a subsequent observation of Patient F's room, on 5/11/15, at 12:50 PM, a male individual was noted lying on the middle bed, awake and alert. Patient F indicated this individual was the resident he was speaking about (Patient B). During an interview with a Certified Nursing Assistant (CNA 1), on 5/11/15, at 12:55 PM, she identified the individual resting in Patient F's room, in the middle bed as Patient B. CNA 1 stated, "[Patient B] is verbally abusive. He's new, but not getting better; he's not getting used to the place." During an interview with a Licensed Vocational Nurse (LVN 1), on 5/11/15, at 1:05 PM, she stated, "I'm [Patient B's] medication nurse. He's verbally abusive." LVN 1 further stated, "He [Patient B] threatened to punch a CNA in the face the other day. He drew back his fist." During an interview with the SSD, on 5/11/15, at 1:20 PM, she stated Patient B was admitted to the facility recently. She stated, "I know he's not easily re-directable [sic]." During an interview with the Administrator, on 5/11/15, at 3:50 PM, he stated Patient A and Patient B were admitted from another facility. He stated he was unaware of any abuse history because the facility where they came from did not have that information in their charts. He stated the DON reviewed their records and was unable to find documentation of abuse history. The Administrator stated, "We are not equipped to handle these types of issues." The facility document titled "Resident (Patient) Interviews" dated 5/12/15 indicated Patient F stated, "I was scared of [Patient B] because he was aggressive and getting into my drawers." B. Patient B to Patient G: Patient G was a 46 year old male with history of quadriplegia, anxiety (a general term for several disorders that cause nervousness, fear, apprehension, and worrying), asthma (a breathing disorder that can severely impact one's ability to breathe in stressful situations), diabetes, and had BIMS score of 15. During an interview with Patient G, in his room, on 5/12/15, at 11:15 AM, he stated Patient B had been moved out of Patient F's room and moved into a room with him and Patient H. During a subsequent interview with Patient G, on 5/12/15, at 11:35 AM, he stated he gained a new roommate (Patient B) last evening into the third bed. Patient G stated, "The bottom line is he needs to move out of here. He threatened my neighbor [Patient H in the middle bed], threatened him over his TV, and said 'Boy, I'll hit you.' We don't need none of that. I don't need to hear that. I wasn't the only one who heard it neither; staffs were in here. They moved him from the other wing for the same stuff. I don't know why they moved him here. Bottom line is he needs to go. Now! Into a private room." Patient G was anxious; his voice was trembling as he spoke. During an interview with Certified Nursing Assistant (CNA 3), on 5/12/15, at 1 PM, she stated she was not in the room during the altercation earlier that day between Patient G and Patient B, but Patient G informed her of it afterwards. CNA 3 stated, "[Patient G] said [Patient B] had threatened to poke his eyes out." CNA 3 stated this threat was verbal abuse. C. Patient B to Patient H: Patient H was a 62 year old male with a history of hypertension, depressive disorder, glaucoma (eye pressure), and had BIMS score of 14. During an interview with Patient H, on 5/12/15, at 11:40 AM, he stated a new roommate (Patient B) had moved into his room in the third bed. Patient H stated earlier that morning, "I guess he [Patient B] thought my TV was his TV. He [Patient B] said some stuff and threatened to hit me. I don't bother nobody. He [Patient B] don't need to be here. Staff was in here at that time, they told me to be quiet." During an interview with a Licensed Vocational Nurse (LVN 2), on 5/12/15, at 11:55 AM, while she was working in the area, she stated, "They just moved [Patient B] to [Patient H's] room yesterday. He had an altercation [on the other wing], now an altercation here. I don't know where he is now. During an interview with a Licensed Vocational Nurse (LVN 3), on 5/12/15, at 1:05 PM, she stated, "I heard [Patient B] yelling. Getting mad over the TV, thought it was his, yelling with 'B' bed. [Other staff] was already in there, I called Social Services. It was abusive, yeah." During an interview with the Activity Director (AD), on 5/12/15, at 1:07 PM, she stated she was present inside the room during part of the altercation between Patient H and Patient B. The AD stated she saw Patient B stand up next to his bed, and say loudly, "Hey! I'll get you, that's my TV, [to Patient H]." The AD stated, "I wasn't there the whole time." The facility policy and procedure titled "Abuse and Neglect Prevention Standard" dated 2013, read in part: "...Our residents have the right to be free from abuse and neglect by anyone, including staff members, other residents, visitors, volunteers, family, friends, or any other individual...Section 4: Identification... A. All staff will be observant for any resident or staff conditions that might be indicative or predictive of potential abuse and/or neglect; such as suspicious bruising, withdrawn behaviors, distress, change in behaviors, etc...Section 6: Protection...C. Residents will be separated or moved to a place of safety, away from a harmful or abusive situation, to prevent a reoccurrence and for their protection...Section 8: Incident Management...All allegations of abuse, neglect, or misappropriation of resident property must be investigated. The operative term in the regulation is 'allegation.' The regulation does not give the community leeway to decide if an allegation is valid before reporting."The facility's failure to prevent continued physical and verbal abuse presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000377 |
Parkview Healthcare Center |
120011780 |
B |
09-Nov-15 |
4O5611 |
5073 |
Health and Safety Code 1418.91(a):(a) A long-term health care facility shall report all allegations of alleged abuse or suspected abuse of a patient of the facility to the department immediately, or within 24 hours. (b)A failure to comply with the requirements of this section shall be a class "B" violation. On 5/11/15, at 3:53 PM, an unannounced visit was made to the facility to investigate a complaint regarding an alleged patient to patient altercation resulting in abuse. Based on interview and record review, the facility failed to report an incident of patient-to-patient abuse to the California Department of Public Health within 24 hours of the discovery of the incident, which had the potential for other abuse incidents to go unreported. Patient A was a 78 year old male with a diagnosis of dementia with behavioral disturbances (behavioral pattern associated with subjective distress, functional disability, or impaired interactions with others or the environment) and a Brief Interview for Mental Status (BIMS) score of 3/15, meaning Patient A was severely impaired cognitively. Patient E was a 91 year old male with a BIMS score of 14 of 15, meaning Patient E's mental state was cognitively intact.During an interview with Family 1, on 5/11/15, at 9:10 AM, she stated Patient E was 91 years old and frail. The facility had moved Patient A into Patient E's room after Patient A had an altercation with Patient D on 5/5/15. Patient A immediately was using foul language toward Patient E. Patient A pushed a bedside table toward Patient E, causing a scratch and bruise to Patient E's hand. Family 1 stated she had spoken with the Director of Nursing (DON) and the Social Services Director (SSD) the next day (5/6/15) about the incident. During an interview with Patient E, on 5/11/15, at 4:12 PM, he stated, "[Patient A] started shoving the [bedside] dining table at me. The table hit my left hand which caused this [bruise and about an inch long scab]. [Patient A] cusses me out [to be cursed at]. I felt threatened and not safe in my own room. All this had happened on the same day [5/5/15] that [Patient A] was moved into my room. I had told (Family 1) on the same day [5/5/15] it happened. Staff was aware about what happened that day [5/5/15]. Staff should have done something on that first day [5/5/15]. I went to Social Services on that first day [5/5/15] and said [Resident A] had abused me. When I went to Social Services office to tell them, the [SSD] said they will try to get [Patient A] out of my room. Meanwhile, [Patient A] kept causing trouble. I stayed out of my room during the day so [Patient A] didn't cause any problems for me. The staff would give [Patient A] a sleeping pill around 9 to 10 at night. Then I would go to sleep after that. [Patient A] wasn't moved out of my room until today [5/11/15]. I feel safe now."During an interview with the SSD, on 5/11/15, at 4:30 PM, she stated [Patient A] was admitted to the facility on 5/5/15. He had an altercation with [Patient D] on 5/5/15 and was moved to a room where [Patient E] lived.During a concurrent observation and interview with Registered Nurse Supervisor (RNS), on 5/11/15, at 5:15 PM, she observed Patient E's left hand and stated, "That is a bruise on his hand. It's red, purple, and yellow. The scab is about one to one and a half inches long." The RNS asked Patient E about the bruise and scab. Patient E stated [Patient A] pushed the [bedside] dinner table causing the scab and bruise on his left hand.During an interview with the Administrator, on 5/11/15, at 5:30 PM, he acknowledged that staff observations of suspected abuse were not immediately reported to the Administrator. The Administrator verified the incident was not reported the Department. During an interview with the Administrator on 5/12/15, at 11:15 AM, he stated Certified Nursing Assistant (CNA) 2 had learned of a skin tear to the left thumb of Patient E during an altercation he had with Patient A, on 5/5/15. The Administrator stated CNA 2 didn't report it to other staff. The Administrator stated licensed nursing staff assessed Patient E after the altercation, but did not see the skin tear, but CNA 2 did.The facility policy and procedure titled "Abuse and Neglect Prevention Standard" dated 2013, indicated "Section 7: Reporting. A. The community ensures that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin, and misappropriation of resident property is immediately reported to the Executive Director and Director of Nursing Services; with subsequent mandatory reporting in accordance with California State Law, through established procedures (including the state survey and certification agency). Section 8: Incident Management. When abuse, neglect, mistreatment, or misappropriation of personal property of a patient is observed or suspected, staff must immediately notify their supervisor on duty, who, in turn, notifies the abuse coordinator (Executive Director [Administrator]) and the Director of Nursing Services."1Complaint CA00442217 |
| 120000377 |
Parkview Healthcare Center |
120011910 |
B |
29-Dec-15 |
QE7X11 |
5035 |
T22-72527(a)(10) - Patients' Rights 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: To be free from mental and physical abuse. Based on observation, interview, and record review, the facility failed to protect one of one sampled patient (1) from verbal, mental, abuse from a staff member (Certified Nursing Assistant [CNA] 1). This resulted in Patient 1 feeling scared and intimidated. On 11/4/15, at 1:12 PM, an unannounced visit was made to the facility to investigate an entity reported incident of an alleged incident of verbal abuse of a patient (1) by a CNA 1. Patient 1 was a 74 year old female with diagnoses including chronic obstructive pulmonary disease (a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing), congestive heart failure (a condition in which the heart has lost the ability to pump enough blood to the body's tissues), atrial fibrillation (An abnormal and irregular heart rhythm), hypertension (high blood pressure), diabetes (abnormal blood sugar levels), cancer, edema (swelling), and generalized muscle weakness.During a concurrent observation in Patient 1's room and interview with Patient 1, on 11/4/15, at 1:31 PM, Patient 1 was alert and oriented to time and place. When asked what happened on 10/29/15, when Patient 1 was late for her doctor's appointment, Patient 1 stated, "[CNA 1] started to get me ready to go. I was naked and freezing, she left me. The transportation was here and I wasn't ready." When asked how CNA 1 treated her, she stated, "When we came back from my appointment, [CNA 1] came into my room and put her face to my face on my nose and tells me how good she was and tells me this and that. My son-in-law was here and told her [CNA 1] to stop intimidating me. My son-in-law asked her to leave the room." When asked how did Patient 1 feel, she stated, "She [CNA 1] makes me upset. She [CNA 1] scares me."During an interview with CNA 1, on 11/4/15, at 2:12 PM, she stated, "I went to apologize to her [Patient 1's] son-in-law and he said why am I apologizing?" When asked how CNA 1 spoke to Patient 1, CNA 1 stated, "I kinda spoke loud because she told me before she was hard of hearing."During an interview with Licensed Vocational Nurse (LVN) 1, on 11/4/15, at 2:45 PM, when asked if LVN 1 informed CNA 1 of Patient 1's appointment time, LVN 1 stated, "I told the CNA [1] in the morning that [Patient 1] had an appointment at 10 AM." When asked if LVN 1 checked Patient 1 at 9 AM if Patient 1 was up, LVN 1 stated, "No, I did not check the resident [1]. It's common sense, [CNA 1] should know that [Patient 1] should be up one hour before."During a review of the clinical record for Patient 1, the "Cognitive Patterns", dated 10/29/15, indicated a Summary Score of 15 (score of 12-15 indicates cognitively intact which means having intact comprehension, judgement, memory, and reasoning). The "Functional Status", dated 10/29/15, indicated, "Bed mobility and Transfer: extensive assist with 2 person assist."During an interview with Family Member 1, on 11/6/15, at 1:19 PM, he stated, "The CNA [1] got down to [Patient 1] nose to nose and said, 'I take good care of you, don't I?'." When asked how did CNA 1 treat Patient 1, he stated, "As far as abuse, yes, [CNA 1] said, 'You should be thankful you made it to the doctor."The facility policy and procedure titled, "Prohibition of Abuse, Neglect, Mistreatment and Misappropriation of Resident Property", dated 10/2014, indicated, "It is the community's policy that every reasonable effort within its control is taken to prevent mistreatment, neglect, abuse of residents, and misappropriation of resident property. Staff must not participate nor permit anyone to participate in verbal, mental, sexual, physical abuse; neglect; mistreatment or misappropriation of resident property. Resident must not be subjected to abuse by anyone, including but not limited to; community staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members, visitors, legal guardians, friends or individuals. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability."The facility's failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 120000377 |
Parkview Healthcare Center |
120011967 |
B |
29-Jan-16 |
7OHF11 |
3606 |
T22-72527(a)(10) - Patients' Rights 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: To be free from mental and physical abuse. Based on observation, interview, and record review, the facility failed to protect one patient (1) from neglect, when a certified nursing assistant (CNA 1) refused to provide a bed pan when Patient 1 requested it. This failure resulted in Patient 1 soiling herself and suffering from mental anguish.An unannounced visit was made to the facility on 12/9/15 at 2:49 PM to investigate an allegation of neglect of a patient by staff. Patient 1 was an 81 year old female who was alert and oriented with diagnoses including cellulitis (a spreading bacterial infection just below the skin surface) of the left lower limb, and dizziness.During a concurrent observation and interview with Patient 1, on 12/9/15, at 4:11 PM, she stated she had fallen at home and developed an infection in her leg and she was admitted to the facility to build her strength up and return home. Patient 1 stated on the morning of 12/5/15, at 6 AM, she used her call light to let the CNA know she had been incontinent (of urine) and needed to be cleaned up. "The CNA told me she would let my assigned CNA know... I don't know the name of the girl who answered my call light." At 7 AM, no one had come to clean her up, so Resident 1 used her call light again. Patient 1 stated, "He (CNA 1) said he would be back (to clean her up), but he never came back until 7:15 AM to deliver my breakfast tray. He told me he couldn't clean me up during breakfast." At 9 AM, Patient 1 stated she used her call light for the third time to request to be cleaned up. Patient 1 stated, "I told him (CNA 1) I had to go poop (resident lowers her voice and whispers the word "poop"). He (CNA 1) told me to just go in the bed and he (CNA 1) would clean me up. I didn't want to but he told me he wouldn't get me up. He (CNA 1) just kept telling me to soil myself so I just had to poop my pants. (Patient 1 averts her eyes and is tearful.) It was humiliating. I'm a pastor's wife, I'm very modest. The only ones who have ever seen me there (indicated the genital area) are my husband and doctor, my kids have never even seen me, so to have a young man who I don't know wiping my butt, was too much for me. I was so humiliated, I just cried the whole time."During an interview with the Director of Nursing (DON), on 12/9/15, at 4:27 PM, he stated "The CNA should have offered a bedpan" to Patient 1.During a review of the clinical record for Patient 1, the "Brief Interview for Mental Status" (assessment which indicates a patient's level of cognition), dated 12/4/15, indicated Patient 1 had a score of "15" out of 15 (cognitively intact).The facility policy and procedure, titled "Abuse and Neglect Prevention Standard", dated 2013, indicated in part "Neglect: is the withholding of goods or services that are necessary with resulting physical harm, pain, or mental anguish. Examples include... Knowingly leaving a resident wet or soiled... denial or delay in care... inadequate help with hygiene or bathing..."This failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 120000377 |
Parkview Healthcare Center |
120011977 |
B |
29-Jan-16 |
0YR211 |
1910 |
Health and Safety Code Section 1418.91 (a) A long term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of the section shall be a class "B" violation. Based on interview and record review, the facility failed to report an allegation of neglect within 24 hours to the California Department of Public Health (CDPH) for one of one sampled resident (1) when facility reported the neglect allegation after 3 days. On December 16, 2015, at 8 AM, an unannounced visit was made to the facility to investigate an entity reported incident regarding an incident of alleged resident neglect. During a review of the clinical record for Resident 1, the "Concern/Grievance Form", dated 12/12/15, indicated, "Resident [1] states that CNA [1] refused to take her to the bathroom stating I don't have time, I have other residents to tend to when [CNA 1] finally took her to the bathroom, [CNA 1] kept rushing her stating, are you done yet? I have other residents to take care of. Incident occurred: 12/11/15. During an interview with the Director of Nursing (DON), on 12/16/15, at 8:10 AM, he stated, "We did not know about the allegation of abuse, the LVN [Licensed Vocational Nurse 1] placed the paper report under my office door on Friday PM shift, on 12/12/15. I found the paper report on Monday, 12/14/15 [after 3 days when incident occurred]." When asked when was it reported to the CDPH, he stated, "It was reported the same day on Monday, 12/14/15.The facility policy and procedure titled, "Abuse and Neglect Policy Standard", dated 2013, read "An initial report will be completed and submitted to the Department of Public Health immediately upon notification of the allegation."Therefore the facility did not report an allegation of abuse to the Department within 24 hours. |
| 120000377 |
Parkview Healthcare Center |
120012021 |
A |
22-Feb-16 |
KD4O11 |
4834 |
F323 Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Based on observation, interview, and record review, the facility failed to protect one of one sampled residents (1) from uneven flooring during remodeling which resulted in her falling and sustaining a laceration (a cut all the way through the skin) to her head requiring medical intervention. An unannounced visit was made to the facility on 12/14/15 at 10:08 AM, to investigate an allegation of sustaining an injury from a hazard in the facility. Resident 1 was an 86 year old female admitted to the facility on 10/31/14 with diagnoses including dementia with behavioral disturbance (a gradual and progressive decline in mental processing ability that affects short-term memory, communication, language, judgement, reasoning, and abstract thinking. Sometimes there are changes in mood and behavior), major depressive disorder with psychotic symptoms (a mental disorder in which a person has depression along with loss of touch with reality), pressure ulcer (an ulcer of the skin layers due to local interference with circulation), and pain. During an observation of Resident 1, on 12/14/15, at 10:16 AM, she was lying in bed with her eyes closed. On the right side of her forehead, beginning at her right eyebrow, was a dark blue-purple area which extended up to the scalp approximately 3 inches high, by 2.5 inches across to the middle of her forehead. There were 2 bandages across the top of her forehead and scalp. During an interview with Staff 1, on 12/18/15, at 1 PM, she stated on 12/11/15, she was in the hallway with her back turned to Resident 1. "(Resident 1) isn't verbal...she makes this sound, like 'Ba-Ba-Ba'...all of a sudden, (Resident 1) stopped making the sound...I turned around and saw her on the floor between 'A' and 'C' Wing...I ran over...(Resident 1) was bleeding pretty bad from a laceration on her head...there was blood everywhere. I applied pressure to the wound (to try to get the bleeding to stop)...there were 2 or 3 nurses (Licensed Vocational Nurses or LVNs) there and some CNAs (certified nursing assistants)...I had to apply pressure because it was bleeding so bad." Staff 1 stated Resident 1 fell from her wheelchair between A and C wing, where new flooring was being put down and the floor was uneven; A wing had the new floor, while C wing was only concrete. Staff 1 said the floor was fixed the next day.During an interview with Staff 2, on 12/18/15, at 1:22 PM, she stated she was at the nurses' station on 12/11/15. "I could hear (Resident 1) down the hall...she makes this noise with her mouth; the noise changed and I knew something was wrong...we (staff and I) ran to her and saw her lying on the floor between 'A' and 'C' wing. Her head was towards 'C' wing, on the concrete, and her feet were towards A wing, on the new floor. It looked like her wheelchair got caught where the floor changed and it was uneven. There was blood everywhere. (Staff 1) applied pressure to the wound...she (Resident 1) was bleeding so much..." Staff 2 stated the very next day, the floor was fixed (where Resident 1 fell).During an interview with Staff 3, on 12/18/15, at 4:05 PM, she stated on 12/11/15, she was at the nurses' station and could hear Resident 1 down the hall making her "Ba-Ba-Ba noise", but then the noise changed. "We went to check on her...she was lying on the floor, on her right side, in between 'A' and 'C' wing (where the old floor had been removed, and new floor was being installed...the floor was uneven). Her head was on the concrete and she was bleeding really bad from a gash in her head. We were providing first aid...Resident 1 was really upset and agitated...Staff 2 was holding her hands to keep her calm.During a review of the clinical record for Resident 1, the "Emergency Department Physician Notes", dated 12/11/15, at 5:16 PM, indicated Resident 1 had a 3 centimeter (cm) laceration with soft tissue loss to her forehead, which required sutures (stitches/repair) to close the muscle and 5 sutures to close the skin. The facility policy and procedure titled 'Fall Prevention and Incident Management', dated 10/2014, read "It is the community's policy, in accordance with the federal Regulations to provide an environment that is free from hazards over which the community has control." Under Fall Risk Assessment, Policy Interpretation and Implementation read, "7. The staff will seek to identify environmental factors that may contribute to falling..."This failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000377 |
Parkview Healthcare Center |
120012022 |
B |
22-Feb-16 |
U31K11 |
4192 |
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: To be free from mental and physical abuse. Based on observation, interview, and record review, the facility failed to protect one sampled patient (1) from physical and verbal abuse. This failure resulted in mental anguish for Patient 1. An unannounced visit was made to the facility on 12/29/16 at 10:05 AM, to investigate an allegation of patient abuse by staff. Patient 1 was a 73 year old female with diagnoses including diabetes (a serious disease in which the body cannot properly control the amount of sugar in the blood), anxiety disorder (a mental disorder characterized by persistent, excessive, and unrealistic worry about everyday things), generalized muscle weakness, and heart failure (a condition in which the heart has lost the ability to pump enough blood to the body's tissues). During a review of the clinical record for Patient 1, the "Minimum Data Set" (MDS-an assessment tool) indicated on 12/9/15, Patient 1's BIMS score (brief interview for mental status) was a 12 out of 15 (an 8-12 score means the patient was moderately cognitively impaired). The "History and Physical Examination", dated 12/3/15, indicated "This resident (patient) has the capacity to understand and make medical decisions...has the capacity to make general daily decisions."During a review of the clinical record for Patient 1, the "Change of Condition Report", dated 12/24/15, at 8:05 AM, indicated "After informed of allegation of abuse by 11-7 (11 AM to 7 PM shift) CNA-body assessment completed (with) focus to face as (Patient 1) indicated CNA held her jaw and told her she was evil and mean..."During a review of the clinical record for Patient 1, the "Social Service Progress Notes", dated 12/24/15, no time, indicated, "SSD (Social Services Director) was called to the room of resident (patient) to discuss a concern. Upon entering the room, resident (patient) became real nervous and stated 'I don't want to say anything'. SSD reassured resident she was safe...Resident (patient) then stated 'The night CNA was mean to me. She grabbed my face with her hand and told me in a mean voice that I was mean.' Resident (patient) then stated 'Please do not tell the CNA she has said something until she goes home'...Resident (patient) stated 'I was fearful of her coming back for her' [sic]."During a concurrent interview with the Assistant Director of Nursing (ADON) and review of Patient 1's clinical record on 12/29/16 at 11:25 AM, he verified the above record review. During a concurrent observation and interview with Patient 1, on 12/29/15, at 2:30 PM, she was lying in bed, awake. A staff member was in the room providing care to Patient 1. When the staff member began to leave, Patient 1 began to cry and begged the staff member not to leave her. The staff member stated she would be nearby and Patient 1 could use her call light if she needed anything. After the staff member left the room, Patient 1 was asked about the incident on 12/24/15 with Certified Nursing Assistant (CNA) 1. Patient 1 began to cry and shake and stated, "I tried to make conversation with her (CNA 1)...she came up and grabbed my face (Patient 1 indicated with her hand, CNA 1 grabbed her chin area) and said I was mean and 'so evil'...I'm not evil! I was just trying to make conversation...I was so afraid of her. I just want to go home."The facility policy and procedure titled "Abuse and Neglect Prevention Standard", dated 2013, indicated "The Resident (patient) has the right to be free from verbal, sexual, physical, and mental abuse... Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff."This failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 120000365 |
PARKVIEW JULIAN CONVALESCENT |
120012265 |
A |
06-Jun-16 |
I7GI11 |
7551 |
F323 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Based on interview and record review, the facility failed to implement it's suicide prevention policy for one of one sampled resident (1), who verbalized suicidal ideation (thoughts). This resulted in Resident 1 attempting suicide and then emergently transferred to an acute hospital.An unannounced visit was made to the facility on 3/29/16, at 12:43 PM, to investigate an allegation of the facility refusing to re-admit Resident 1 from the hospital.Resident 1 was a 71 year old admitted with diagnoses that included major depressive disorder (a mood disorder causing a persistent feeling of sadness and loss of interest), anxiety disorder (a chronic condition characterized by an excessive and persistent sense of apprehension), suicide attempts, poisoning by drugs, intentional harm, hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD-a disease of the lungs that makes breathing difficult), and dependence on supplemental oxygen .The clinical record for Resident 1 was reviewed. The social service initial assessment for Resident 1 dated 10/30/15, indicated "Social History: HX (history) OF SUICIDAL ATTEMPTS X 2 IN PAST." "MOOD," feeling down at times, tired, poor appetite, and feeling restless." Focus: The resident has mood problems AEB (as evidence by) feeling down, feeling tired, having poor appetite and feeling restless r/t (related to) Depressive Disorder, COPD."The order summary report for Resident 1 dated 2/1/16, indicated Resident 1 was on Sertraline (anti-depressant) for statements of hopelessness related to depressive episodes, lorazepam (anxiety medication) for anxiety, and Ambien (insomnia [sleeping disorder] medication because Resident 1 was unable to sleep.The Minimum Data Set (MDS- a comprehensive assessment tool) for Resident 1 dated 2/5/16, indicated under Brief Interview for Mental Status (BIMS-a short assessment of cognitive ability-the mental process of knowing, including aspects such as awareness, perception, reasoning, and judgment), a score of 14 indicating Resident 1 was cognitively intact. The Resident Mood Interview indicated Resident 1 was feeling down, depressed, or hopeless.The psychological consultation progress note for Resident 1 dated 2/3/16, at 5:11 PM, indicated "Response: Patient was resistive to treatment interventions. Patient appears to be regressing."The "Nurses note" for Resident 1 dated 3/5/16, at 11:55 PM, indicated "Approximately 2345 (11:45 PM), noted resident is not responding... called to Doctor... order to send resident to ER (Emergency Room) for further evaluation and treatment."During a review of the hospital clinical record for Resident 1, the doctor's discharge summary dated 3/10/16, at 2: 45 PM, indicated "She (Resident 1) admitted that she took a lot of Tylenol PM (a combination of acetaminophen-pain reliever and diphenhydramine-a sleep aid that causes drowsiness) because she felt depressed."The hospital clinical note by the social service staff, dated 3/7/16, at 2:34 PM, indicated "Pt. (patient-Resident 1) acknowledges attempting to OD (Overdose) again on Tylenol... Pt. indicates she had thought about taking the pills "For a few days" and finally decided to take them due to continuing to struggle with her breathing... Pt. indicated "I thought if I took the pills (Tylenol) I wouldn't have to wake up and worry about my breathing again. Pt. indicates that the staff at the SNF (facility) ...administers meds (medication) to her but she had hidden a bottle of Tylenol in her purse... Pt. expresses feeling hopeless and states, "I'm 71 yo (years old), I can't do anything. I can't even walk down the hall because I can't breathe. When I woke up here in the hospital I was upset that I didn't die."During a concurrent interview and record review with the Director of Nurses (DON), on 3/29/16, at 2:13 PM, the DON stated the incident happened on 3/5/16, at approximately 11:45 PM, when the nurse found Resident 1 unresponsive. The nurse attempted to wake up Resident 1 and was unsuccessful. The DON reviewed Resident 1's clinical record and was unable to find documented evidence where the facility Social Service staff and/or the nursing staff performed follow-up assessments on Resident 1's emotional state during her stay in the facility. The DON stated she was aware of Resident 1's prior suicide attempts. She stated the daughter informed her of suicide attempts during Resident 1's admission to the facility. The DON stated the facility's Suicide Prevention Policy was not put in place to keep Resident 1 safe from possible suicide attempts. The DON stated the facility provided no safety teaching for Resident 1, staff, and family members to ensure safety for Resident 1.During an interview with Resident 1's Responsible Party (RP), on 4/15/16, at 2:42 PM, she stated she informed the facility of her mother's prior suicide attempts on 10/30/16, Resident 1's first day of admission. The RP stated she informed the social service person, nurses, and the Director of Nurses.During an interview with Licensed Vocational Nurse (LVN) 2, on 4/20/16, at 1:14 PM, she stated "I didn't know that she had suicide attempts in the past. I didn't look at her diagnosis, so I didn't know... No one told me."During an interview with LVN 3, on 4/20/16, at 4:45 PM, she stated, "I didn't even know that she had suicide attempts in the past. I didn't look at her diagnoses."During an interview with LVN 1, on 4/20/16, at 4:53 PM, she stated, "One day a doctor came and was speaking with her (Resident 1). When he (doctor) finished speaking with her (Resident 1), he (doctor) came and spoke with me to make sure the sleeping pills were kept in the medication cart because he said she had a history of attempting suicide with sleeping pills." "I didn't think anything about what he said until it happened. I was surprised." LVN 1 stated she did not document the conversation with the doctor in Resident 1's clinical record to ensure all nurses were aware of the precaution.During an interview with the Social Service Designee, on 4/21/16, at 1:21 PM, she stated, "Because she (Resident 1) verbalized hopelessness and sadness didn't mean that she was suicidal. She had no access to anything to commit suicide. I did not follow up on her (Resident 1's) emotions. I let the Psychologist do that. I didn't do anything."The facility policy and procedure titled "Suicide Prevention Policy," undated, read in part "Criteria to be Considered for Suicide Potential: Prior attempts... Major Depression... 1. Suicide precautions may be initiated by the attending physician, psychiatrist, psychologist, director of nursing or charge nurse with a doctors order... 4. The IDT will collaboratively determine the following levels of observation the resident shall be placed on: a. 1:1 observation, b. Line of sight, c. Every 15 minute observation... 10. Perform mouth checks when administering oral medication, 11. Residents on suicide precaution will have room and person searches for the following contraband...g. personal medication... 13. The resident will be reassessed each shift for suicide impulses... 14. Resident and family... will be educated about the suicide precautions..."These failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000365 |
PARKVIEW JULIAN CONVALESCENT |
120012266 |
B |
06-Jun-16 |
I7GI11 |
5003 |
T22 72520(a) (b) (c) (a) If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or the patient's representative. (b) Upon admission of the patient to the skilled nursing facility and upon transfer of the patient of a skilled nursing facility to a general acute care hospital, the skilled nursing facility shall inform the patient, or the patient's representative, in writing of the right to exercise this bed hold provision. No later than June 1, 1985, every skilled nursing facility shall inform each current patient or patient's representative in writing of the right to exercise the bed hold provision. Each notice shall include information that a non-Medi-Cal eligible patient will be liable for the cost of the bed hold days, and the insurance may or may not cover such costs. (c) A licensee who fails to meet these requirements shall offer to the patient the next available bed appropriate for the patient's needs. This requirement shall be in addition to any other remedies provided by law. Based on interview and record review, the facility failed upon transfer to an acute hospital, to uphold the seven day bed hold, and to readmit or offer the first available bed for one of one sampled patient (Patient 1). This resulted in a violation of Patient's admission agreement and regulation.An unannounced visit was made to the facility on 3/29/16, at 12:43 PM, to investigate an allegation of the facility refusing to re-admit Patient 1 from the hospital. The clinical record for Patient 1 was reviewed. A bed hold notification for Patient 1 dated 3/6/16 at 8:57 AM, indicated Patient 1's Responsible Party (RP) was offered and accepted a 7 day bed hold for Patient 1. This bed hold document indicated the facility would hold Patient 1's bed for seven days and if her hospitalization lasted longer than seven days, Patient 1 would be re-admitted to the first available bed.During an interview with the Administrator, on 3/29/16, at 2 PM, he stated that after Patient 1 was transferred to the hospital, "We" did not accept her back to the facility. The Administrator stated "We did not offer her a bed hold."During an interview with the Director of Nurses (DON), on 3/29/16, at 2:13 PM, she stated on (3/5/16) resident (Patient 1) was transferred to the acute hospital because she attempted suicide by taking Tylenol PM (sleeping pills). The DON stated the resident was not offered a seven day bed hold and the facility decided not to readmit the patient back to the facility.During an interview with Patient 1's RP, on 4/15/16, at 2:42 PM, she stated when her mother was in the hospital the plan was for Patient 1 to return to the facility since it took her a long time to find a facility in Bakersfield. The RP stated a staff member offered her a seven day bed hold on 3/6/16, which the RP accepted. The RP stated the DON spoke with her and told her the facility was not going to accept her mother back. The facility had packed all of her mother's belongings and asked her to take them. The RP stated, "She didn't give me an option. She just told me that my mother could not come back to the facility... I didn't know that my mother had rights."The facility provided the booklet titled "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" dated 10/30/16, as the admission agreement provided to all admitted residents (or patients). This Admission Agreement read "If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed. You or your representative have 24 hours after receiving this notice to let us know whether you want us to hold your bed for you. If Medi-Cal [Medicaid] is paying for your care, then Medi-Cal will pay for up to seven days for us to hold the bed for you. If you are not eligible for Medi-Cal and the daily rate is not covered by your insurance, then you are responsible for paying $... for each day we hold the bed for you. You should be aware that Medicare does not cover costs related to holding a bed for you in these situations. If we do not follow the notification procedure described above, we are required by law (Title 22 California Code of Regulations Sections 72520(c) and 73504(c) to offer you the next available appropriate bed in our Facility. You should also note that, if our Facility participates in Medi-Cal and you are eligible for Medi-Cal, if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our Facility and wish to be readmitted. "This failure had direct or immediate relationship to the health, safety, or security of patients. |
| 120000365 |
PARKVIEW JULIAN CONVALESCENT |
120012398 |
B |
25-Jul-16 |
UV4V11 |
4955 |
F223 The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Based on observation, interview, and record review, the facility failed to follow the plan of care for two of two sampled residents (Resident 1 and Resident 2) who had a history of altercations. This resulted in Resident 2 hitting Resident 1 in the chest. An unannounced visit was made to the facility on 6/1/16, at 12:54 PM, to investigate an allegation of resident abuse by another resident. Resident 1 was a 67 year old female with diagnoses that included anoxic brain damage (injury to the brain due to lack of oxygen), major depressive disorder (a condition characterized by a long-lasting depressed mood or marked loss of interest or pleasure in all or nearly all activities), anxiety disorder (nervous disorder characterized by a state of uneasiness or apprehension), cataracts (a medical condition in which the lens of the eye becomes progressively opaque, resulting in blurred vision), glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of sight), and generalized muscle weakness. Resident 2 was a 90 year old male with diagnoses that included heart disease, hypertension (high blood pressure), and cerebrovascular disease (conditions caused by problems that affect the blood supply to the brain). During an interview with Resident 2, on 6/1/16, at 1:09 PM, he stated Resident 1 grabbed his chair. Resident 2 stated, "They [staff] turned her loose and I hit her as hard as I could swing. [Resident 1] had someone but they [staff] got her loose." During a review of the clinical Record for Resident 2, the "Cognitive Patterns", dated 4/7/16, indicated a Summary score of 15 [score of 13-15 indicates cognitively intact]. The "Care Plan", dated 3/23/15, indicated in the Interventions: Encourage resident to move out of area where resident (Resident 1) may approach him in halls. The "Progress Notes", dated 5/26/16, dated 9:59 AM, indicated, "He [Resident 2] stated as long as [Resident 1] comes near me, I will continue to hit her." During a review of the clinical record for Resident 1, the "Cognitive Patterns", dated 4/13/16, indicated a Summary Score of 3 [score of 0-7 indicates severe cognitive impairment. The "Functional Status", dated 4/13/16, indicated, "Supervision, One person physical assist." The "Care Plan", dated 6/13/15, indicated in Interventions: Ensure safety of other residents, if necessary move them to another area. The progress note for Resident 1 dated 1/30/16 indicated Resident 2 hit Resident 1 three times during an altercation. Another progress note dated 5/21/16 at 9:06 PM, indicated Resident 2 hit Resident 1 on her chest during another altercation. During a concurrent observation and interview with Resident 1, on 6/1/16, at 1:17 PM, in Resident 1's room, Resident 1 was sitting in her wheelchair with a Private Sitter [PS] beside her. Resident 1 was unable to recall the incident between her and Resident 2. During the interview, Resident 1 turned away and rocked in her wheelchair while grabbing at the table and hand rails that were within her reach. During an interview with the PS on 6/1/16, at 1:18 PM, she stated [Resident 1] grabs at things around her. The PS stated it was her responsibility to redirect Resident 1 to ensure her safety. During an interview with the Certified Nursing Assistant (CNA 1), on 6/1/16, at 2:05 PM, she stated she was the CNA watching Resident 1 when the altercation happened. CNA 1 stated nobody told her [Resident 1] should be kept away from [Resident 2] due to previous history of altercation between the two of them. CNA 1 stated, "I had her [Resident 1] in the lobby, I pulled her wheelchair but she was able to reach [Resident 2's] wheelchair handle. The man [Resident 2] did swing his arm and hit [Resident 1] in the chest." CNA 1 stated she could have prevented the altercation but she stated she had no idea they [Resident 1 and 2] had an altercation before. During an interview with the Licensed Vocational Nurse (LVN 1), on 6/1/16, at 2:11 PM, she stated she did not tell CNA 1 to keep Resident 1 and 2 apart. LVN 1 stated she assumed CNA 1 knew the reason they [staff] were watching Resident 1. The facility policy and procedure titled, "Abuse Policy", date revised 4/3/06, indicated, "Every resident has the right to be free from mistreatment, neglect, and misappropriation of property. This includes the facility's identification of residents, whose personal histories render them at risk for abusing other residents, and development of strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment on a regular basis." These deficient practices had a direct relationship to the health, safety, or security of patients. |
| 120000530 |
POSITIVE DIRECTIONS # 3 |
120013167 |
B |
10-May-17 |
0YN111 |
10588 |
W 192 -
For employees who work with clients, training must focus on skills and competencies directed toward client's health needs.
On 1/27/17, at 8:30 AM, an unannounced visit was made to investigate a fall which resulted in a fractured left hip.
The facility failed to ensure staff were trained in proper procedure after a fall which resulted in a change of condition for Client (1) not being acted upon timely.
This failure resulted in undue suffering and a delay in medical/surgical intervention for Client 1, who sustained a left hip fracture
Client 1 is a 79 year old male who is alert, verbally responsive, and cooperative. He is ambulatory without use of any assistive devices. Client 1 has diagnoses of severe intellectual disability, arthritis (painful inflammation and stiffness of the joints), anxiety disorder, PICA (persistent craving and compulsive eating of nonfood substances), and self-injury behavior.
During an interview with Direct Support Professional (DSP) 1, on 1/30/17, at 2:38 PM, she stated Client 1 fell in the bathroom on 1/19/17, at 8:30 PM, while she was passing medications to the other clients. Client 1 was not able to get himself up or bear weight as he normally did. DSP 1 stated she and DSP 2 used a wheelchair that belonged to another client and placed Client 1 on the couch where he laid from approximately 8:30 PM to 8:05 AM. DSP 1 stated after placing Client 1 on the couch she texted the House Supervisor (HS) 1 one time and never got a response. DSP 1 stated "We are supposed to call the RN [RN 1], but we didn't...By the time I [DSP 1] left at 11 PM he [Client 1] did not attempt to get up at all..." DSP 1 confirmed Client 1 not moving around continuously after the fall was very unusual. DSP 1 confirmed vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), and monitoring of Client 1's condition were not initiated after the fall as required per the facility policy.
During an interview with DSP 2, on 1/30/17, at 3:05 PM, she stated Client 1 had a fall on 1/19/17, at 8:30 PM. DSP 2 confirmed she saw Client 1 on the floor of the bathroom when she went to check on him, and he was not able to stand up or bear weight as he normally did. DSP 2 stated, "We [staff] weren't able to carry him so we used a wheelchair... [Client 1] just laid down in a side position on the couch [after staff placed him there]... [Client 1] did not get up the rest of my shift [end of shift is 11 PM]...We were supposed to call the nurse [Registered Nurse-RN 1] but we [DSP 1, DSP 2] didn't think he was seriously injured..." DSP 2 confirmed Client 1's usual activity is to walk around the facility during her shift but, "after [the] accident he did not get up, he [Client 1] stayed on the couch my whole shift after the incident..." DSP confirmed vital signs and monitoring were not done for Client 1 after the fall as indicated per the facility policy.
During an interview with DSP 3, on 1/30/17, at 4:05 PM, she stated, "When I got in for my shift [11 PM] [Client 1] was laying down on the couch and I asked [DSP 1, DSP 2] if anything was wrong with him...I asked what was wrong with [Client 1] because he was laying in an awkward position [on the couch]..." DSP 3 stated (DSP 1, DSP 2) informed her Client 1 fell in the bathroom and they had texted HS 1. DSP 3 stated Client 1 was able to sit himself up and walk around prior to the fall, but when she tried to pick him up off the couch to place him in bed or on the toilet when he requested Client 1 stated "I don't want to anymore" and remained on the couch. DSP 3 stated, "He stayed on the couch all night because I couldn't move him [Client 1]...It concerned me but I thought everything was covered because they [DSP 1, DSP 2] told me they told [HS 1] and I thought that meant [RN 1] knew too...[Client 1] was not his normal self..."
During an interview with HS 1, on 1/27/17, at 8:30 AM, he stated Client 1 walked independently prior to falling in the bathroom. HS 1 confirmed Client 1's fall was an unusual occurrence. HS 1 stated, "I got the text [Client 1 fell] around 8:55 PM on 1/19/17...I was asleep so I didn't notice the text until 3 AM...I came in [to the facility] around 7:30 AM [on 1/20/17]... [RN 1] was first contacted around 8 AM [1/20/17]...The staff texted me and they should have called me, they know that..."
During an interview with RN 1, on 1/27/17, at 9:50 AM, she confirmed Client 1's fall on 1/19/17 was an unusual occurrence. She was not made aware of the fall until around 8 AM the next morning, and stated, "If you text somebody and they don't respond, you need to call or contact someone else...that night [DSP1, DSP 2] should have contacted me..." RN 1 stated when she arrived to assess Client 1 the next morning at 8:05 AM; Client 1 was still refusing to get up. RN 1 (with the assistance of HS 1) then carried Client 1 to the restroom since he could not walk, and assessed him for injuries. RN 1 stated she felt that Client 1 was not injured but was having increased difficulty from his arthritis, and left instructions with HS 1 to "keep [Client 1] home and monitor him". RN 1 stated around 1 PM on 1/20/17 she received a call from HS 1 regarding Client 1 still refusing to ambulate. RN 1 then made the decision to send Client 1 to the emergency room for x-rays. In the emergency room Client 1 was diagnosed with a left hip fracture.
During an interview with the Qualified Intellectual Disability Professional (QIDP), on 1/27/17, at 9:30 AM, she stated the expectation for her staff when a client falls is for the staff to "leave [Client 1] where he fell, assess him, if anything noted wrong, then call the [RN 1]...they should have texted [HS 1] or called until he responded...if there is a change in [client] condition or a client cannot resume normal activity they should have called the RN...They should have called the RN after he fell..."
During a review of the clinical record for Client 1, the facility progress notes were reviewed. On 1/19/17, at 9:53 PM, DSP 1 indicated, "Client [1] fell down in restroom..." On 1/20/17, at 8 AM, RN 1 indicated, "Client [1] had fallen...required full assistance to be toileted...will keep at [facility and] keep very close monitor..." On 1/20/17, at 11:23 AM, HS 1 indicated, "Client [1] appears to continue to have difficulty ambulating..." On 1/20/17, at 12:55 PM, indicated "half on - half off couch in a twisted position...expressed pain with any movement...appears to not ambulate at all... [HS 1 and RN 1 notified]." On 1/20/17, at 9 PM, RN 1 indicated "[Client 1] was taken to [emergency room] after lunch for further evaluation... [Client 1] waited to be seen in [emergency room] for [four hours]...Once taken to the room x-ray of both hip and knees done...Dr. stated that [Client 1] has a [fracture] to his [left hip]...[Client 1] will require surgery...[Client 1] will be medicated as needed for pain..."
During a review of the clinical record from the hospital for Client 1, the following was noted:
The "History and Physical" dated 1/20/17, at 7:45 PM, indicated, "Caretaker states [Client 1] fell on 1/19/17 at [8:30 PM]. [Client 1] states pain to the knees and ankles...tenderness to palpitation [left hip] area, and to [left] knee area, mild foreshortening (prematurely or dramatically shorten or reduce) LLE [left lower extremity]...unable to bear weight...fracture left hip..."
The "Consultation Document" dated 1/23/17, at 12:50 PM, indicated a diagnosis of left hip fracture with displacement (a traumatic bone break in which two ends of a fractured bone are separated and out of their normal positions) was made. "Left lower limb is shortened and externally rotated." Surgery would be needed to correct the fracture.
The "Operative Report" dated 1/23/17, at 12:50 PM, indicated the preoperative diagnosis was a "Closed intertrochanteric (between the greater and lesser trochanter) fracture of left femur (thigh bone)". The patient was given spinal anesthesia (regional anesthesia [the use of medication to induce the insensitivity to pain]). An incision was made to Client 1's left femur; a 380 millimeter long by 12 millimeter diameter nail was utilized to correct the fracture.
During a review of the clinical record for Client 1, the facility progress note by RN 1 dated 1/26/17, at 3 PM, indicated Client 1 was discharged six days after presenting to hospital, "[Client 1] discharged from hospital...is able to put full weight bearing to Lt (left) leg. Has difficulty standing which [Client 1] required full/max assistance [with] ADLs (activities of daily living). Client [1] has front wheeled walker, Client [1] is fearful of getting up, Client [1] will require gait belt (a device used to transfer people from one position to another, from one place to another or while ambulating people that have problems with balance) for transferring, wheelchair as needed. Also will need to toilet seat raised (sic)...incision...with staples... [Pain medication] Q (every) 4 hrs (hours) PRN (as needed) for 10 days for pain...PT (Physical Therapy) as outpatient 3x (three times) week..."
The facility policy and procedure titled "Notification of RN and/or Physician", undated indicated, "...report any change in the individuals condition to their supervisor who will then report this to the RN and/or to the attending physician...For non-life threatening change in condition, staff shall notify the RN immediately, or as soon as practical, so that the RN may determine the course of action necessary regarding the clients condition... PROCEDURE...Take individuals [temperature, pulse, respiration, and blood pressure], and be able to provide baseline for these vital signs for that individual. "
The facility policy and procedure titled "FALLS" undated, indicated, "Falls can further incapacitate an individual...The staff should stay with the resident and call for help. If a fall results in head, neck or back injury the individual must be checked for injury before moving or being moved. Never try to lift an individual from the floor by yourself. Always ask for help..."
Therefore the facility failed to ensure staff were trained in proper procedure after a fall which resulted in the staff not acting upon a change of condition for one sampled Client (1) timely. This failure resulted in undue suffering and a delay in medical/surgical intervention for Client 1.
The above violation has a direct or immediate relationship to the patient's health and safety. |
| 170001877 |
PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD (STP) |
170009106 |
B |
02-Apr-14 |
OOXQ11 |
6079 |
76345(a)(5)(c) Health Support Services - Nursing Services (a) Facilities shall provide nursing services in accordance with the needs of the clients for the purposes of: (5) Control of communicable diseases and infection through: (c) Implementation of appropriate protective and preventive measures. 76315(b) Individual Program Plan (b) The individual program plan shall be implemented as written. 76521(b)Policies and Procedures (b) All policies and procedures required of these regulations shall be in writing, made available upon request to clients or their agents, employees and the public, and shall be carried out as written. Policies and procedures shall be reviewed at least annually, and revised as needed. The facility failed to comply with the above regulations when the facility failed to: 1. Ensure that appropriate protective and preventive measures, i.e., condoms, were used when Client 1 had unprotected sexual contact with Client 2, who was diagnosed with immune deficiency virus (HIV). 2. Ensure that appropriate policies and procedures were in place and implemented to prevent unprotected sexual contact between clients. 3. Ensure that Client 2's individual program plan (IPP) was implemented when cross-contamination was not prevented between Client 2 and clients who were not infected with HIV. Client 1, a 20 year old male was admitted to the facility on 1/25/07 with diagnoses of mild intellectual disability and conduct disorder (a childhood disorder in which the child repeatedly violates the basic rights of others). Review of Client 1's clinical record on 2/28/12 revealed that his IPP (Individual Program Plan), indicated that he had displayed inappropriate sexual behavior prior to and since his admission to the facility. On 1/25/12 he had unprotected anal sex with an HIV+ peer, Client 2. Prior to this incident, he had tested negative for Hepatitis C and HIV (Human Immunodeficiency Virus). On 1/27/12, he again tested negative for baseline values of Hepatitis C and HIV. Due to the unprotected sexual contact, Client 1 had to receive Truvada, an antiretroviral medication used in the treatment of HIV infection. In this case, the drug was being ordered as prophylaxis to try to prevent infection, after the fact. Client 2 is a 38 year old male who was admitted to the facility on 12/12/00 with diagnoses of moderate intellectual disability, impulse control disorder and HIV positive. Review of Client 2's clinical record on 2/28/12 revealed that his IPP indicated that he had a history of inappropriate sexual behaviors and continued to engage in sexually promiscuous behaviors that required him to be under a level of close supervision in order to protect him and others from unwanted sexual advances and/or disease transmission. A review of Client 2's IPP indicated that because of his diagnosis of HIV, staff needed to prevent cross-contamination with non-infected clients. On 1/25/12 he had unprotected anal sex with Client 1. A review of the facilities Incident Report (IR) dated 1/25/12 indicated that Client 1 went into Client 2's room, told him to turn off the lights and take his clothes off. Staff making rounds at 8:55 PM noted Client 1 was not in his room. All the rooms on the residence were checked and Client 1 was not seen. Two staff entered Client 1's room and also checked his bathroom. As they were leaving his room, Client 1 appeared at the door, stating he had been in the laundry room. During the investigation of the incident, both clients admitted to having unprotected anal sex with each other. In an interview with Client 1 on 2/28/12 at 1:00 PM, he acknowledged that he had had unprotected sexual contact with Client 2. He stated that he had had HIV training but that he did not remember very much about what was taught. In a second interview on 3/5/12 at 10:30 AM, Client 1 stated he did not know that condoms were available on the residence. In an interview with Client 2 on 2/28/12 at 1:05 PM, he stated that Client 1 came to his room and asked to have sex with him. He stated that he told Client 1 that he should wear a condom, but Client 1 stated he "didn't care" and he just wanted to have sex. He stated that they did have sex without condoms. He stated that he was aware that condoms are available and that they just have to ask for one.In an interview with Staff A and B on 2/28/12 at 1:10 PM, they stated that the most of the clients know that Client 2 is HIV+ because he makes no secret of his diagnosis. They also stated that all the clients know that condoms are available and they just have to ask for them. They acknowledged that none of the clients had ever asked them for a condom. They stated that if clients were to ask for condoms, staff would need to initiate a teaching interaction, letting clients know they really shouldn't be having sex and then would have to document in the clients' medical records that a condom had been dispensed. They acknowledged that having to ask for a condom could act as a deterrent to obtaining them and using them.In an interview with Staff C on 3/1/12 at 12:00 PM, he stated that there is no official policy for distribution of condoms to clients. He stated that the official position of the facility is that clients can ask for condoms and the condoms will be available to them free of charge. He acknowledged that having to ask for a condom could be a deterrent to using one, especially with the clients that the facility serves.Therefore, the facility failed to: 1. Ensure that appropriate protective and preventive measures, i.e., condoms, were used when Client 1 had unprotected sex with Client 2, who was diagnosed with immune deficiency virus (HIV). 2. Ensure that appropriate policies and procedures were in place and implemented to prevent unprotected sexual contact between clients. 3. Ensure that Client 2's individual program plan was implemented when cross-contamination was not prevented between Client 2 and Client 1 during unprotected sex. These facility failures had a direct or immediate relationship to the health, safety, or security of clients. |
| 170001878 |
PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD |
170009188 |
A |
27-Feb-14 |
K13W11 |
8769 |
Welfare and Institutions Code 4502 (h) 4502. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: 4502 (h) A right to be free from harm, including physical restraint, or isolation, excessive medication, abuse, or neglect. The facility did not comply with the above regulation by failing to ensure Client 1's right to be free from harm, abuse and physical restraint. Client 1 was provoked into an argument, pushed face first to the ground, kicked, and choked by Staff A resulting in a loss of consciousness, respiratory failure and cardiac arrest. Respiratory failure is a condition in which not enough oxygen passes from the lungs into blood, heart and brain, and can potentially cause coma and death. When the flow of blood to the heart stops, the heart stops beating and Cardiac arrest occurs. Staff B, C, D, E, and F neglected to intervene and protect Client 1 from abuse.Client 1 required community emergency medical care in the intensive care unit on a ventilator (life support machine that supports breathing) for 11 days. On 12/23/2010, the ventilator was removed and Client 1 was transferred out of ICU, to a medical floor for three days. On 12/26/10, Client 1 was discharged from the community hospital.Review of the Individual Program Plan dated 3/23/2010, revealed Client 1 was 44 year old individual with mild mental retardation and an intelligence quota of 61. An IQ of 61 is representative of a cognitive level equal of a 9 or 10 year old child. Client 1 was 5 feet 8 inches tall, and weighed 218 pounds. An interdisciplinary note dated 12/8/10 described Client 1 as polite to peers and staff, using please and thank you when needed.He/she had received a gold level (advanced) in the residence reward system and had no documented incidents of physical aggression for the previous six months.Review of facility incident reports revealed on the afternoon of 12/11/10, Staff A told Client 1 to stay in the group area located on the residence, however Client 1 went to his/her room and lay down on the bed. Between 3:45 PM and 4 PM, Staff A found Client 1 in his room, resting in bed. Staff A demanded he /she return to the group area, provoking an argument with Client 1.During interview on 6/24/2011 at 1 PM, Staff B indicated that while in the group area on 12/11/10, Client 2 and 3 observed Staff A push Client 1 face down to the ground and stated Staff A "stomped Client 1 on the chest and back," with his feet.Hearing screaming in the group area, Staff C, D, E and F ran to the group area and discovered Client 1 struggling on the ground face down with Staff A. Staff B, C, D and E got onto the ground and each held one of Client A's limbs.Staff A knelt with his knees onto Client 1's back. Staff A put his arm around Client 1's neck and pulled Client 1's head back. Client 1 screamed, he couldn't breathe and lost consciousness, urinated, turned grayish blue, and his/her respirations and heart stopped. When Client 1 became unresponsive, Staff C, D, E and F "panicked" and left the group area. Staff B pushed Staff A off Client 1 and rolled him/her over onto the back, assessed for breathing and heart rate, finding none; began mouth to mouth resuscitations. Staff A complied with Staff B's request to help and did 10 chest compressions then abruptly stood up and said "Fuck Him" referring to Client 1 and refused to assist any further. An alarm had been sounded and other unit personnel began arriving to render emergency aide to Client 1 who was in respiratory and cardiac failure. The facility emergency team arrived and placed the client on an automated external defibrillation (AED) device at which time he began breathing. An AED is a device that checks to ensure the heart is beating.The community emergency medical service arrived at 4:27 PM and Client A was transported to the community hospital via ambulance, where he/she was intubated, and placed on a ventilator (tube into windpipe / throat attached to a machine to push air in and out of lungs).Client 1 was admitted to intensive care unit with diagnoses of acute (sudden) respiratory failure, cardiac arrest (heart stopped), conjunctiva hemorrhage (ruptured blood vessels in the eye from choking) and food / vomit pneumonitis, (gagging on vomit and breathing it into the lungs).The community hospital's records dated 12/11/10 revealed Client 1's right eye was red and had ruptured capillaries in the white part of the eyes (due to choking), both eyelids were swollen, and there were abrasions to the right upper arm, right thigh and a bruise to the left upper arm. Facility investigations determined the bruising appeared to be shoe prints.Personnel record review revealed Staff A was a male in his 30's, who weighed more than 400 pounds and stood 6 feet 3 inches tall, with a history of employee misconduct related to client abuse allegations occurring on: 11/26/2007, pushed a client to the ground, 4/1/2008, twisted the arms of a client, 11/21/2009 hit a client on top of the head, 5/3/10 sexual assault of a client. After each of these allegations Staff A was cleared to return to work with developmentally disabled individuals as an unlicensed psychiatric technician / certified nurse assistant.After the assault of Client 1, Staff A immediately conspired with Staff B, Staff C, Staff D, Staff E and Staff F to report and falsify reports that Client 1 spit, struck out and was placed in an emergency wall containment, (holding a client while standing against the wall), lost consciousness because he/she was struggling and was then lowered to the floor.On 1/16/2011, in an interview with the facility special investigator, Staff B admitted Staff A assaulted Client 1 and pressured others to lie for him. Staff B indicated in interviews on 6/24/2011, Staff A's family had called her at home, threatening her to "stick to the story."Client 2 and 3 indicated in interview beginning on 7/18/2011 at 2:50 PM, that they were in the group area at the time of the incident. Client 1 was never in a wall containment and they saw Client 1 face down on the ground, Staff A kicking him, Staff A's knees on Client 1's back, and choking him/her. They indicated Client 1 said he /she couldn't breathe, passed out and pissed on him/herself. Client 2 and 3 indicated Staff B was screaming to get off, get off of Client A.On 6/24/2011 at 12:50 PM in an interview with Client 1, he/she stated Staff A 'beat up on me."In an interview on 7/25/2011 at 3 PM, with the Staff G, Program Director (manager) she confirmed Client 1's injuries should have not happened during wall containment, Staff A should have let Client 1 pace in the hallway, sounded his alarm and waited for more people. The Program Director indicated the facility Special Investigator either didn't arrive soon enough or left too soon and "staff had opportunity to get together and work it all out."On the afternoon of 12/11/2010, Client 1 wanted to smoke a cigarette and Staff A denied him/her a break, Client 1 asked to go to his/her room to lay down and Staff A refused to let him/her relax quietly. Staff A left the group area and Client 1 requested to use the restroom which Staff B granted, however Client 1 went to his/her room and laid down. Staff A found Client 1 resting quietly on his/her bed and demanded Client 1 return to the group area. Client 1 obeyed and went to the group area where an argument occurred. Staff A then assaulted Client 1; pushed Client 1 face down to the ground, kicked, put his knees onto Client 1's back, his arm around Client 1's neck and pulled his /her head back until Client 1 lost consciousness and went into respiratory and cardiac arrest. The facility failed to ensure Client 1's right to be free from harm, abuse and physical restraint. Client 1 had been resting quietly on his bed when Staff A provoked him/her into an argument, pushed face first to the ground, kicked, and choked him/her, resulting in Client 1 suffering a loss of consciousness, respiratory failure and cardiac arrest. Staff B, C, D, E, and F neglected to intervene and protect Client 1 from abuse. 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. |
| 170001877 |
PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD (STP) |
170009430 |
B |
02-Apr-14 |
UDU011 |
6845 |
76525(a) (20) Clients' Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) or this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint, isolation, excessive medication, abuse or neglect.During the investigation of a reported event the facility failed to: 1. Ensure that Client 1 was free from harm when staff pushed him against the wall while the client was getting his blood pressure checked.Review of Client 1's clinical record on 7/18/12 revealed that Client 1 is a 28 year old male who was admitted to the facility with diagnoses of moderate intellectual disability and impulse control disorder (a disorder in which people repeatedly fail to resist an impulse, drive, or temptation to perform an act that is harmful to themselves or to others). According to his IPP (Individual Program Plan) he had a history of physical and verbal aggression. He also had a behavior plan for harm to others that included steps that staff was to use counseling and redirection of the client to an alternate activity. If that step was ineffective and the client continued to escalate the behavior, staff could restrain the client with wall containment and 5-point restraints.Due to a recent increase in aggressive and assaultive behaviors,the Interdisciplinary Team along with the client had decided to change his anti-psychotic medication regimen and a new medication started on 7/11/12. A review of the IR (Incident Report) dated 7/11/12 indicated that Client 1 was brought to the treatment room by Staff 3 to have his blood pressure checked. Staff 3 was standing in the treatment room, along with Staff 2, who was checking Client 1's blood pressure. Staff 1 was in the chart room, immediately adjacent to the treatment room. Client 1 was verbalizing that he did not want to take his medication and that staff could not make him take the medication. Staff 1 and 3 was counseling Client 1 on the importance of taking his medication. Client 1 continued to be verbally aggressive toward staff and Staff 3 approached Client 1 and pushed him against the wall. Staff 1 and 2 immediately attempted to verbally and physically separate Client 1 and Staff 3. Client 1 and Staff 3 continued to push each other and Client 1 hit Staff 3 in the face. Both men were eventually separated. Client 1 suffered no physical harm although he stated that he had been hit in the nose by a staff member. On 7/24/12 at 1:35 PM, an attempt was made to interview Client 1, however, Client 1 refused to be interviewed. In an interview on 7/25/12 at 10:10 AM, Staff 1 stated that Staff 3 had brought Client 1 up to the treatment room for his blood pressure check and Staff 3 was standing just inside the door. He stated that Client 1 was saying that he was not going to take his medications and the staff could not make him do so. He stated that both he and Staff 3 were verbally counseling Client 1 to take his meds when all of a sudden Staff 3 started walking toward Client 1 and pushed him against the wall. He stated that he told Staff 3 to stop and then grabbed his arm and tried to hold him back. Staff 2 had been still trying to take Client 1's blood pressure and tried to get between Staff 3 and Client 1. Staff 1 stated that the treatment room is an extremely small and narrow room and it only took Staff 3 one to two steps to reach Client 1. He stated that he did not feel that Client 1 was threatening; he was just "mouthing off" and if Client 1 really did not want his medications they would have notified Client 1's physician. Staff 1 stated that he did not feel there was a need for any type of physical intervention at that point.In an interview on 7/31/12 at 1:30 PM, Staff 2 stated that he was checking Client 1's blood pressure. He stated that Staff 1 was talking to Client 1 about taking his medications but was also just "letting him talk" and vent his feelings. Staff 3 was standing just within the treatment room by the door. He stated that Client 1 did not appear threatening in any way; if he had, Staff 2 would not have attempted to take his blood pressure. Staff 2 stated that he saw Staff 3 approaching Client 1. Staff 3 then grabbed Client 1's right arm and pushed him against the wall. Staff 2 stated he backed up, with his stethoscope still in his ears and saw Staff 1 grab Staff 3's arms and try to pull him back and telling Staff 3 to stop. He stated that Client 1 and Staff 3 were pushing each other, and then Client 1 hit Staff 3 in the face. Staff 2 stated that he got between Client 1 and Staff 3 and hustled Client 1 out into the hall while Staff 1 got Staff 3 away from the treatment room. He stated that when Client 1 was out in the hall he started crying, stating he didn't know why he [Client 1] was acting the way that he was.In an interview on 8/8/12 at 2:40 PM, Staff 3 stated that he brought Client 1 up to the treatment room for his blood pressure check. He stated that Staff 2 was attempting to take Client 1's blood pressure and the client was saying that he didn't want to take his medication. Staff 1 was counseling him to continue taking the medication. He stated that Client 1 started getting agitated and got off the exam table and put his fists up in a threatening manner. Staff 3 perceived Client 1 to be a threat to himself and others and he moved in to "wall contain" him. He stated he moved in and grabbed Client 1's arm, assuming the other staff would follow his lead and assist in the wall containment. Client 1 and he were pushing each other and then Client 1 hit him in the eye.He stated Staff 2 was attempting to get between him and Client 1 and get the client out the door. Staff 1 had grabbed his arm and told him to stay in the treatment room but he really didn't understand what the problem was.In an interview on 8/8/12 at 3:15 PM, Staff 4 stated that staff should never use physical intervention in response to verbal interactions. Staff should "back off" and use verbal interventions instead. He stated that he had been involved in revising the Active Treatment Crisis Management techniques and there is never a time when just one person would attempt any type of containment. It is always a team effort, in order to protect both the client and the staff. There also has to be some type of communication so each member of the team knows what the others are doing. Therefore, the facility failed to: 1. Ensure Client 1 was free from abuse when Staff 1 pushed him against the wall in the treatment room. These facility failures caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the client. |
| 170001878 |
PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD |
170009596 |
B |
10-Apr-14 |
8UUJ11 |
5926 |
W285 483.450(b)(2) Interventions to manage inappropriate client behavior must be employed with sufficient safeguards and supervision to ensure that the safety, welfare, and civil rights of clients are adequately protected.The facility failed to ensure that Client A, a client with'pica (ingesting inedible items) had sufficient supervision to prevent Client A from obtaining and swallowing several inedible items. These inedible items had the potential to cause harm to Client A's throat, esophagus (portion between the throat and stomach), stomach and intestines.Review of the clinical record on 10/25/12, noted that Client A, age 43, was admitted on 10/23/80. Current diagnoses include profound intellect disorder and pica.Review of the Interdisciplinary Notes indicated the following documentation:10/12/2012; 7:00 a.m -7:30 a.m. The client appeared pale and lethargic. Possible x-ray of abdomen due to PICA problem.10/12/2012; 10:35 a.m. Per medical doctor, the x-ray of the abdomen was positive for 3 bolts, 1 nail and 1 needle.10/12/2012; 5:30 p.m. Fecal matter had 3 foreign objects "inconsistent" with the consistency of the feces.10/12/2012; 8:30 p.m. Staff observed during the shift that the client defecated (bowel movement)-2 yellowish crayons measuring 2 inches long coupled with folded paper material.10/14/2012; 2:45 p.m. Client had small bowel movement with part of a crayon box.10/14/2012; 6:00 p.m. Client had large bowel movement with a green crayon, 3 cm (centimeters) long, tip of latex glove and a hexagon nut about 1.5 cm.10/17/2012; 6:10 p.m. Client's fecal matter had a lip smacker lip gloss tube which measured 6 cm long and what appeared like a jelly bean measuring Y2 cm. long.On each of the aforementioned days, it was noted that the client was on one to one supervision.Review of the X-ray reports noted the following results:10/12/2012...0paque or metallic foreign bodies in the abdomen consisting of one long needle,approximately 4 cm; few nuts and one short nail and a nut.10/15/2012...Previously described needle is actually a bobby pin. One of the nuts is actually a coin believed to be a nickel. The small metallic screw remains.10/25/2012... There were metallic foreign bodies in the abdomen consisting of a coin, small screw and a nut. The bobby pin had been passed.Review of the Physician Progress Notes dated between 10/12/2012 and 10/25/2012, noted that besides the orders of x-rays, staffs were to observe Client A for signs of pain, fever and abdominal distention (enlargement of the stomach).The day shift senior psychiatric technician (Sr. PT 1) stated during an interview on 10/26/12 at 8:15 a.m. that Client A had been on 1:1 supervision for a few years due to his severe pica behavior. He stated that he tried to assign consistent staff members to supervise the client. He stated that all staff assigned to the client denied having any knowledge that Client A ingested inedible items.Sr. PT. 1 stated that the crayon usage was not a part of Client A's active treatment plan. He stated that only one client, Client B, had access to crayons which were her personal possessions. He stated that only two clients on the residence, Client C and Client D, who were high functioning clients, had lip gloss as a part of their personal possessions. He stated that Clients B, C, and D were assigned to the same group area as Client A, but were never at the same table with Client A or in the same area as Client A.The client's room was observed on 10/26/2012 at 8:40 a.m., with Sr. PT 1. One screw was observed missing in the flat plate latching area ofthe client's locker. Sr. PT 1 stated that the screw had been missing for some time.Shortly thereafter, in the residence clinic room area, in the presence of Sr. PT 1, a plastic lip gloss shaped item with an attach label imprinted "lip smacker"with brownish affixed particles, was observed in a plastic see-through container.Review of the Approaches and Strategies dated 10/1/2012, noted a behavioral alert that Client A had a life-threatening behavior of ingesting non-edible items. It was also noted that Client A was on one to one supervision during waking hours and on one to two supervision at night.Review of Policy, Facility Bulletin No. 48, Standards of Care, dated November 2011, noted II. Standards, C. Client Supervison: "The safety and well-being of the clients is of primary importance. Sufficient staff shall be assigned on duty, and alert at all times to the clients' needs, to provide client protection and safety".Review of Program 5 Staff Procedure, Section 1-30, Levels of Supervision, dated April 13, 2012: One to One/Constant Supervision are defined as close enough to protect the client and themselves....The night shift senior psychiatric technician (Sr. PT 2) stated during an interview on 1/11/13 at 6:30 a.m. that prior to this incident, Client A had been on 1:2 supervision for some time. Sr. PT 2 stated that the assigned staff sat in the hallway between Client A's room and the room of another client (with pica behavior) which was located directly across the hallway from Client A's room. Sr. PT 2 stated that none of the staff on the shift had seen Client A exhibit pica behavior..The evening shift senior psychiatric technician Sr. PT 3, stated during an interview on 1/14/13 at 10 p.m. that Client A had been on 1:1 supervision (within arm length reach of staff) for a long time. Sr. PT 3 further stated that staff denied seeing the client ingest any inedible items.The facility's failure to comply with the above requirements by failing to provide sufficient safeguards placed Client A in harm when Client A, a diagnosed pica client, obtained and ingested inedible items. This had the potential of causing harm to Client A's throat, esophagus, stomach and intestines.These actions had a direct or immediate relationship to the health, safety or security of long term care facility patients or residents. |
| 170001878 |
PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD |
170009757 |
B |
10-Apr-14 |
0VTA11 |
6746 |
76525(a)(20) Clients' Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. 76315(b) Developmental Program Services - Individual Program Plan (b) The individual program plan shall be implemented as written. During the investigation of a reported event the facility failed to: 1. Ensure that Client 1 was not neglected when staff failed to properly monitor him while he was using the restroom and the staff member was across the room, by the door. The lack of monitoring necessitated that the staff member used her foot to try to prevent Client 1 from falling off the toilet when he bent over to pull up his pants. 2. Ensure that Client 1's individual program plan was implemented when he was not placed on a shower/commode chair with a safety belt during toileting to help him maintain his balance and prevent falls. Client 1 is a 58 year old male who has diagnoses of profound intellectual disability, right hemiplegia (paralysis of one half of the body) and stereotypical movement disorder. According to his individual program plan (IPP) dated 9/4/12, he has profound hearing loss and staff are to use simple sign language and gestures in order to communicate with him. He also requires assistance to complete all of his hygiene and grooming tasks. Client 1 requires assistance with his toilet hygiene needs, washing his hands, ensuring privacy, flushing the toilet and wiping himself.The client had an open health care plan for spastic hemiplegia that included steps for staff to observe for signs of instability, weakness, changes in balance, irritability, agitation and pain. His activity level was as tolerated but he was to use a wheelchair for moving around the unit and outside and a shower chair/commode chair with a safety belt for bathing and toileting.A review of the General Event Report (GER) dated 1/29/13 indicated that Staff 1 went to assess Client 1 and found that he was in the restroom. Staff 1 entered the restroom and observed the client seated on the toilet, trying to pull up his pants. Staff 1 observed Staff 2 kick the client on his right knee. Staff 1 twice told Staff 2 "You do not kick clients!" Staff 2 apologized and informed Staff 1 that she thought the client was going to fall. Staff 1 then went out and notified facility staff of the incident. In an interview with Staff 1 on 2/21/13 at 12:20 PM, he stated that went to Client 1's living area and staff there told him that the client was in the bathroom. He knocked and then entered the bathroom and saw that the client was trying to get up off the toilet. He observed Staff 2 raise her foot and kick Client 1 on the right knee. He stated that he was shocked and upset and stated to her "You do not do that!" and he repeated this once more. He stated that Client 1 is known to have poor balance and ataxia (defective muscular coordination) and requires assistance with his activities of daily living (ADL's). He stated that Staff 2 was standing by the door to the bathroom, about 4-5 feet away from the toilet. Staff 1 stated that this would not be the place to stand if one is concerned about the client's balance or the client attempting to get off the toilet by himself. He stated that there was no way that she could have reached him in time if Client 1 had started to fall. He stated that he judged the kick to be of moderate intensity but not hard enough to have caused marks or bruising. He stated that Client 1 has a very high tolerance for pain and did not react. He also stated that the client is non-verbal and could not tell anyone what happened. He stated that kicking out with one's leg is not in any way an acceptable method to prevent a client from getting up from a sitting position or to prevent a fall. In an interview with Staff 2 on 2/27/13 at 11:00 AM, she stated that she had taken care of Client 1 for many years and knew his IPP and health care plans. She stated that on that day Client 1 was not overly active in the group area where he was sitting in his wheelchair. She stated she took him out of the wheelchair and walked him to the bathroom and sat him on the toilet. She stated that he became more agitated while sitting there. She stated she was standing near the door to the bathroom, monitoring Client 1 but also monitoring what was happening in the group area. She acknowledged that she was looking away from Client 1 while she was monitoring the group area and that it could take only seconds for someone to fall.She stated that she was about 3-4 feet away from Client 1 when she was standing near the door. She stated that Client 1 was rocking back and forth while on the toilet and suddenly lifted his buttocks off the toilet, rocked forward until his head was about one foot above the floor. She thought he was going to fall so she put her foot out to stop him from falling. She stated that when he saw her foot, he sat back up. It was at this time that Staff 1 came in and said something to her about not kicking the client. She acknowledged that she should have been using the shower chair with Client 1 due to his agitation and his high potential for falls but she did not use it on that day. Staff 2 denied that she kicked Client 1; however, when she demonstrated to the surveyor what she had done to prevent Client 1 from falling, she inadvertently kicked the surveyor in the shin and did not seem to notice the kick. She acknowledged that she had never been taught to prevent a fall by using her leg or foot to "catch" a client from falling. Staff 2 could not explain why she used that method to try to stop the client from falling. Therefore, the facility failed to: 1. Ensure that Client 1 was not neglected when staff did not monitor him continuously while he was in the bathroom and was not in close proximity while he was in an agitated state. 2. Ensure that Client 1's IPP was implemented when the proper safety equipment, i.e. a shower chair with a safety belt, was not used to help prevent him from getting up off the toilet and potential falls. He also was not closely monitored as stated in his care plans when in an agitated state when staff was standing near the door of the bathroom instead of right next to the client, where they could assist him and control his movements. These facility failures caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the client. |
| 170001878 |
PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD |
170010153 |
A |
31-Jul-14 |
DS1011 |
7944 |
Title 2276525(a)(20) Clients? Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. During the investigation of an entity reported event, the facility failed to ensure that clients were protected from sexual abuse when a mildly intellectually disabled client, with a history of sexual crimes, was placed on a co-ed residence and committed a sexual crime against a severely intellectually disabled client. The facility also failed to protect female clients on the co-ed residence when they remained on the residence with other male clients who had criminal sexual histories or sexually acting-out behaviors. Allowing the female clients to remain on the residence increased the potential that other incidents of a similar nature could occur. On 6/11/13, an investigation of an entity reported incident (ERI) was initiated that documented an incident of sexual intercourse between two peers, witnessed by a third peer on 5/30/13. The witness did not report the incident until three days later, on 6/2/13, at which time the facility reported the incident to the Department. The initial police report done on 6/2/13, indicated that the sexual intercourse was ?consensual?.Upon review of the clients? medical records it was found that Client 1 is male and was diagnosed as being mildly intellectually disabled. He also had a history of previous sexual assault of a developmentally disabled female. Client 2 is female and has a history of having been sexually assaulted when she was a teenager, precipitating her psychosis, and is diagnosed as severely intellectually disabled and unable to give consent in any form.Client 1 had been transferred from the Secure Treatment Program of the facility to Unit 26 in the General Treatment Area of the facility on 8/23/12, because it was felt he would benefit from a less restrictive living situation. At the time of the transfer and up until the incident, Unit 26 was a co-ed unit with three female clients, one of which was Client 1.A review of the Interdisciplinary Notes (IDN?s) for Client 1, dated 5/30/13 at 8:45 PM, indicated he was seen several times walking toward the short hall [where the female clients resided on Residence 26]. Staff redirected him and reminded him of unit rules and planned to continue to monitor him. IDN?s of 6/2/13 at 5:25 PM, indicated that Client 3 had reported to staff that she had witnessed Client 1 having sex with Client 16 three nights ago. Staff spoke with Client 1 and he admitted to having sex with Client 2. The clients were immediately separated and Client 1 was ?guested? on another unit for the night.A review of Client 2?s Approaches and Strategies dated 11/28/12, indicated that ?The client is developmentally incapable of responding appropriately in an emergency situation and would willingly go with a stranger and would not be able to protect herself in an exploitive situation.? A review of the IDN?s for 6/1/13 at 6:15 AM, indicated that that Client 2 was awake on and off throughout the night shift, pacing back and forth to the restroom. Client 2 was redirected back to her room each time. Client 2 has no signs of pain or discomfort noted by staff and that staff indicated they would continue to monitor her. After Client 3 reported the incident to staff on 6/2/13, Client 2 was examined by the Health Services Specialist (HSS) and the physician on duty and no physical or emotional trauma was noted.In an interview with Client 1 on 6/12/13 at 12:35 PM, he stated that he went to Client 2?s room to check on her as she often wets her bed and he changes it for her. He stated that all the staff were down at the other end of the hall at that time dealing with another client?s behavior. He stated that Client 2 was naked at that time and she waved her hand at him to come into her room and told him that she wanted him to ?do it to her, real fast?. He stated that he then had sex with her. When asked to repeat what happened, he stated that he had sex with Client 2 but she did not say anything. He stated that he knew that he was not supposed to be in the short hall with the female clients. He also stated that he knew he was not supposed to have sex with any of the females. He stated that Client 3 saw him having sex with Client 2 and told him to get out of her room. In an interview with Client 2 on 6/12/13 at 1:05 PM, with a familiar staff to her acting as an interpreter, the surveyor attempted to speak with her. When asked if she remembered Client 1, she simply smiled and repeated his name. When she was asked if Client 1 was her friend, she giggled and repeated ?friend?. When asked if she had had sex with Client 1, she appeared upset and would not say anything more.In an interview with Staff A on 6/19/13 at 12:30 PM, he stated that he didn?t know Client 1 had a history of rape until the client had been on the residence for about 30 days He stated that over the past year most of the female clients had been moved off the residence and the three who remained were felt to be able to protect themselves. They all required single rooms and there just was no other units available for them. He stated, ?We did the best that we could.? He stated that the facility was merging programs at the time and the other ICF residences were all full. He stated that Client 2 would bite and scratch anyone who came too close to her so it was felt she could probably handle herself with the male clients.In an interview with Staff I on 6/19/13 at 4:20 PM, she stated that the Team was aware of the disparity of functioning levels on the unit and of the male clients? sexual histories, but they felt that the female clients would be OK because they were verbal and would be able to yell or tell staff if someone was bothering them. She did acknowledge that it should be the facility?s responsibility to protect the clients, not the clients themselves. She stated that at first the facility police felt that the incident was one of consensual sex but she acknowledged that Client 2?s cognitive and social levels of functioning were such that she could never consent to anything, let alone having sex with someone. She stated that the Team was aware of the disparity of functioning levels on Residence 26 and of the new male clients? histories of sexual crimes or behaviors, but felt the other clients would be all right with them. In an interview with Staff L on 7/2/13 at 11:05 AM, she stated she was not immediately aware of Client 1?s past history with sexual assault but as time went on, she became aware of his past history.She stated that during the time of his transfer, the residence was receiving a number of clients who had sexual behaviors and she had a ?heightened awareness? of all of the clients on the residence because of this.Client 1 has since been arrested and is in the county jail, awaiting trial. Therefore, the facility failed to ensure that clients were protected from sexual abuse when a mildly intellectually disabled client, with a history of sexual crimes, was placed on a co-ed residence and committed a sexual crime against a severely intellectually disabled client. The facility also failed to protect female clients on the co-ed residence when they remained on the residence with other male clients who had criminal sexual histories or sexually acting-out behaviors. Allowing the female clients to remain on the residence increased the potential that other incidents of a similar nature could occur. These facility failures presented either imminent danger that serious harm would result or a substantial probability that serious physical harm would result. |
| 170001878 |
PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD |
170010246 |
B |
10-Apr-14 |
D1HO11 |
6405 |
483.410 (a) (1) Governing Body The governing must - Exercise general policy, budget, and operating direction over the facility. The facility failed to ensure the governing body exercised direction and developed a plan addressing the cockroach infestation and presence of rodents, met with plant operations, dietetics, housekeeping and infection control committees to develop an action plan consisting of surveillance, prevention, sanitation, trapping and chemical control. These failures meant that there was an effective pest control program was in place. Cockroach infestation and rodent droppings were identified in the central kitchen and three residence satellite kitchens.On 10/14/13 at 3:30 PM, evidence of cockroach infestation and rodent droppings were observed in the central kitchen. Live and dead cockroaches, cast skins, egg capsules and droppings are evidence of an infestation.A food mixer and a blue foam battery cover contained dark brown cockroach feces and decomposing bodies, resembling coffee grounds. A dead cockroach was found in a clean mixing bowl, three cockroaches were found on a food preparation counter, a dead cockroach was next to a cutting board. Under the food preparation counter, were nine dead cockroaches, one of which had an egg case attached to its abdomen. The dish room and butcher shop walk-in refrigerator revealed more dead cockroaches. The cockroaches were identified as belonging to the German cockroach species. The German cockroach is brown to black with two parallel streaks running from the head to the base of the wings. The German cockroach is particularly associated with restaurants, food processing facilities and nursing homes.In a closet storing kitchen brooms and staff clothing, rodent droppings were observed over a quarter of the floor space. Through-out the central kitchen sanitation concerns were observed contributing to cockroach infestation; pooled standing water, broken floor tiles and unsealed grout around floor tiles were observed. Cockroaches favor hiding spots near food and water and nest in small tight places.On 10/14/13 at 6 PM, evidence of cockroach infestation was observed in three of five residence satellite kitchens, with rodent dropping in one.Interview on 10/15/13 at 10 AM with the facility Pest Control Technician (PCT) revealed use of a chemical pesticide (ULD BP300) to spray the kitchen.On 10/15/13 under the dish washing machine on residence 26 satellite kitchen were ten dead roaches. Water was leaking from the dish washing machine. Food particles floating in the water into the floor drains provided food sources for cockroaches. Bait traps were placed in all residence satellite kitchens on 10/15/13 and on 10/16/13; all bait traps showed presence of live and dead roaches.On 10/17/13 at 9AM, Residence 6's satellite kitchen had a live cockroach on a wall and three dead cockroaches on a bait trap. Residence 5's satellite kitchen had live cockroach on a wall and crawling on the floor, three cockroaches were smashed in a door jam and one was in a bait trap.Interview with food service workers on 10/17/13 at 9 AM and 9:30 AM, indicated the satellite kitchens were sprayed based on a schedule posted on the bulletin board. The posted schedule in each kitchen was dated September 2013 and the food service workers were unaware of the last time the kitchen was treated.Review of the log titled "Pest Control Spray at Main Kitchen and Stores," showed that the PCT "fogged" ( spraying insecticides into the air to form a fog) the central kitchen, dietetics, warehouse and docking area in May 2013, July 2013, September 2013 and on 9/27/13, 10/2/13 and 10/9/13.Review of the log titled "Pest Control Trap Locations," showed traps had been placed in the central kitchen, dietetics, warehouse and docking area, although only one mouse trap was observed.On 10/16/13 at 1:30 PM, a review of the chemical pesticide in use by the facility was completed. The manufactures recommendations and instructions attached to the container, suggested use of the pesticide daily if re-treatment was necessary. The PCT indicated he did not read the manufacture instructions and was unaware of the recommend frequency for successful abatement of the cockroaches.On 10/17/13 at 1 PM, the facility contracted with a (vendor) pest control management company for an inspection. The vendor toured the central kitchen and identified three different species of cockroach involved in the infestation, and indicated cockroaches develop immunity to pesticides when not used correctly.Interviews conducted beginning 10/14/13 with dietetic and plant operations, and review of facility documents revealed knowledge of cockroach infestation and presence of rodents for the previous two years. The facility "Vector Control" guideline dated April 2009 indicated, the facility will contract with an outside vendor to provide pest and vector services when necessary, but failed to do so.Review of "Effective Management of Cockroach Infestations" by the County of Los Angles Vector Management Program, revealed the German cockroach is the most common and reproduces more rapidly than any other of the cockroach species. The cockroach is believed to be capable of transmitting disease causing organisms such as Staphylococcus, Streptococcus, hepatitis, coliform bacteria, typhoid and dysentery. Center for Disease Control web site indicated that cockroaches transmit bacteria that cause food poisoning and carry salmonella and poliomyelitis virus. Cockroach saliva, feces and decomposing bodies trigger the severity of asthma symptoms. Rodents spread disease thru their urine, feces and fleas. Diseases associated with rodents include plague, typhus, leptospirosis, rickettsial pox and rat-bit fever. The facility's governing body failed to exercise direction and develop a plan addressing the cockroach infestation and presence of rodents, failed to meet with plant operations, dietetics, housekeeping and infection control committees to develop an action plan of surveillance, prevention, sanitation, trapping and chemical control. These failures led to an ineffective pest control program in that cockroach infestation and rodent dropping were identified in the central kitchen and three residence satellite kitchens. These violations had a direct or immediate relationship to the health, safety or security of individuals residing at the facility. |
| 170001878 |
PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD |
170010248 |
B |
24-Apr-14 |
GG1311 |
7633 |
483.460(c) The facility must provide nursing services in accordance with their needs. The facility failed to comply with the above regulation to provide nursing services and supports for three clients with Type 1 Diabetes. The facility failed to ensure insulin was administered in compliance with physician orders and failed to demonstrate competency in medication safety for the use of insulin when three licensed psychiatric technicians (LPT) incorrectly administered insulin to three clients who were hypoglycemic. Administering insulin when hypoglycemic placed Clients 1, 2, and 3 at risk for seizures, coma, brain damage and death.The facility failed to ensure health care plans and objectives for daily monitoring of hypoglycemia related to diabetes were implemented for Clients 1, 2 and 3.The facility failed to identify a pattern of insulin medications errors, provide health support services to Clients 1, 2, and 3 and education and training to the LPT's resulting in a systemic failure of health services and supports for the client with diabetes.According to the National Institute of Diabetes, Diabetes is the condition in which the body does not properly process food for use as energy. Blood glucose monitoring is a way of testing the concentration of glucose in the blood and allows for quick response to low blood sugar (hypoglycemia). In type 1 diabetes, the body does not produce insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. Insulin is administered by a syringe into body fat and used to lower high blood sugar levels in the blood. Hypoglycemia, also called low blood glucose or low blood sugar, occurs when there is not enough sugar (glucose - food) in the body and blood glucose drops below normal levels, hypoglycemia can happen suddenly and cause confusion, clumsiness and or fainting. Severe hypoglycemia can lead to seizures, coma and death. For people with diabetes, a blood glucose level below 70 mg/dl is considered hypoglycemia. Treatment for hypoglycemia can include consuming 15-20 grams of glucose or simple carbohydrate foods.1. Review of Client 1's record revealed a diagnosis of Type 1 Diabetes for which the physician prescribed two different types of insulin, Humulin R and Lantus. Humulin R insulin is a short acting insulin and may promptly lower blood sugars. Lantus is a long acting insulin for the control of high blood sugars.The physician order indicated Client 1 was to receive Humulin R insulin 4 units, 15 minutes before breakfast and lunch, and 6 units 15 minutes before dinner. Lantus insulin 12 units were ordered to be given at bedtime. Insulin was to be administered except if Client 1's blood sugar was less than 70, then the insulin was to be held or not given and the physician notified. Client 1's medication administration record revealed between 8/21/13 and 10/3/13 on six occasions Client 1's blood sugar was less than 70 (43, 45, 47, 60, 62, 66) and the LPT did not hold the insulin and call the physician. The LPT gave both types of insulin and placed Client 1 at risk for significant harm.Interview on 10/15/13 at 10 AM, with the LPT who administered the insulin incorrectly to Client 1, revealed she thought the physician order was to give the insulin for blood sugar less than 70 and then call the physician. The physician order was to hold or not give the insulin for blood sugar 70 or less and call the physician.Client 1's health care plan and objective for diabetes indicated that daily and as needed monitoring for hypoglycemia would be completed. The monitoring included observing, documenting and notifying the physician and registered nurse of symptoms including sweating, tremors, pallor, rapid heartbeat, confusion and or nervousness. There was no documented evidence of daily monitoring for hypoglycemia. Interview with the registered nurse, "Health Services Specialist" on 10/17/13 at 1:30 PM confirmed there was no documentation of daily monitoring for symptoms of hypoglycemia for Client 1.There was no evidence of a comprehensive review by the registered nurse, physician or pharmacist of Client 1's prescribed insulin medication regime and medication errors were not identified. 2. Review of Client 2's record revealed a diagnosis of Type 1 Diabetes for which the physician prescribed Lantus 55 units daily.Client 2's medication records documented 21 hypoglycemic events from 8/21/13 to 10/14/13, ranging from blood sugars of 43 to 68, where the LPT incorrectly administered insulin. On 10/15/13 at 10:59 AM, in an interview with the LPT administering Client 2's insulin, she indicated incorrectly that Lantus insulin should always be given even with low blood sugar.Client 2's health care plan and objective for diabetes indicated that daily and as needed monitoring for hypoglycemia would be completed. The monitoring included observing, documenting and notifying the physician and registered nurse of symptoms including sweating, tremors, pallor, rapid heartbeat, confusion and or nervousness. There was no documented evidence of daily monitoring for hypoglycemia. Interview with the registered nurse, "Health Services Specialist" on 10/17/13 at 1:15 PM confirmed there was no documentation of daily monitoring for symptoms of hypoglycemia for Client 2.There was no evidence of a comprehensive review by the registered nurse, physician or pharmacist of Client 2's prescribed insulin medication regime and the medication errors were not identified. 3. Review of Client 3's record revealed a diagnosis of Type 1 Diabetes for which the physician prescribed Lantus 45 units daily and a sliding scale based on the blood sugar results of Lispro insulin at 8 AM, 12 PM, 5 PM and 8 PM. Lispro is rapid-acting long lasting insulin used to lower high blood glucose. The physician order included instructions to call the physician if the blood sugar was less than 65 or greater than 400.Client 3's medication record documented 36 hypoglycemic episodes from 8/19/13 thru 10/15/13 with blood sugar as low as 20 and several blood sugars in the 30's ( 30, 32, 34, and 37). On average Client 3 was hypoglycemic once every 1.6 days (57 days divided by 36 hypoglycemic events).Client 3's health care plan and objective for diabetes indicated that daily and as needed monitoring for hypoglycemia would be completed. The monitoring included observing, documenting and notifying the physician and registered nurse of symptoms including sweating, tremors, pallor, rapid heartbeat, confusion and or nervousness. There was no documented evidence of daily monitoring for hypoglycemia. Interview with the registered nurse, Health Services Specialist A on 10/17/13 at 1:30 PM confirmed there was no documentation of daily monitoring for symptoms of hypoglycemia for Client 3.There was no evidence of a comprehensive review by the registered nurse, physician or pharmacist of Client 3's prescribed insulin medication regime and the medication errors were not identified. The facilities failure to provide Client 1, 2 and 3 nursing services in accordance with their Type 1 Diabetic needs resulted in a pattern of insulin medication errors placing them at significant risk for seizures, coma, brain damage and death.The facilities failure to identify the insulin medications errors, provide health support services to Clients 1, 2 and 3 and education and training to the licensed psychiatric technicians resulted in a systemic failure of the facility to assure nursing service and supports were provided.These failures had a direct or immediate relationship to the health, safety, or security of clients. |
| 170001877 |
PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD (STP) |
170010955 |
B |
09-Dec-14 |
None |
10660 |
REGULATION VIOLATION: Title 22 76301 Required Services and 76525 Client's Rights 76301 (e) Client care provided by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice. AND 76525 (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to: 1. Provide safe and effective care as indicated by Client A's needs when the client was not supervised at a medical appointment by a direct care staff familiar with Client A's IPP (Individual Program Plan: a written document describing training, supports and activities to be provided for the client as planned for the upcoming year). 2. Ensure that the client was free from harm by failing to ensure that a direct care staff remained with Client A at his medical appointment. Client A was under the supervision of a facility police officer (a facility staff unfamiliar with the Client's IPP) when Client A became agitated due to having to wait for his peer's medical appointment to finish. The facility police officer took Client A down to the ground when the client became agitated and attempted to leave the facility grounds. Client A sustained a comminuted fracture (a fracture in which the bone is splintered or crushed) of the right distal (away from midline) clavicle (collar bone). Review of Client A's medical record indicated he has diagnoses of mild mental retardation, post-concussion syndrome, bone/cartilage disorder and a comminuted fracture (a fracture in which the bone is splintered or crushed) of the right distal (away from midline) clavicle (collar bone). Complications due to having a fractured clavicle include nerve trauma to the arm and shoulder, injury to the subclavian vein or artery from a bony fragment and malunion (growth of fragments of a fractured bone in a faulty position, forming an imperfect union)(Brunner and Suddarth, Textbook of Medical Surgical Nursing, 1992, p. 1381).Due to a past closed head injury, Client A has short-term memory impairment and has difficulty retaining information. A review of his Individual Program Plan (IPP) dated 6/12/14 indicated that his supervision needs are 1:1 ratio of staff to client on campus for medical appointments. The IPP also indicated that the client "has a high pain threshold." A nursing fracture risk assessment was completed on 5/6/14 with results showing that Client A has a moderate risk for fracture. The IPP also indicated that Client A does not like being bossed around and told what to do. He has an open behavior plan for harm to others that is defined as hitting, punching, kicking, pushing, etc... that he will engage in when he is frustrated or staff is setting limits for him. Client A's behavior plan indicated that staff are to counsel him if he is becoming agitated or demonstrating behaviors leading to assault. Staff can counsel him to use techniques he has learned in Anger Management classes, ask him what the problem is and help him resolve it. Staff can also instruct him "...about the consequences of acting out in anger... [and] discuss with him alternative ways to deal with his anger, frustration and/or disappointment." A review of the General Event's Report (GER), dated 8/11/14 indicated that on 8/8/14 Client A had an appointment for a chest X-Ray to be done on the facility grounds. While waiting for another peer and the direct care staff to return from the x-ray room Client A became upset. He left the building and attempted to leave the facility grounds. The Staff 4 who had accompanied him to the appointment attempted to redirect him but the client became upset and aggressive toward the police officer, stating he was going to fight with the police officer. In order to prevent the client from leaving the facility grounds and for the safety of the police officer, the officer physically took Client A to the ground. A review of Client A's medical record indicated that on 8/11/14, Client A was noted to have a large bruise his right shoulder by the Health Services Specialist RN at 9:10 AM. The bruise measured 11x14 centimeters (2.5 centimeters = 1 inch). Client A refused to allow physicians to examine him until 8/13/14 at 11:40 AM, when a large bruise was noted, with no swelling to the right shoulder area and only mild pain. At 7:30 PM that same day the physician noted Client A to have bruising to the right shoulder and shoulder blade, with swelling to the area and limited ability to move his shoulder or extend his right arm in the upright position. The plan was to re-evaluate Client A and possibly order an X-Ray in the morning. Client A was seen by a physician on 8/14/14 at 10 AM and a X-ray of his right shoulder, arm and clavicle was ordered.A review of the X-ray report, dated 8/14/14 indicated that the chest X-ray done on 8/8/14 was reviewed and "There was no fracture involving either clavicle on the chest examination of 8/8/14. There is now a definite comminuted fracture involving the tip of the right clavicle which was not present on the prior chest examination...This is assumed to be the result of recent trauma resulting in this fracture."A review of the police report, dated 8/8/14, the incident was described essentially as noted above. Client A was escorted to the X-Ray appointment, along with another client, accompanied by one direct care staff and one facility police officer. While the direct care staff went in to the x-ray room with the other client (leaving Client A alone with the facility police officer), Client A got tired of waiting for the other client to complete his X-ray, got agitated, and started to leave the building. The direct care staff was in the X-ray area with the other client, so the facility police officer followed Client A and attempted to talk him out of leaving the facility. Client A continued to escalate and threatened the police officer physically. The Staff 4 physically placed the client on the ground in a controlled manner. When the client was placed on the ground, he calmed down and was able to return to the inside of the X-ray area without further problems. Client A sustained some scratches on his elbows during the take-down. In an interview with Staff 1 (the Unit Supervisor), on 8/13/14 at 11:25 AM, he stated that Client A had a similar incident when he was on another unit. The client just wants to be with familiar staff and gets anxious if he is with unfamiliar staff. He will attempt to leave to go find familiar staff to relieve his anxiety. Staff 1 stated that the Team [Interdisciplinary Team] will need to look into changing Client A's supervision ratio to be a 1:1 status; he stated that he believed Client A was currently a 1:2 supervision ratio (one direct care staff to two clients). In a second interview with Staff 1 at 3:00 PM that same day, he stated that he had a list of escort ratios for each client and his list was apparently incorrect. Client A was listed as 1:2 escort ratio and he should have been listed as 1:1 escort ratio. Staff 1 went on to say that the list was an old one and it was simply a "Unit Supervisor (US) blunder"; there was not a lack of staff or any other reason that the incorrect escort ratio was used that day - it was "a mis-information issue". In an interview with Staff 2 on 8/13/14 at 2:15 PM, she stated that facility police are not counted in the escort ratio, according to facility policy. She acknowledged that Client A should have had another staff present when he was escorted to the X-ray appointment to meet the 1:1 escort ratio listed in Client A's IPP. In an interview with Staff 4 g(the Facility Police Officer) on 8/20/14 at 11:10 AM, he stated that Client A was in a good mood and cooperative that day, but that he got tired of waiting for the direct care staff and the other client. Staff 4 tried to talk to Client A but the client took off out of the building with Staff 4 following him and Client A was attempting to leave the facility grounds. Client A then threatened to fight with Staff 4 and swung at him. In order to prevent Client A from leaving and for his own protection, he took Client A down to the ground. Staff 4 went on to say that Client A fell on Staff 4's arm when he was taken down. He stated that Client A immediately became docile once he was on the ground; they both got up and Staff 4 escorted Client A back into the building. He stated that Client A was moving both arms freely and in no apparent pain and that he had only sustained a scrape on his right elbow. In an interview with Staff 5 on 8/20/14 at 3:00 PM, he stated that Client A had had a chest X-ray on 8/8/14 and no fractures were visualized at that time. On 8/11/14, the client had a large bruise on his right shoulder, and had some pain with limited range of motion in that arm. An X-ray was ordered on 8/14/14 and the fractured clavicle was discovered at that time. Staff 5 stated that a large amount of force, like that of a fall, would be needed to cause a fracture of the clavicle. He also stated that the fracture could be caused from a physical altercation but the amount of force needed to fracture a clavicle would be large. He felt that Client A's clavicle was probably fractured in the fall but since the client has a high tolerance for pain he didn't start complaining until the bruising and swelling were noted a few days later.Therefore, the facility failed to: 1. Provide safe and effective care as indicated by Client A's needs when the client was not supervised at a medical appointment by a direct care staff familiar with Client A's IPP. 2. Ensure that the client was free from harm by failing to ensure that a direct care staff remained with Client A at his medical appointment. Client A was under the supervision of a facility police officer (a facility staff unfamiliar with the Client's IPP) when Client A became agitated due to having to wait for his peer's medical appointment to finish. The Staff 4 facility police officer took Client A down to the ground when the client attempted to leave the facility grounds. Client A sustained a comminuted fracture (a fracture in which the bone is splintered or crushed) of the right distal (away from midline) clavicle (collar bone).This failure had a direct or immediate relationship to resident health, safety and security. |
| 170001876 |
PORTERVILLE DEVELOPMENTAL CENTER D/P SNF |
170011344 |
A |
28-Jul-15 |
9LFS11 |
5726 |
REGULATION VIOLATION: F 323 483.25(h) Accidents - The facility must ensure that- (1) The resident environment remains as free from accident hazard as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to prevent accidents for Resident A, after the Resident fell out of bed when a malfunctioning bedrail had become disengaged. Resident A was sent to an acute care hospital emergency room immediately. Resident A was subsequently diagnosed with a right shoulder non-displaced fracture of the clavicle (collar bone), fractures of the right 2nd, 3rd, 4th, and 5th ribs without major displacement, a right femoral head (hip) fracture. A Computerized Tomography (CT)(x-ray) of Resident A's head showed small interval areas of hemorrhage (bleeding) which subsequently required two days of hospital admission for observations. On 2/13/15 at 10:00 am an unannounced visit was made to the facility to investigate an entity reported incident. Resident A was a 73 year old male admitted on 6/3/53. A review of the Annual Individual Program Plan (comprehensive assessment) dated 4/17/14 for Resident A was reviewed. Resident A had a profound intellectual disability and had diagnoses that included abnormal involuntary movements, visual impairment, hearing loss, osteoporosis and cognitive loss. Resident A was totally dependent on facility staff for all care related activities of daily living (ADL).An interview was conducted with the Unit Supervisor (US) on 2/13/15 at 10:00am. The US stated that on 1/31/15 at approximately 2:20am Psychiatric Technician 1 (PT1) rolled Resident A over to one side of the bed to provide personal care. Due to Resident A's positioning the resident's knees pressed outward against the opposite bedrail and caused the bedrail to malfunction and drop to the down position. When the bedrail went down Resident A rolled out of the bed onto the floor onto his right side. The Unit Supervisor went on to say that the side rail was properly up and locked into place, but became disengaged possibly due to a loose screw. The Unit Supervisor stated the HSS was called to assess Resident A. Resident A was assessed and was found to have a hematoma to his right forehead and a bruise to his right hip. Resident A was moved back to the bed and the physician was immediately contacted. Resident A was transferred to the general acute care hospital via ambulance at 3:20 am. Initial computed tomography (CT) scan of the brain on 1/31/15 showed small areas of hemorrhage density in the dependent occipital horns (portion of the brain), axial image 17, small area of hemorrhage density also in the left temporal horn (portion of the brain), axial image d14,7 mm and prominent ventricular enlargement noted. On 1/31/15 a CT scan of the pelvis was severely limited and a follow up recommended to best exclude hip fractures, a CT of upper right extremity/shoulder was done. Findings no AC (shoulder) joint separation, nondisplaced fracture distal most clavicle (collar bone)... No humeral neck or proximal shaft fracture depicted. Fracture without major displacement anterior right second rib, right third rib, right fourth rib, right fifth rib. Resident A was discharged back to the facility on 1/31/15 with a prescription of Ibuprofen (pain reliever) for pain management. CT scans were ordered as follow up on 2/5/15 of the pelvis, neck/shoulders, and head/brain. On 2/11/15 a follow up CT scan of the cervical spine impression showed no acute cervical fractures seen. A CT scan of the pelvis impression showed a comminuted un-displaced fracture of the right femoral head (hip) and severe osteoporosis (porous condition of the bone) of the pelvis. A CT scan on 2/11/15 of the brain was compared to the CT scan of the brain on 1/31/15. Findings showed prominent ventricular enlargement again, small areas of hemorrhage density of the dependent occipital horns, and small area of hemorrhage density also in the left temporal horn. No extra-axial hemorrhage identified, no mass effect upon the ventricular system, cranial vault appears intact, extensive left maxillary sinus disease fourth ventricle midline. Based on Resident A's CT scans dated 2/11/15, Resident A was readmitted to the acute care hospital on 2/11/15 through 2/13/15. Resident A returned backed to the facility on 2/13/15. On 2/18/15 a review of Resident A's General Event Report, and Interdisciplinary Notes showed no additional accidents or injuries to Resident A occurred from 1/31/15 to 2/11/15. I observed Resident A in the room on 2/18/15. Resident A's head of bed was slightly elevated, both side rails were up. I checked both side-rails which were secure when pressure was put on them. Resident A was appropriately dressed and groomed. The physician notes dated 2/13/15 included follow-up care to be provided by neurosurgery and orthopedics, due to the multiple injuries sustained by Resident A.Therefore the facility failed to prevent accidents for Resident A, when Resident A fell out of bed when a malfunctioning bedrail had become disengaged. Resident A was sent to an acute care hospital emergency room and was subsequently diagnosed with a right shoulder non-displaced fracture of the clavicle, fractures of the right 2nd, 3rd, 4th, and 5th ribs without major displacement, a right femoral head (hip) fracture. A Computerized Tomography (CT)(x-ray) of Resident A's head showed small interval areas of hemorrhage (bleeding) which subsequently required two days of hospital admission for observations. This failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 220001046 |
PALO ALTO SUB-ACUTE AND REHABILITATION CENTER |
220009413 |
B |
01-Aug-12 |
VM3911 |
10889 |
T22 DIV5 CH3 ART3-72311(a)(1)(A) Nursing Service--General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. T22 DIV5CH3 ART3-72311(a)(3)(B) Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. T22 DIV5 CH3 ART3-72315(g)(h) Nursing Service-Patient Care (g) Each patient requiring help in eating shall be provided with assistance when served, and shall be provided with training or adaptive equipment in accordance with identified needs, based upon patient assessment, to encourage independence in eating. (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. These regulations were not met as evidenced by: The facility failed to: 1. Identify Resident A's need for eating assistance and assess the adequacy of his fluid intake. 2. Notify the attending physician when monitoring showed Resident A's fluid intake was inadequate. 3. Provide Resident A, who was totally dependent on staff to eat and drink, with assistance to eat and drink. 4. Provide Resident A with good nutrition and necessary fluids for hydration when the facility's monitoring showed his oral and fluid intake were inadequate.When Resident A was admitted to the facility, his diagnoses included osteomyelitis of vertebra (bone infection of spine, including neck), diarrhea and protein-calorie malnutrition. Even though his daughter told staff he could not feed himself, his Nursing Admission Assessment and care plan did not state that he needed to be fed, and there was no documentation to show that staff ever fed or offered him fluids. In the seven days Resident A was in the facility his fluid intake was a third to a half of the USDA's recommended minimum of 1500 ml/day of fluid necessary to avoid dehydration. Resident A was sent to the hospital where he died on 5/14/11 with diagnoses including, "Hypotension secondary to inanition/dehydration" (low blood pressure due to the abnormal depletion of body fluids), urinary tract infection, and septic shock. Resident A was admitted to the facility on 5/7/11 with diagnoses including diarrhea, diabetes, and chronic kidney disease and protein-calorie malnutrition. His Nursing Admission Assessment, dated 5/7/11, indicated he was alert, and "unable to orient." The section showing the amount of staff assistance he needed to eat was blank, and "No recent history of nutrition, hydration, or weight issue," was checked, even though Resident A's admitting diagnoses included diarrhea and protein-calorie malnutrition.Review of Resident A's "Physician Orders," dated 5/7/11, indicated his Dietary order was, "Pureed diet ADA 2000 (calories) check by LN (licensed nurse) Q (every) Sat." Review of Resident A's, "Nutrition Care Plan," dated 5/7/11, indicated a Goal of, "Will consume at least 75% of meals." The Interventions included, "Encourage to consume 75% of meals," and "Offer substitute if less than 75% meal intake." Review of Resident A's Skilled Documentation Flow Sheet, dated 5/7/11, indicated, "Pt noted with poor appetite, ate 20% of dinner. According to daughter, (patient) has a (history) of poor appetite and malnutrition. She is requesting nutritional supplements."Review of a document entitled "History" written by Resident A's daughter about her fathers stay in the facility indicated, "May 7, 2011. Dad is transported to (the facility) by medivan. I arrive shortly after him......Someone came in and dropped off a tray of food for dinner. Every plate/dish had plastic covers that needed to be removed- which they did not remove. They placed the tray out of Dad's reach and just left it there (for me to help him?) He needed help feeding himself because of the (intravenous) line in his arm and the hard collar (to stabilize his neck) and they did not help him. He wasn't even sitting up, he was still laying flat. It was like there was no regard for his condition. They delivered his food tray and just left.....I found the charge nurse and expressed my concerns about...someone needs to help dad eat or he won't eat." On May 8, 2011, Resident A's daughter's "History" indicated, "I spoke to the charge nurse about my concerns regarding staff assisting him to eat. She assured me it would be tended to..."On 5/9/11, the physician's orders included, "Healthshakes TID (3 times a day) between meals-Record % intake." Review of the "Nutritional Status/Progress Record," dated 5/10/11, showed Resident A was 69 inches tall (5'9"), weighed 141 lbs, his ideal body weight was 160 lbs, he was on a "fortified puree 2000 cal" diet, and "total dependence while dining," was indicated, meaning he needed to be fed his meals and supplements. The section on "Risk Scoring for Altered Nutrition," indicated Resident A had "stable weight within past 3 months," even though he had only been in the facility four days, and his weight of 141 lbs was 20 lbs below his ideal body weight of 160 lbs. Review of Resident A's "Supplemental ADL (Activities of Daily Living) Record" showed the percentage of meal Resident A consumed between 5/7/11 to 5/13/11 was as follows:Breakfast:Lunch: Dinner: 5/7/11(blank)(blank)20% 5/8/1125% 50%25% 5/9/1125% 50%20% 5/10/11 25% 50%20% 5/11/11 25% 50%30% 5/12/11 Refused 25%Refused 5/13/11 Refused 25%Refused The top of the Supplemental ADL Record stated, "Report to LN (licensed nurse) Meal intake < (less than) 50%." The Supplemental ADL Record showed "0" in all the "Substitute" columns for breakfast, lunch and dinner from 5/7/11 to 5/13/11 showing that no food substitutes were offered or consumed by Resident A, even though the care plan stated to "Offer substitute if less than 75% meal intake." "0" was also entered in the columns for PM (evening) Nourishments from 5/7/11 to 5/13/11. He consumed 20-25% of his snacks on 5/7/11, 5/8/11 and 5/9/11, and accepted a bedtime snack on 5/10/11 and 5/11/11. There was no documentation to show that the CNA reported Resident A's poor nutritional intake of less than 50% to the nurse, and no documentation that health shakes were ever offered to him or consumed. In an interview with the 6/9/11 at 5:55 PM, the DON was not able to explain why the staff did not notify the MD regarding Resident A's inadequate nutritional intake and why the Registered Dietician (RD) did not re-evaluate Resident's nutritional status, needs and interventions. Review of Resident A's Nurses Notes from 5/7/11 to 5/14/11 showed no documentation that assistance was provided for breakfast, lunch or dinner, and only one note on 5/7/11, the date of admission, indicating that Resident A was provided encouragement to eat ("Enc pt to eat."). Review of Resident A's Intake and Output sheet showed he received the following amounts of fluids by mouth and by IV (intravenous) per 24 hours: By Mouth IV Parenteral 5/7/11 400 cc 0 5/8/11 670 cc 0 5/9/11 600 cc 260 cc 5/10/11720 cc 260 cc 5/11/11Not Recorded 5/12/// 920 cc 260 cc 5/13/111180 cc According to the September 2002, USDA (U.S. Department of Agriculture) Center for Nutrition Policy and Promotion publication, "More Than One in Three Older Americans May Not Drink Enough Water," the USDA, "recommends a total fluid intake of 30 ml/kg body weight, and "a minimum of 1500 ml /day. We use this criterion to assess the adequacy of water intake by the elderly U.S. population."Review of Resident A's Nurses Notes from 5/7/11 to 5/14/11 revealed no documentation to show that nursing assessed the resident's inadequate fluid intake and called the doctor to report it.In an interview on 6/9/11 at 6:30 PM, the DON stated Resident A's appetite remained fair to poor but was unable to explain why nurses notes did not document Resident A's inadequate fluid intake and why the MD was not notified.In a telephone interview on 6/9/11 at 3:00 PM, Resident A's daughter said when she visited her father during mealtime, a facility staff brought in her father's meal tray, placed it on the overbed table, and left the room without offering her father any assistance to eat. No other staff came in to assist her father, or to encourage him to eat. In an interview on 6/9/11 at 5:55 PM, the Director of Nurses (DON) stated, "Resident A refused meals most of the time." When asked if her staff attempted to assist Resident A to eat and drink, if her staff notified the MD about Resident A's poor intake, or if her staff documented all these encounters with Resident A, the DON had no response.In a telephone interview on 9/1/11 at 11:58 AM, the facility dietician said, "By the time I went to assess the patient he was discharged." Even though Resident A was admitted with diagnoses of diarrhea, diabetes, chronic kidney disease and protein-calorie malnutrition, he was not assessed by a dietitian the week he was at the facility.Review of facility policy and procedure on Nutritional Care Management indicated, "Residents are interviewed upon admission to the facility and a nutritional assessment will be completed within 5 to 14 days from admission. All residents are interviewed within seventy-two hours of admission by the Nutrition Services Manager, Consultant R.D. . . "In an interview on 3/7/12 at 3:00 PM, the DON provided a list of staff that cared for Resident A on May 7-14, 2011. In telephone interviews on 3/12/11 and 3/13/11, 14 facility staff on the list stated they could not recall assisting him to eat.Resident A's 5/14/11 hospital Emergency Department (ED) Provider Notes showed he was brought into the ED by ambulance with admitting diagnoses of, "Hypotension secondary to inanition/dehydration" (low blood pressure due to the exhausted condition that results from lack of food and water and abnormal depletion of body fluids), urinary tract infection, and septic shock. The ED Consult/H&P Notes show he had "hypotension (low blood pressure) with a BP in the 60's." It also stated, "Apparently per daughter...he has not been eating or drinking for the last three days. Has been moaning and groaning since yesterday." His Code Status was listed as, "Family does not want any aggressive measures including central line." He died on 5/14/11, diagnosed with septic shock, pneumonia, acute renal failure, and acute urinary tract infection.The above violations, either jointly, separately, or in any combination, have a direct or immediate relationship to the patient health, safety or security. |
| 230000031 |
Paradise Ridge Post-Acute |
230009006 |
B |
24-Feb-12 |
39X811 |
3767 |
A 882 T22 DIV5 CH3 ART5-72527(a)(11) 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: (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. The facility failed to ensure Patient 1's right to be treated with consideration, dignity, respect and to have her personal care needs met when Certified Nurse Assistant (CNA) A neglected to provide toileting assistance to Patient 1 upon request. As a result of having to wait for toileting assistance, Patient 1 wet herself and expressed feeling "upset" about the incident. This failure had the potential to cause a decline in Patient 1's bladder function and psychosocial well-being. Patient 1 was a 79 year old retired Licensed Vocational Nurse who was originally admitted on 2/26/08 with diagnoses that included Parkinson's Disease, Diabetes, and urinary frequency with occasional incontinence. The Minimum Data Set (MDS), an assessment tool, dated 11/22/11, identified that Patient 1 had independent cognition, no memory problems, and needed extensive assistance of 2 persons with toileting needs.On 12/2/11 at 3:35 pm, in an observation and interview with Patient 1, she stated that a few days ago when the CNAs were passing out the dinner trays, she asked CNA A to take her to the bathroom at about 5:15 pm. CNA A told her that she had to wait until after she finished passing the trays. Patient 1 waited and asked CNA A for assistance again at which time she was told she still had to wait. Patient 1 stated that she was left in her wheelchair for two hours and she wet herself, and that she felt "upset" about the incident.On 12/6/11 at 10:45 am, in an interview with CNA A, she stated that she was assigned to be Patient 1's caregiver. CNA A was also assigned to pass dinner trays to those patients who prefer to have meals in their rooms and to answer the call lights on 11/30/11. She confirmed that Patient 1 did ask for assistance with toileting while she was passing the dinner trays and that she told Patient 1 that she had to wait until after dinner. CNA A stated that she did not ask for help from other facility staff to assist Patient 1 at that time and confirmed that Patient 1 waited about one and a half hours for toileting assistance and was wet when she assisted her to the bathroom. On 12/2/11 at 3:10 pm, in an interview with the Director of Staff Development (DSD), she stated that CNAs are told to try to toilet patients before and after meals and verified that CNAs should also toilet patients during meals and whenever requested. In an undated Policy and Procedure titled, "Abuse Training and Reporting Policy, on page 2, the policy said that Neglect included, but is not limited to the following: #1. states "Failure to assist in personal hygiene...."#5. states "Failure of a person to provide the needs as defined above due to ignorance......"Therefore, the facility failed to ensure Patient 1's right to be treated with consideration, dignity, respect and to have her personal care needs met when Certified Nurse Assistant (CNA) A neglected to provide toileting assistance to Patient 1 upon request. As a result of having to wait for toileting assistance, Patient 1 wet herself and expressed feeling "upset."These violations had a direct relationship to the health, safety or security of patients. |
| 230000031 |
Paradise Ridge Post-Acute |
230009063 |
B |
02-Mar-12 |
6CHI11 |
4922 |
A 880 T22 DIV5 CH3 ART5-72527(a)(9) Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. Based on interview and record review, the facility failed to protect Patient 1 and 2 from mentally and physically abusing each other when Patient 2 wandered into Patient 1's room on 10/26/11. Patient 1 dumped a pitcher of water on Patient 2. Patient 2 became upset when the pitcher of water was dumped on him and then physically abused Patient 1 by repeatedly hitting her face and chest with his closed fists which resulted in two bruises on her face.Findings:On 11/7/11 at 2 pm, Certified Nurse Assistant A (CNA A) was interviewed. CNA A stated that on 10/26/11, shortly after dinner, he was walking down the hall and witnessed Patient 2 hitting Patient 1 in the jaw and the chest with his closed fists. CNA A stated that he ran into Patient 1's room, separated the two patients and took Patient 2 to his room while another CNA ran into Patient 1's room to comfort her. CNA A stated that the facility's conclusion to the incident found that Patient 2 had wheeled himself into Patient 1's room and Patient 1 yelled at Patient 2 to get out of her room and then dumped a pitcher of water on Patient 2. CNA A stated that Patient 2 told him that he was very upset because Patient 1 had dumped a pitcher of water on him and that is why he started hitting Patient 1.On 11/7/11 at 2:15 pm, a family member (FM C) of the patient that lived across the hall from Patient 1 was interviewed and stated that she witnessed this event on 10/26/11. FM C stated, "It brought tears to my eyes for both of them." FM C stated that Patient 2 moved surprisingly fast in his wheelchair and before anyone noticed, he was in Patient 1's room. FM C stated that she saw Patient 2 hitting Patient 1 with his hands back and forth while Patient 1 was sitting in her chair screaming. On 11/7/11, Patient 1's record was reviewed. Patient 1 was admitted to the facility on 3/23/07 with a diagnosis of dementia (loss of mental ability). The facility's Minimum Data Set, (MDS, an assessment tool), dated 9/11/11, described Patient 1 as not being capable of making daily decisions by herself. Patient 1's activity care plan, dated 7/7/10, stated that she wanted to be left alone most of the time. Patient 1 was described as a woman who hated men. On 10/28/11 at 1 pm, two days after Patient 2 hit Patient 1, Patient 1's nurses notes documented that Patient 1 developed two bruises, one on the left side of her face by her left lower lip and one on her lower jaw left of her chin.On 11/7/11, Patient 2's record was reviewed. Patient 2 was admitted to the facility on 4/30/11 with a diagnosis of dementia. Patient 2 was very hard of hearing and had limited vision. Patient 2 was described in the facility's MDS dated 8/9/11, as not being capable of making daily decisions for himself. Patient 2 moved his wheelchair with his feet to travel independently from place to place in the facility. On 5/10/11, a care plan titled, "Psychosocial" was developed that listed concerns that Patient 2 was combative at times with staff and resistant to care. A care plan titled, "Elopement risk," was developed on 7/2011 that identified the problem that Patient 2 propelled himself in his wheelchair and wandered into neighboring patient rooms. One approach listed in Patient 2's elopement risk care plan was for staff to conduct frequent rounds to monitor his whereabouts. On 11/7/11 the facility's undated policy and procedure titled, "Abuse training and reporting" was reviewed. The policy stated that forms of abuse included physical abuse, such as slapping and hitting and mental abuse such as humiliation (a state of disgrace or loss of self respect) and harassment (an unpleasant or hostile situation that occurred by uninvited and unwelcomed verbal or physical conduct). Therefore, the facility failed to protect Patient 1 and 2 from mentally and physically abusing each other when Patient 2, who had a known history of wandering in to other patient rooms, was not monitored by staff and wandered in to Patient 1's room on 10/26/11. Patient 1, who had a history of being a loner and a woman who hated men, dumped a pitcher of water on Patient 2. Patient 2 became upset when the pitcher of water was dumped on him and then physically abused Patient 1 by repeatedly hitting her face and chest with his closed fists which resulted in two bruises on her face.This violation had a direct relationship to the health, safety and security of patients. |
| 230000031 |
Paradise Ridge Post-Acute |
230009116 |
B |
15-Mar-12 |
Z6QJ11 |
1815 |
A 197 T22 DIV5 CH3 ART3-72315(b) Nursing Service--Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The facility failed to ensure that Patient 1 was treated with dignity and respect, and not subjected to physical abuse when Certified Nurse Assistant (CNA) B slapped Patient 1's right upper arm.Patient 1 was an 84 year old male admitted to the facility on 6/20/11 with diagnoses that included dementia, anxiety with behaviors of striking out, and depression. A Minimum Data Set (MDS - an assessment tool), dated 6/20/11, indicated that Patient 1 had short and long term memory problems and that his ability to make decisions was severely impaired. The MDS further indicated that Patient 1 had difficulty being understood and understanding others. During an interview on 8/22/11 at 2:20 pm, CNA B stated that on 8/14/11 at 11:50 am, she and CNA D and E were in Patient 1's bathroom, providing personal care, after the patient experienced an episode of bowel incontinence. CNA B explained that she was squatting in front of Patient 1, changing his pants, when he suddenly punched her in the stomach with a closed fist. CNA B stated that she had a reflex reaction; she stood up and automatically swung her arm, slapping Patient 1's arm away with the back of her hand. During a concurrent interview on 8/22/11 at 3 pm, CNA D and E stated, on 8/14/11 at 11:50 am, they witnessed CNA B slap Patient 1's arm away after he punched her in the stomach.Therefore, the facility failed to ensure that Patient 1 was treated as an individual with dignity and respect and was not subjected to physical abuse of any kind. The violation of this regulation had a direct relationship to the health, safety, or security of patients. |
| 230000173 |
Pine View Center |
230009248 |
B |
07-Jun-12 |
ENCO11 |
6369 |
F329 483.25(l) Drug Regimen is Free from Unnecessary Drugs Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Based on observation, interview, and record review, the facility failed to ensure Resident 1 was closely monitored, after Licensed Nurse (LN) B simultaneously administered three medications to him on 3/11/12 that resulted in him becoming oversedated. This failure resulted in Resident 1 falling, sustaining a fractured nose, and requiring hospitalization for treatment for over sedation.Resident 1 was a 69 year old male with diagnoses that included pneumonia, difficulty walking, hypersomnia (excessive sleepiness), and congestive heart failure (condition in which the heart's function as a pump is inadequate to meet the body's needs.) Resident 1 had independent cognition (ability to make daily decisions and problem solve) and could make health care decisions on his own. A care plan, dated 3/6/12, identified him as being at risk for falls because he had recent changes to existing medications, and had medications that could cause a drop in his blood pressure when he stood up. During an interview and observation of Resident 1 on 4/19/12 at 8:10 am, he was lying in bed. Resident 1 stated after he fell he remembered having a "couple of black eyes afterward."During a review of Resident 1's record, the physician's orders, dated 3/5/12, indicated that Ativan 1 mg tablet was to be given by mouth every four hours as needed for agitation, Ambien 5 mg tablet by mouth as needed for insomnia, and Norco 10/325 mg tablet by mouth every four hours as needed for pain.The "Davis Drug Guide for Nurses-10 the Edition" was reviewed on 4/19/12. The following excerpts from the publication included: ** Ambien- sedative, hypnotic. Adverse reactions/side effects include amnesia, drowsiness, and dizziness. Avoid concurrent use of CNS (Central Nervous System) depressants. Contraindicated (not indicated) in patients with pulmonary (lung) disease. Interaction- increased CNS depression with sedative/hypnotics and opioid analgesics (strong painkillers.) ** Ativan-hypnotic, benzodiazepine. Adverse reactions/side effects include dizziness, drowsiness, lethargy (sluggish) and physical dependence. Geriatric patients may be more sensitive to CNS effects; monitor closely and assess fall risk. ** Norco-opioid agonist. Adverse reactions/side effects include respiratory depression, confusion, sedation, hallucinations, and physical dependence. Avoid concurrent use of other CNS depressants and assess blood pressure, pulse and respirations before and periodically during administration. Assess pain type, location and intensity prior to and one hour following administration. During a review of Resident 1's 3/2012 Medication Administration Record (MAR), LN B documented that Resident 1 had received Ambien 5 mg, Norco 10/325 mg, and Ativan 1 mg, all at 3 am.An interview was conducted with LN B on 4/19/12 at 11:10 am. He stated that on 3/11/12, he gave Resident 1 Ativan (antianxiety medication) 1 mg (milligram), Ambien (sleeping pill) 5 mg, and Norco (pain reliever) 10/325 mg at 3 am. LN B stated that Resident 1 wanted some sleep, was agitated, and was in pain. These medications were individually ordered by the physician to be administered on an "as needed" basis. LN B stated that he did not monitor the patient for the sedation effects of giving all three medications at the same time, and that Resident 1 "would have been all right if he stayed in bed." CNA (Certified Nurse Assistant) E was interviewed on 4/20/12 at 10:05 am. She said she was Resident 1's aide on 3/11/12 from 10:30 pm to 7 am. CNA E stated that she had seen Resident 1 watching TV at 11:30 pm and that he told her he wanted a sleeping pill. CNA E informed LN B about the resident's request.CNA E also stated she had not been asked by LN B to monitor Resident 1's vital signs or condition any more closely than the routine frequency during her shift.She further stated she had not been told Resident 1 had received multiple medications that could result in sedation.CNA E stated she was called to a room by another CNA at 5:30 am, after Resident 1 was found on the floor, laying face up, and was not responsive. She stated that LN B assessed Resident 1, while he was on the floor, and 911 was called. Resident 1 was then transferred to an acute care hospital. A discharge summary, dated 3/12/12, was reviewed on 4/19/12. The reason for admission to the hospital included "accidental opiate overdose with acute on chronic inflammatory failure." The discharge summary further indicated that Resident 1 was administered Narcan (a drug to counteract narcotic overdose), that he responded well to it, and that he was admitted to the Intensive Care Unit due to hypocapnic (CO2) ventilatory failure (decreased amount of carbon dioxide in the blood). The report further indicated that the CO2 narcosis was caused from the narcotics that he had been receiving in addition to the sleeping pills. The discharge summary also indicated Resident 1 had sustained an acute facial abrasion, a subcutaneous head contusion (bruise), and a nasal bone fracture. The facility failed to ensure Resident 1 was closely monitored, after Licensed Nurse (LN) B simultaneously administered three medications to him on 3/11/12 that resulted in him becoming over sedated. This failure resulted in Resident 1 falling, sustaining a fractured nose, and requiring hospitalization for treatment for over sedation. This violation had a direct relationship to the health, safety, or security of patients. |
| 230000031 |
Paradise Ridge Post-Acute |
230009304 |
B |
16-May-12 |
Y95G11 |
6351 |
A 165 T22 DIV5 CH3 ART3-72311(a)(1)(C) 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: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.The facility failed to provide supervision and care to prevent Patient 2 from wandering into Patient 1's room, knocking Patient 1 to the floor resulting in a serious head injury that required stitches. During an interview on 11/17/11 at 12:45 pm, Patient 1 stated that on 11/15/11, shortly after breakfast, she was standing at her closet which was behind the bedroom entry door, when Patient 2 started to push the partially closed door open. She stated she yelled, "Wait a minute" but Patient 2 kept on pushing the door, knocking Patient 1 to the floor, causing a laceration to the back of her head that required stitches. Patient 1 stated she had a great deal of pain and could not get up. She stated the nurses called an ambulance and she was taken to the hospital where a doctor cleaned and stitched up the back of her head. During a phone interview with LVN A on 11/17/11 at 2:30 pm, she stated that she was the medication nurse assigned to Hall A on the morning of 11/15/11. LVN A stated that while passing medications, she saw Patient 2 down the hall pushing on Patient 1's door. She heard Patient 1 say, "Wait a minute," then she heard Patient 1 yelling for help. When she responded to Patient 1's room, LVN A found Patient 1 lying on the floor with blood on the floor around her head. An ambulance was called and Patient 1 was transported to the emergency room. The CNA assigned to care for Patient 2 was in another patient's room at the time of the incident.Patient 1, an 89 year old female, was admitted to the facility on 11/18/09 with diagnoses that included difficulty walking, weakness, and an eye disease that progressively limits vision. Her Minimum Data Set (MDS), an assessment tool, dated 10/22/11, indicated she had no memory problems, could make her needs known, and required assistance for mobility. Patient 2, a 66 year old female was admitted to the facility on 5/17/11 with diagnoses that included stroke and cognitive deficits due to cerebrovascular disease. The initial admission assessment, dated 5/17/11, indicated Patient 2 was confused and wandered but was easily redirected and a Care Plan Conference Summary, dated 5/31/11, indicated Patient 2 wandered about the facility, was confused, and required verbal direction and supervision. A Wandering/Elopement care plan, dated 5/26/11, indicated that direct care staff were to monitor Patient 2's location with visual checks at least every two hours.A nurse's note, dated 8/11/11, indicated Patient 2's behaviors were unpredictable and worsening, she wandered about the facility for several hours a day, and could rarely be redirected. A review of an MDS, dated 8/24/11, indicated she had memory problems, disorganized thinking, could not understand or answer when people talked to her, had behaviors of striking patients and wandered about the facility several times daily. A review of the Behavioral Symptom care plan, dated 10/13/11, indicated that Patient 2 was known to wander into other patients rooms, exhibited verbal and physical agitation and aggression, was socially inappropriate, had no social boundaries, took things/belongings from rooms, was difficult to redirect, and was a risk of injury to self and others. Approaches included remove from situation, ask resident to stop behaviors, and make sure all other patients are safe and out of harm's way. The care plan did not include interventions to address Patient 2's need for supervision and redirection. A review of November 2011 nurses notes indicated that Patient 2 exhibited dangerous or aggressive behaviors:On 11/1/11, Patient 2 punched a young visitor in the stomach, and that same day, went into another patient's room and pushed the visitor. There were no updates to the Behavioral Symptom care plan for this incident to address Patient 2's continued wandering into other patient rooms.On 11/4/11, Patient 2 slapped another resident on the wrist while standing at the nurses station. A Short Term Care Plan, dated 11/4/11, for Patient 2's wandering and episodes of aggression included assess for pain, inform responsible party and physician, and attempt to redirect Patient 2 when aggressive behavior was present. These approaches failed to prevent Patient 2 from continuing to wander about the facility and exhibit agitation and aggression towards others.On 11/6/11, Patient 2 went into another patient's room and poured liquid on his head. There were no updates to the Behavioral Symptom care plan to address Patient 2's continued wandering into other patient rooms and aggression towards others. During an observation on 11/17/11 from 1:30 pm to 1:45 pm, Patient 2 was observed walking rapidly through the hallways unsupervised and walked into a room and picked up a sweater belonging to the patient in that room. No staff were observed to be supervising or redirecting Patient 2 during the surveyor's observation. During an interview with LVN B on 11/17/11 at 3:15 pm, she stated Patient 2 was getting worse, having increased behaviors of wandering and striking other patients.On 11/17/11 at 3:45 pm, during an interview with the Director of Nursing (DON), she stated that the facility had provided 1:1 nursing care in August 2011, which was effective, the patient was calmer and less aggressive during the 1:1 care. The DON stated that Patient 2 needed to be placed elsewhere, as she was a danger to herself and others in the facility. When the DON was asked if 1:1 supervision and care had been provided after August 2011 to Patient 2, she stated no, "staff just keeps an eye out for her."Therefore, the facility failed to provide care planned interventions to ensure sufficient supervision and care to prevent Patient 2 from wandering into Patient 1's room, knocking Patient 1 to the floor, resulting in a serious head injury that required stitches. This violation had a direct relationship to the health and safety of patients. |
| 230000031 |
Paradise Ridge Post-Acute |
230009330 |
B |
17-Apr-13 |
79NU11 |
2923 |
T22 DIV5 CH3 ART3-72315(b) Nursing Service-Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The facility failed to ensure that Patient 1 was treated with respect and dignity, and was free from verbal, mental abuse, when Licensed Vocational Nurse (LVN) A spoke in a rude and threatening manner to Patient 1 on 11/16/11. This failure resulted in Resident 1 experiencing a loss of dignity, emotional distress, and isolation from staff. Patient 1 was re-admitted to the facility on 11/6/11 for rehabilitation after a right hip fracture repair. His Minimum Data Set (MDS assessment) showed on 11/14/11 that he was alert and oriented, with intact memory, and could make his own decisions. It also showed that he was in almost "constant pain" that interfered with sleep and activity. During an interview on 11/21/11 at 11:55 am, Patient 1 stated that the staff of the facility "make it perfectly clear that he is the last to get his medication, because I get mad and holler." He continued to state "It hurts my feelings. It's pretty obvious there are numerous people here that don't like me." He stated that the pain medications he receives help lower his level of pain from severe to moderate levels. During an interview on 11/21/11 at 9 am, the Director of Nurses (DON) stated that she investigated Patient 1's allegation that on 11/16/11, on the day shift, LVN A had told him "If you don't start behaving I will see to it that you will get your meds last." The DON stated that LVN A acknowledged, without hesitation, making the statement that Patient 1 had reported, and that LVN A stated Patient 1 had "pushed her buttons." During an interview on 11/30/11 at 5:05 pm, LVN A stated that Patient 1 had been asking for pain medications from the moment she came on duty. She stated that Patient 1 had been yelling at her the entire day and she felt like she needed to hide from him. LVN A acknowledged that she may have made the statement to Patient 1 that his medications would not be available, due to a pharmacy delay, but could not remember threatening to give him his medications last. On 11/17/11, a written staff request was made to the physician to restart Patient 1 on Cymbalta (an antidepressant medication) due to depression as manifested by "tearful episodes."The facility's "Abuse Training and Reporting" policy, reviewed 4/6/11, had the following definition: " Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation." Therefore, the facility failed to provide respect and dignity when LVN A spoke in a rude and threatening manner to Patient 1 on 11/16/11. This failure resulted in Resident 1 experiencing a loss of dignity, emotional distress, and isolation from staff. This violation had a direct relationship to the health, safety and security of patients. |
| 230000031 |
Paradise Ridge Post-Acute |
230009421 |
B |
17-Apr-13 |
79NU11 |
6149 |
T22 DIV5 CH3 ART3-72311(c) Nursing Service-General (c) Licensed nursing personnel shall ensure that patients are served the diets as prescribed by attending physicians. The facility failed to follow a physician's ordered diet for Patient 1 when he was provided more than four ounces of wine on 11/19/11. This failure resulted in Patient 1 experiencing adverse side effects of increased sedation, weakness, and heavy bladder incontinence.Patient 1 was admitted to the facility on 7/15/10 and was re-admitted to the facility on 11/6/11 for rehabilitation after a right hip fracture repair. His Minimum Data Set (MDS), an assessment tool, showed on 11/14/11 that he was alert and oriented, with intact memory, and could make his own decisions. It also showed that he was in almost "constant pain" that interfered with sleep and activity. On 11/16/11 Patient 1 had a verbal physician's order that read he may have four ounces of wine with his Thanksgiving dinner.On 5/2/12 at 11 am, the Director of Nurses (DON) stated that on 11/19/11, the facility provided a Thanksgiving celebration luncheon for patients and visitors that included wine. She stated that most of the facility patients were allowed to have wine.On 5/2/12 at 12:30 pm, Certified Nurses Assistant (CNA) C stated that on 11/19/11, Patient 1 had asked her to get him another glass of wine, and that she relayed the request to Social Service staff (SS) D. On 5/2/12 at 1:45 pm, SS D stated that she had given Patient 1 a glass of wine and "did not particularly pay attention" to if he already had a glass or not. On 5/2/12 at 2 pm, Medical Records staff (MR) E stated that on 11/19/11, there was a table set up outside the main dining room that had four rows of five or six glasses of wine poured at once. She stated that family members were also drinking the wine, and that she did not recall that any specific staff were keeping track of the amount of wine going out into the facility to residents. On 5/2/12 at 2:45 pm, Maintenance Staff (MS) F stated that he had poured the glasses of wine. For residents he would only fill the 6 ounce wine glasses 2/3 full to equal four ounces and for family he would fill the glass full. He stated that he did not see a list of who was getting the wine, that he only poured the wine and did not serve it. On 7/11/12 at 3:20 pm, CNA G stated that on 11/19/11 she was assigned Patient 1, but did not serve him his lunch meal or wine as he ate in his room and she was assigned to a different area at the meal time. She stated she was aware that he had had some wine. She stated that Patient 1 "knows how to work the system," and that he may have had more than one glass of wine. CNA G stated that although Patient 1 used incontinence briefs, that he was usually continent of urine and was able to use his urinal.On 11/19/11, the medication administration record showed that Patient 1 had taken multiple medications that included Tenex (for blood pressure), Cymbalta (for pain and depression), Trazadone (for sleep), Ativan (for anxiety), Percocet ( for acute pain), and Methadone ( for chronic pain). The amount of wine that Patient 1 consumed on 11/19/11 was not documented. The manufacturer's recommendations for all these medications advise that patients should avoid the use of alcohol as it may cause increased levels of sedation. A 11/20/11 night shift nurse's note read that Patient 1 appeared extremely over medicated. Exhibiting signs and symptoms of extreme lethargy. It also read that Patient 1 stated that he had two glasses of wine with dinner, pain medications, and valium. The note also read that Patient 1's pupils were "pinpointed" (a sign of excess alcohol or opioid medication). The 11/20/11 night shift nurse's note further read that all pain medications and anxiety medications were held and that the nurse had explained to patient that it would be unsafe to administer the medications that he requested, until the signs and symptoms of oversedation subside.On 5/2/12 at 9:50 am, LVN H stated that when she came on shift, 11/19/11 at 10 pm, Patient 1 was sleeping. LVN H stated that shortly after shift change she had asked Patient 1 if he had wine. Patient 1's speech was slurred and he denied drinking wine. She stated that one of the CNA's working that night talked with him and Patient 1 had told him that he had "several glasses of wine."LVN H stated that she was concerned for his Patient 1's welfare, that Patient 1's change of condition included moving slower than usual and having heavy urinary incontinence, which was not his normal state. She stated that about an hour later Patient 1 asked for medications that he would routinely request for pain and anxiety. LVN H stated that she was going to call the doctor to send the patient out for an emergency assessment, but that his condition seemed to improve by 3 am (five hours after the start of her shift). She faxed the doctor a notification regarding his condition change before going off shift at 6 am the next morning. She stated that the next morning on 11/20/11, two am shift CNA's had reported giving him wine the previous day during the Thanksgiving dinner.CNA I stated that she answered Patient 1's call light around 1:30 am on 11/20/11, and he was sitting on the side of his bed and stated that his legs had given out and he had fallen to the floor.CNA I stated Patient 1 was weaker than usual that night. CNA I stated that she notified the nurse that Patient 1 had said he had fallen. She stated that Patient 1 seemed "over medicated."On 11/20/11, nurse's medication notes for midnight and 6 am read that Patient 1 was "oversedated and unable to do (participate in the inhaler administration) med" for his routine dosing of Combivent inhaler given every six hours for his respiratory wheezing. Therefore, the facility failed to follow a physician's ordered diet for Patient 1 when he was provided more than four ounces of wine on 11/19/11.This failure resulted in Patient 1 experiencing adverse side effects of increased sedation, weakness and heavy bladder incontinence. This violation had a direct relationship to the health, safety and security of patients. |
| 230000031 |
Paradise Ridge Post-Acute |
230009708 |
A |
20-Feb-13 |
N2HZ11 |
10098 |
T22 DIV5 CH3 ART3-72311(a)(2) Nursing Service (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. An unannounced visit was made to the skilled nursing facility (SNF A) on 9/13/11 for an investigation of an unusual incident (Entity Reported Incident 282927) reported by the facility. As a result of the investigation, it was determined that the facility failed to ensure the safety of Patient 1 by not providing assistance with toileting, in accordance with the plan of care. This occurred during the early morning of 9/9/11, when CNA A left Patient 1 alone and unattended on a bedside commode. Later that morning, Patient 1 was found on the floor bleeding from her head and required emergent transfer to a hospital emergency room. In the emergency room she had extreme weakness, mental confusion, forgetfulness, and difficulty breathing. Patient 1 was admitted to Hospital B with a diagnosis of subarachnoid bleed (bleeding between the brain and the thin tissues that cover the brain). In Hospital B, Patient 1's need for more intense medical care required that she be transferred via helicopter to Hospital C. Patient 1, a 76 year old female, was originally admitted to the facility (SNF A) on 8/13/11 to recover from hip surgery with diagnoses that included rheumatoid arthritis (a disorder that affects the bones and joints with symptoms of pain, redness, swelling, and joint deformity), lung congestion, irregular heart rhythm, a history of small strokes, and the need for rehabilitation therapy. Patient 1's discharge plan was to return home to her prior independent level of functioning. Prior to admission, Patient 1 lived at home alone and was independent in all of her affairs, including finances and medication management. She walked without an assistive device and drove a car. She was her own responsible party and decision maker. An "Admission Evaluation and Interim Care Plan," dated 8/13/11, described Patient 1 to be alert, oriented, able to make her needs known, and to make independent decisions regarding her care. The neurological assessment concluded that while walking her gait was irregular, she had difficulty turning and she was unstable. The physical functioning section indicated that Patient 1 required extensive hands on physical assistance for her activities of daily living. Patient 1's fall risk evaluation within this evaluation was scored as 13 of 20 (a score of 10 or higher indicated a risk of falling). The PT (Physical Therapy) assessment, dated 8/14/11, documented that Patient 1 had impaired walking, balance, strength, safety awareness, difficulty with transfers, and was at increased risk for falls. The PT assessment further commented that she had an inability to recognize her physical limitations and recognize when she needed to rest, which contributed to a lack of safety awareness. An OT (Occupational Therapy) assessment, dated 8/16/11, also documented Patient 1's need for assistance in grooming, dressing, bathing, toileting, functional transfers, functional mobility, and decreased standing ability/balance. Patient 1's "Fall Risk Interdisciplinary" care plan, dated 8/25/11, indicated her Fall Risk score had increased from 13 to 16. Patient 1 had reportedly had 1 or 2 falls in the previous three months, and she had problems with standing, walking, and decreased coordination. All of these findings indicated Patient 1's need for stand-by supervision and physical assistance with all activities.Patient 1's "ADL"-(Activities of Daily Living) care plan, dated 8/25/11, documented these deficits and planned interventions. The planned interventions included: 1) extensive assistance (meaning that Patient 1 was involved in the activity but required staff to provide weight-bearing support) with transfers and use of the bedside commode; 2) verbal cueing as needed to assist in accomplishing tasks; 3) reminding Patient 1 frequently to use the call light for assistance; 4) having a call light available and answered promptly; and 5) reminding Patient 1 to ask for help when needed. In an interview with RN B on 9/13/11 at 8:40 am, he stated that Patient 1 had been admitted to the facility primarily for rehabilitation services with the goal to return to living independently at home. RN B stated that on 9/9/11 at 6:45 am, he heard a loud noise coming from Patient 1's room. He responded to the room and found Patient 1 lying on the floor with a large gash on the side and towards the back of her head. RN B stated that Patient 1's head was "bleeding heavily." After the fall, for approximately 10 minutes, RN B stated that Patient 1 appeared "foggy," was confused and disoriented, and had no memory of the fall. He stated Patient 1 was normally alert and oriented to person, place, and time.RN B called for help and stayed with Patient 1, applying pressure to her bleeding head until the emergency response team arrived and transported Patient 1 to the local hospital emergency department (Hospital B). Patient 1's hospital documentation showed that she arrived in the emergency department on 9/9/11 at 7:36 am. She had a 3 inch long gash on the right side of her scalp. Patient 1 had no memory of the fall. A radiologic scan of her head confirmed bleeding in her brain at the area of trauma. During that night, her blood pressure dropped. A repeat scan showed more extensive bleeding in her brain. Mentally, Patient 1 demonstrated more confusion, drowsiness, and weakness in her left upper extremity. Patient 1 was transferred to a large medical facility (Hospital C) out of the area by helicopter for more intense treatment. In an interview with CNA A on 9/13/11 at 9:10 am, she stated that 9/9/11 was the first time she had provided care for Patient 1. She stated that on the morning of 9/9/11, she was the CNA who assisted Patient 1 onto the bedside commode. She said that she laid the call light within reach. She indicated that the call light was a special flat light she laid on Patient 1's lap so all Patient 1 had to do was touch it. CNA A then pulled the privacy curtain, and left the room to assist another patient in the room next door. She stated she intended to return when Patient 1 turned on the call light. CNA A stated she was in the room next door for "about 10 minutes" when she heard someone in the hallway yell to clear the hallway for the paramedics. On 9/13/11 at 9:45 am, during an interview, CNA C stated that she was frequently assigned to care for Patient 1 and was familiar with her care needs. CNA C stated that Patient 1 needed assistance transferring onto and off of the bedside commode. She stated that the usual routine was to assist Patient 1 to sit on the bedside commode, primarily by making sure the oxygen tubing was out of her pathway. She stated that Patient 1 was able to position herself on the seat, toilet herself, and push the call light for assistance. CNA C stated she stayed in the room and Patient 1 usually called her name when she was finished. CNA C stated she never left Patient 1 sitting on the bedside commode alone in the room. She stated she was always within earshot or visually able to see Patient 1.In an interview with Patient 1's daughter on 9/26/11 at 11 am, she stated that Patient 1 required transfer to a trauma center out of the area because of worsening of the bleed in her brain. Patient 1's daughter stated that since the fall, she noticed a drastic change in Patient 1. She stated Patient 1 was now much weaker and more fragile. She had periods of confusion and difficulty talking, only able to give one or two word responses to any conversation. She stated that replying to any conversation often took several minutes. She stated that Patient 1 now resides at a different facility (SNF D). Since transfer to SNF D on 9/21/11, Patient 1 has received speech, physical, and occupational therapy services. On 9/22/11, review of the Speech Therapy Evaluation at SNF D showed that Patient 1 was oriented only to self, was easily distracted, and had difficulty paying attention to a task. She was only able to follow one-step directions and answer simple questions 50% of the time. The Physical and Occupational Therapy Evaluations, dated 11/14/11, documented that Patient 1 required 50% to 75% physical assistance from another person to perform feeding, toileting, grooming, personal hygiene, bathing, and dressing activities. On 9/9/11, the facility failed to provide Patient 1 with the planned assistance she needed to safely use her bedside commode. In so doing, the facility failed to implement Patient 1's care plan as specified in the "Fall Risk Interdisciplinary Care Plan," developed on 8/25/11. The care plan described Patient 1 as having a fall risk score of 16 (10 and above is considered high risk). Staff were to "monitor for signs and symptoms of dizziness or vertigo; remind Patient 1 frequently to use the call light for assistance; and ask for help when needed." The "ADL Function Care Plan", dated 8/25/11, outlined staff's approach to Patient 1 which included "monitoring and assistance with transfers; assist in toilet use; verbal cueing to assist in accomplishment of tasks; and verbal reminders to assist in orientation." Patient 1 was left alone in her room on the bedside commode. As a result, Patient 1 fell striking her head on the floor and suffered a bleed into her brain. The fall and subsequent bleed into her brain harmed her greatly and caused her serious physical harm. Consequently, she is left without many functions she was able to do, prior to the injury. She is no longer able to live alone, independently at home; no longer can she drive a car or walk without assistance; no longer can she be her own decision maker. The facility failed to implement Patient 1's care plan according to the methods indicated in the plan. 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. |
| 240000094 |
Providence Ontario |
240009037 |
B |
27-Feb-12 |
YLVN11 |
7190 |
REGULATION VIOLATION: Title 22, 72313 Nursing Service - Administration of Medications and Treatments and 72311 Nursing Service - General 72313 (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. AND 72311 (a) Nursing service shall include, but not limited to, the following: (3) Notifying the attending physician promptly of: (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient.The facility failed to ensure the correct, prescribed, intravenous antibiotic doses were administered to Patient A, to treat the patient's endocarditis. As a result, Patient A required re-admission to the acute care hospital, to re-start the correct intravenous antibiotic regimen, for the treatment of endocarditis (Infection affecting the heart and possible heart valves). In addition, the facility failed to promptly notify the physician of the inability to continue to utilize the patient's PICC (Peripherally inserted central catheter) line to administer intravenous antibiotics. On June 9, 2010 at 10:00 AM, an unannounced visit to the facility was conducted to follow-up on a complaint regarding a medication error. According to the complainant, the facility failed to administer the correct amount of IV (Intravenous) antibiotics. Subsequent follow-up visits to the facility were conducted on August 17, 2010 and December 23, 2010.Review of the "Final Progress Note" from the acute care facility dated and signed on April 20, 2010, showed that Patient A was admitted on April 14, 2010 and was transferred to the skilled nursing facility on April 20, 2010. Documentation indicated Patient A presented to the acute care hospital with infective endocarditis and was started on intravenous antibiotics. Patient A was discharged to the skilled nursing facility with order to continue "Ampicillin 500 mg (milligram) per hour times 24 hours per day for a total of 12 grams per day, times 38 days, completes 5/28/10." Documentation stipulated the infusion be continuous via PICC.Review of Patient A's medical records on August 17, 2010 at 10:10 AM showed Patient A was a 40 year old female, who was admitted to the skilled nursing facility on April 20, 2010 from the acute care hospital. Patient A's diagnoses included endocarditis, atrial fibrillation, pulmonary valve disorder, hypertension, hypothyroidism, and mental retardation. Review of the facility's transcribed medication orders included "Ampicillin 500 mg IVPB (Intravenous piggyback) every 24 hours times 38 days" for endocarditis. Review of the facility's "IV (Intravenous) Therapy Order" form dated April 20, 2010, showed an order for, "Ampicillin 500 mg every 24 hours for 38 days" for endocarditis. Review of the facility's "Intravenous Therapy Medication Record", revealed that Patient A received Ampicillin 500 mg every 24 hours from April 21, 2010 through May 4, 2010, a total of 14 days. During an interview with the DON (Director of Nurses) and ADON (Assistant Director of Nurses) on August 17, 2010 at 12:12 PM, staffs confirmed that Patient A received Ampicillin 500 mg every 24 hour while at the facility. During a telephone interview with RN 1 (Registered Nurse) on December 28, 2010 at approximately 10:51 AM, RN 1 stated that the RN from the acute care hospital did talk to her and told her about Patient A's medications to include, Ampicillin IV, the strength and for how many days duration of treatment. (This was confirmed by the DON during the December 23, 2010 at 12:10 PM interview). RN 1 confirmed that she was aware that Patient A was admitted to the facility for continuity of antibiotic administration.RN 1 also stated that she did receive the "Final Progress Note" from the acute care hospital during Patient A's admission on April 20, 2010 which stipulated the different medications ordered for Patient A. (This was confirmed by the DON during the December 23, 2010 at 12:10 PM interview). RN 1 stated that she, "Transcribed whatever I read on the paper." RN 1's statement referenced the "Final Progress Note" from the hospital. RN 1 also stated that she read the orders from the acute care hospital, one by one, to the facility's Physician Assistant (PA) and then wrote the order on the facility's physician order form.RN 1 confirmed and stated that she faxed to the pharmacy the "Final Progress Note" from the hospital, together with the facility's transcribed medication order form. (This was confirmed by the DON during the December 23, 2010 at 12:10 PM interview). RN 1 was informed that the Ampicillin order was 500 milligram (mg) per hour times 24 hours per day for a total of 12 grams per day however; the transcribed order was Ampicillin 500 mg per day, which was the wrong dose. RN 1 stated, "I just transcribe what I read on the paper." RN 1 made no further comment. Additionally, review of the licensed nurse's note dated May 1, 2010, showed the following, "Both lumens of PIC line clotted, unable to flush either line...peripheral line established to administer IV antibiotics - will notify MD in the AM re: PIC line not patent." However, there was no documented evidence in the patient's record that the physician was notified of the inability to continue to use the PICC line. The "Internal Medicine History and Physical" report from the acute care hospital, dated May 4, 2010, revealed that Patient A was re-admitted to the acute care hospital on May 4, 2010 secondary to "bacterial endocarditis." The plan was to restart the intravenous antibiotic. The report included the following, "The facility was giving only 1/24 of Ampicillin dose required ...error in dosing of antibiotic at (facility)."Review of the discharge summary from the acute care hospital dated May 6, 2010, revealed that Patient A was re-admitted secondary to bacterial endocarditis and was discharged to the skilled nursing facility with orders to include Ampicillin 12 grams per day continuous infusion to run at 500 mg per hour. During an interview with the DON (Director of Nurses) and ADON (Assistant Director of Nurses) on August 17, 2010 at 12:12 PM, staffs confirmed that the physician was not notified of the clogged PICC line and initial insertion of a peripheral IV line. The facility's failure to ensure continuity of the plan of care to administer Ampicillin 12 grams per day, as prescribed by the physician, resulted in the patient receiving the incorrect infusion of Ampicillin for a total of 14 days, a medication error. Patient A received Ampicillin 500 mg every 24 hours rather than the prescribed continuous dose, which would equal 12 grams per day.In addition, the facility failed to notify the physician of the inability to administer the Ampicillin through the PICC line, as prescribed. These failures resulted in the patient's re-admission to the acute care hospital for treatment of bacterial endocarditis. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000855 |
PALMYRA HOUSE |
240009282 |
B |
08-May-12 |
ERCU11 |
7169 |
REGULATION VIOLATION: Title 42 W483.420 Standard: Staff Treatment of Clients and W483.460 Standard: Drug administration W483.420 (d)(1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. AND W483.460 (k)(1) The system must assure that all drugs are administered in compliance with physician's orders.Based on observation, interview and record review, the facility failed to ensure that its policy and procedures for securing a wheelchair in transport were followed. The Direct Care Staff (DCS) assigned to transport Client A from Day Program to her home, neglected to apply all four straps to secure her wheelchair before transporting her. This resulted in Client A's wheelchair falling forward causing her to strike her head and sustain a laceration to her forehead requiring sutures. In addition, the facility failed to administer medications and treatments as prescribed by the physician. On August 12, 2010, the physician instructed facility staff to cleanse Client A's wound with normal saline. However, wound care was not initiated until August 17, 2010. Additionally, staff administered Tylenol without a physician's order. On August 26, 2010, an unannounced visit was conducted to investigate a facility reported accident that involved Client A. Client A was a 54 year old woman admitted to the facility on July 11, 2008,with diagnoses to include: profound mental retardation (IQ < 20), convulsive disorder, cerebral palsy (a trauma at before or during birth that causes neurological deficits), scoliosis (curvature of the spine) and osteoporosis (a thinning of bones making the bones susceptible to fractures). Client A was documented as alert but non verbal.Documentation indicated Client A had a customized wheelchair that needed to have four straps applied near the base to secure it during transport. On August 16, 2010, the California Department of Public Health (CDPH) received an Entity Self-Report which indicated, "Client A was wheelchair bound was being transported in the facility van to the facility. On the way to the facility Client A's wheelchair fell over and she hit her head as a result of the fall. Client A received a laceration on the forehead." On August 26, 2010 at 10:40 AM, the Qualified Mental Retardation Professional (QMRP) was interviewed. The QMRP related the same information. He stated the Direct Care Staff (DCS 1) was suspended over not securing the wheelchair with the use of straps. He provided her with retraining and "took her off of transporting clients." During an interview with Client A's mother at 9:50 AM, she stated she was upset that the staff did not call an ambulance; instead they took Client A back to the home. The client's mother stated, "The staff let my daughter bleed until they got to the facility. The staff told me she was heavy and they are not supposed to call the ambulance." Client A was subsequently taken to the Emergency Room (ER) and had stitches applied to her forehead, above her right eye. On September 20, 2010 at 9:30 AM, Client A was observed sitting up in her wheelchair watching television. She had a scar approximately 2 1/2 inches above her right eyebrow that had healed. She was non-verbal and unable to answer questions. DCS 2 and DCS 3, who were at the home at the time of the visit, were asked to demonstrate how the wheelchair was to be tied down with the straps. They were able to detail the steps per their undated policy and procedure titled, "Drive Safe."A review of the policy, under the section titled, "Boarding Wheelchair," the following was noted, "Secure the wheelchair with the 4 color coded tie downs in addition to the seat belt for every trip."An "Interdisciplinary Team Note" dated August 12, 2010 at 3:30 PM, indicated "Client A [used her name] being transported in facility van to facility. W/C (wheelchair) fell over and she hit her head as result of the fall, Client A received a 3 inch laceration on the forehead. Staff picked her up and took her to [name of acute care hospital used] ER (Emergency Room). She had a CT scan (used to detect bleeding in the brain) and 9 sutures (stitches)." A review of the employee file for DCS 1 showed she had been employed since June 2000. Her file contained the suspension letter dated August 13, 2010 written by the QMRP. The following was noted in the file, "Above employee failed to properly secure a wheelchair bound resident while being transported resulting in wheelchair falling and sustaining 3 inch laceration to forehead. Re-inserviced. She was returned to work on August 15, 2010 on the 11:00 PM - 7:00 AM shift and no longer transports clients." A review of the Registered Nurses (RN) notes dated August 12, 2010, indicated, "Notified by QMRP client fell over in van and has large cut to forehead. Client transported to [names acute care hospital] Emergency Room (ER) for evaluation. The next note was dated August 14, 2010 and written by the same RN. She documented, "Client received sutures to laceration on forehead August 12, 2110. CT head negative (computerized scan of the head used to rule out bleeding). 6 cm (1 cm = 2.57 inches) laceration. Sutures intact with scabbing. No excessive redness or drainage noted. Bruising to right eyelid with some swelling. Staff instructed to give Tylenol for signs of pain." A review of the Physician Orders showed an order for wound care, as follows, "Cleanse wound with N/S (Normal Saline) for 7 days."There was no physician's order found for the Tylenol the nurse had advised the staff to give Client A. Review of the Medication Administration Record (MAR) dated August 1 through August 31, 2010, showed the wound care treatments were not started as ordered by the physician. DCS 2 looked at the MAR and said that they had not received the normal saline. On the back of the MAR a nurse documented the normal saline would be at the facility by August 16, 2010. Further review of the MAR reflected that the treatment had not been started until August 17, 2010 and was only done until August 22, 2010. The order stipulated seven days of treatment. During a telephone interview with the RN on September 20, 2010 at 9: 50 AM, she stated, "They had trouble getting the normal saline but they should have called me so I could have notified the doctor for a new order." The RN stated, "I cleaned it on the 14th when I came." However, there was no documented evidence the treatment was administered on the 14th. When asked why she had not called the doctor to initiate the after care instructions for wound care sent home from the emergency room, the RN did not answer. Based on the information obtained, the facility failed to protect Client A from injury by neglecting to follow the protocols for securing her wheelchair for transport. In addition, the facility failed to protect Client A from potential wound infection by not notifying the physician when they were unable to follow his wound care orders. Additionally, the facility failed to consistently implement the wound care treatments. These facility failures had a direct relationship to the health, safety, or security of patients. |
| 240000156 |
Providence Waterman |
240009308 |
B |
23-May-12 |
3GYU11 |
15150 |
REGULATION VIOLATION: Title 22 72315 Nursing Service - Patient Care and 72523 Patient Care Policies and Procedures 72315 (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by physician's orders. And 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.The facility failed to ensure Patient A was provided with an orthotic device, as ordered by the physician. As a result, Patient A did not receive the care and therapy needed to assist her in achieving her highest level of independence.The facility failed to implement their policy and procedure regarding The facility's failure to promptly replace Patient A's lost orthotic device, had a detrimental effect on the patient's physical, mental, and psychosocial well-being, and safety. On June 15, 2011 Patient A was discharged from the facility without replacement of the lost orthotic device needed to facilitate and achieve the physician's recommended physical therapy goals, which included walking two hundred feet without stopping and without the use of a walker.A telephone interview was conducted with Patient A on July 1, 2011 at 4:00 PM; she stated she was sent from the acute care hospital to the facility to receive physical therapy. Patient A stated she was at the acute care hospital only a "short while," was in a lot of pain and "did not get a good start with physical therapy while there." The patient said she was admitted to the Skilled Nursing Facility (Facility) on May 7, 2011. Her attending physician ordered a brace for her left leg on May 14, 2011, and the doctor gave instructions for the facility's physical therapy department (PT) to follow the orthopedic surgeon's orders for her rehabilitation therapy. She further stated this was the third hip replacement surgery and was versed on what to expect of PT services in order to meet the orthopedic surgeons goals for her rehabilitation. Patient A stated that on May 27, 2011, the Orthotist (a clinician involved with assessment design, fabrication, and evaluation of orthoses a device that is intended to mechanically compensate for a pathological condition) delivered the left leg brace for fitting and also ordered for her a modified shoe for the brace which was subsequently delivered on June 7, 2011. At that time, the Orthotist wanted to fit the shoe with the brace; however, the brace was not in its usual place, on the cabinet shelf in her room. Patient A stated, "I do not know exactly when it went missing." She stated the Orthotist and she reported the loss immediately to the nurses; they looked around for it and did not find it. Patient A stated she also notified the facility's social worker that day, who wrote a report. The following day June 8, 2011 Patient A made a police report of the theft.On Friday June 10, 2011 the facility's Administration had a meeting about her brace; however she was not contacted by anyone until five days later, on Wednesday June 15, 2011. The patient stated, "The Administrator went to her room and in the presence of my husband said my conclusion is your husband took the brace home to keep you here longer." Patient A stated, "I was very upset and offended she would accuse him of that, there is no reason to do something like that." Patient A added, "The Administrator also accused the gentleman (orthotist) of taking it."Patient A stated the nurses, the physical therapists and her attending physician all saw the brace in her room. She stated shortly thereafter she was informed of her last covered day at the facility. Patient A requested an extension to stay until her brace was found so she could use it during therapy. Patient A stated, "I am to walk two hundred feet without stopping, and I have only walked seventy five feet with a lot of stopping in between. My doctor (named) was very supportive of my situation, she tried to see if the insurance would cover another brace, I was told by the case manager, no. Then on June 16, 2011, I was discharged home without my brace, and to this day (July 1, 2011, 25 days after loss first reported) nothing, I have heard nothing from the Administrator." An unannounced visit was made to the facility on July 6, 2011 for the purpose of investigating the allegation of loss/ theft of the patient's orthotic device. Patient A was admitted to the facility on May 7, 2011, with diagnoses that included status post left hip fracture with ORIF (open reduction internal fixation). Patient A was admitted from the acute care hospital to the facility for rehabilitation to include, physical therapy (PT) and occupational therapy (OT) in order to achieve independence in walking and activities of daily living.Record review of a physicians order dated May 14, 2011, included an order for "use of a left foot splint (a device that is intended to mechanically compensate for a pathological condition) for foot drop (describes the inability to raise the front part of the foot due to weakness or paralysis of the muscles that lift the foot)."Record review of the physicians order dated June 4, 2011, stipulated the following, "Please make arrangements for patient to see orthopedic specialist next week regarding foot drop." Record review of the Physicians progress notes for the following dates indicated: June 4, 2011; "Discharge only if walking two hundred feet, as per orthopedic surgeon's orders". The order was signed by the attending MD. June 6, 2011; "Discharge when walking two hundred feet." The order was signed by attending MD. Review of the Physical Therapy Evaluation notes dated May 9, 2011, showed Patient A was status post left total hip replacement with a left prosthetic revision. Documentation included, "Patient lives with husband and ambulates with walker independent." The documentation showed the patient's goal and discharge plans were, "To be able to walk and go home." In the section titled bed mobility and transfers (sit to stand, bed to chair, wheel chair to bed) the documentation indicated the patient required maximum assistance, and had complaints of left hip pain.Record review of the Physical Therapy Care Plan initiated on May 9, 2011, indicated the goal was to increase the patient's bed mobility for transfers to the bed/wheelchair with minimal assistance and increase strength in both legs. In addition, the goal addressed increased ambulation (walking) with the aid of a walker and left lower extremity foot brace, one hundred feet with minimal assistance. The target date to meet that goal was "until patient is discharged." Record review of the Physical Therapy (PT) Progress Notes documentation dated May 9, 2011 to June 15, 2011 revealed Patient A did not achieve the care plan goal to be able to walk two hundred feet without stopping while using the left lower leg brace, and without a walker. The documentation indicated the patient walked one hundred feet one time only on June 6, 2011.June 7, 2011, documentation indicated, "Patient needs frequent rests with therapy services for ambulation, secondary to feeling tired." June 8, 2011, documentation indicated, "The patient was upset about the lost left ankle/foot orthotic (AFO). Nursing and case manager are aware." June 13, 2011, documentation indicated the following, "Patient still concerned about left AFO brace that is lost, [Patient A] said, "I could have done better with my left leg brace, as my left leg hurts." Documentation included the following, "Mild swelling noted to both feet and right and left leg." June 14, 2011, "[Patient A] complaining of pain in left foot and leg. Patient may benefit from PT when patient is discharged home." June 15, 2011, Patient A told staff, "I feel tired... I will walk less today." "[Patient A] tolerated therapy well, said after therapy her left foot and leg hurts and wants her left AFO brace." June 16, 2011, "Patient and husband trained for safe car/wheelchair transfers, no complaints of pain during car transfer, patient is discharged home." An interview was conducted with the Registered Physical Therapist (RPT) on July 6, 2011 at 10:00 AM. He stated he did the initial evaluation for physical therapy (PT) services for the patient on May 9, 2011 and stated the patient required maximum assistance with transfers, mobility and walking. The RPT stated that the patient's doctor ordered a left ankle/foot orthotic (AFO), due to the patient's complication of foot drop. He mentioned the patient's complaint of pain, that the patient's care plan goal included walking a distance of two hundred feet without stopping and without aid of a walker had not been met prior to her discharge. When asked what was done about the lost AFO, the RPT stated, "The charge nurse, licensed and certified nurses and case manager were told about it, he further stated the patient wanted to speak with the Administrator, that's what I know." An interview was conducted on July 6, 2011 at 11:45 AM, with the patient's Case Manager, who stated, "The doctor ordered the foot brace on a weekend May 14, 2011. I placed the referral the next week on Friday May 20, 2011. The patient received the brace on May 27, 2011, and the orthotic shoe on June 7, 2011 shortly thereafter the patient told me the facility lost her brace." An interview was conducted on July 6, 2011 at 11:00 AM, with the facility's Social Services Director (SSD). When asked for information concerning Patient A's lost orthotic device, the SSD stated, "[Patient A] reported the missing AFO to me on June 9, 2011, I turned in the theft and loss report to the Administrator on June 15, 2011." The SSD added the patient filed a police report, when asked if she'd advised the patient to file the police report, she stated she did not. Additionally, the SSD stated she did not follow up any further with the patient regarding this incident. The SSD stated, "I do not know what happened." The SSD was asked for clarification for the six day delay in initiating the theft and loss report after it was first discovered and reported to her, she did not give an answer ."I only turned in the theft and loss paper work to the administrator on June 15, 2011." Review of the facility's policy and procedure titled "Personal Property" Copyright 3/93. Included the following: "Purpose" "1. To assure that the resident's rights to personal property are preserved." "Procedure:" "...10. Follow the facility's Theft and Loss procedures for any misplaced items." "Theft and Loss Program Policy" "1... It is the policy of this facility to make reasonable efforts to safeguard its Resident's property. In implementing the procedures set forth below, it is the intention of the facility to meet each of the reasonableness requirements specified in California Health & Safety Code 1289.4". "C. Documentation and Investigation After a Theft or Loss Has Been Reported." "Include, among other pertinent information, the following:" "...g. The action that was taken by the facility." "4. The Administrator shall investigate all reports of theft or loss utilizing any or all of the following techniques as deemed reasonable by the Administrator: Interviews with Residents, their families and or responsible parties; interviews with facility staff members; facility searches; and any other actions recommended by the management team." "5. Once the Administrator has completed the investigation the results shall be reported to the person(s) who made the report and replacement or reimbursement shall be made if deemed appropriate, as follow:" "a. If the Administrator determines the Facility is responsible for the theft of loss, prior to reporting the results of the investigation, the Administrator will forward a copy of the completed Theft & Loss Report to facility attorney with a request for authorization for reimbursement or replacement. Once the authorization is received, the investigation findings shall be verbally reported to the person(s) making the initial report. Such reports/findings shall be documented on the Theft & Loss Report in the section labeled "Final Disposition". "6. Any reimbursement for or replacement of a lost or stolen item shall be made at the item's then current value." "...8. If the Administrator has reason to believe a Resident's property with a then current value of one hundred dollars ($100) or more has been stolen, he/she shall report the theft to the local law enforcement agency within 36 hours. Copies of such reports for the preceding twelve months shall be made available to the State Department of Health Services and law enforcement agencies upon request. [Health & Safety 1289.4(i)]. An interview was conducted on July 6, 2011 at approximately 12:40 PM with the Administrator in her office, a third request was made to review the Theft and Loss Report of the investigation outcome regarding Patient A's lost AFO. She stated "I just could not find it...I know I sent the report to our corporate office." She was asked for clarification on the date, the time and delivery method used to send the report to the corporate office for determination. The Administrator stated she scanned the report and e-mailed it as an attachment to corporate office, and further added "I did just resend it today." Record review conducted with the Administrator found no documented evidence the facility sent the Theft & Loss Report to the corporate office for determination, prior to this interview/record review, although the patient filed the report on June 7, 2011. The Administrator further stated, "I do not have it." Then stated, "Yes I know, it was lost here and we need to replace it, she needs it, I agree." The Administrator then proceeded to call the corporate office and request the claim be settled for reimbursement of Patient A's lost AFO. A telephone interview was conducted with the Orthotist on July 6, 2011 and July 12, 2011 at approximately 4:00 PM. The Orthotist stated that Patient A had a condition called foot drop of the left side. The Orthotist stated, "She is unable to lift the foot and her toes point down...the brace and shoe support the foot to enable the patient to walk and is vital to perform rehabilitation and vital for protection to avoid falling...for [Patient A] it is very important." When asked, the Orthotist stated that when the brace was initially reported lost to the facility personnel, he was accused by the facility of taking it. A follow up telephone interview was conducted with Patient A on July 18, 2011 at approximately 10:50 AM. She stated she is still without the foot brace and without it cannot lift her left foot to walk, and has not benefited from the physical therapy she needs for rehabilitation. Patient A further stated, "I have not heard a word from the Facility in regards to replacement of my brace." These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000156 |
Providence Waterman |
240009563 |
B |
25-Oct-12 |
PEEV11 |
3402 |
REGULATION VIOLATION:Title 42 483.25(h) (2) Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. (h) Accidents. The facility must ensure that (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility must ensure that the resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure for one patient (Patient 1), that she was supervised while in the bathroom. This failure resulted in Patient 1 falling in the bathroom and sustaining a laceration to her head and a skin tear to her right arm. An unannounced visit was made to the facility on January 9, 2012 to investigate a complainant reported incident regarding a patient falling. Review of Patient 1's admission face sheet noted that Patient 1 was an 88 year old female admitted to the facility on December 12, 2011, with diagnosis which included cerebral vascular accident (stroke). Review of Patient 1's "RAI" (Resident Assessment Instrument) completed December 12, 2011, identified the resident as needing two staff assistance for transfers. The document described the patient as being able to make her needs known. An interview was conducted on January 9, 2012 with Registered Nurse (RN1). RN 1 stated that on December 29 2011, she was called to Patient 1's room by the Certified Nursing Assistant (CNA 1). RN 1 stated that CNA 1 stated that she was helping Patient 1 while in the bathroom. RN 1 stated that CNA 1 had left the bathroom to get a towel for Patient 1. RN 1 stated that when CNA 1 returned back to the bathroom, Patient 1 had fallen off the toilet onto the floor hitting her head. Patient 1 sustained a laceration on the back side of her head and left third finger. RN 1 stated that Patient 1 was assessed and was oriented to name only. RN 1 stated that Patient 1 was transferred to the acute hospital for treatment. Another interview was conducted with Certified Nursing Assistant CNA 1, assigned to Patient 1 on December 29, 2011. CNA 1 stated that on December 29, 2011, she was caring for Patient 1. CNA 1 stated that she assisted Patient 1 to the bathroom, sat her on the toilet, and then turned around to get a towel from the bed. When she returned, Patient 1 had attempted to get off the toilet, and fell. Review on February 9, 2012, of the acute care hospital admission history and physical completed on December 29, 2011, revealed that Patient 1 received repair to her third left finger for lacerations and sustained a subacute infarct in the right temporal lobe. Patient 1 was subsequently admitted to the acute care hospital on December 29, 2011, and remained at the acute care hospital for six days before being discharged on January 4, 2012 to another skilled nursing facility, per the patient's family request. The facility failed to ensure Patient 1 was provided with supervision at all times. This failure resulted in the patient being left alone in the bathroom and subsequently falling to the floor, sustaining injuries and requiring hospitalization.These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000096 |
Plymouth Village |
240010850 |
A |
09-Jul-14 |
0XWN11 |
14823 |
REGULATION VIOLATION: 72311 (a)(3)(B)(a) Nursing services shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs and symptoms, or behavior exhibited by a patient. The facility failed to notify the physician (MD) of a significant change in Patient 1's condition as follows:, abdominal pain and diarrhea, multiple refusals of meals, shaking and abdominal distension on September 8, 2013 and after September 9, 2013 to September 12, 2013. This failure caused Patient 1 to experience a delay in assessment and treatment for acute peritonitis (inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen and covers and supports most of your abdominal organs. Peritonitis is usually caused by infection from bacteria or fungi. Left untreated, peritonitis can rapidly spread into the blood (sepsis) and to other organs, resulting in multiple organ failure and death- a life threatening condition) and bowel perforation (a fatal condition; complete transmural disruption of the intestinal wall resulting in bacterial contamination of the abdominal cavity/peritonitis; a hole that develops through the intestine, a medical emergency). Patient 1 was transferred to an acute hospital on September 12, 2013 after medication was administered to her in error. Upon admission to the acute hospital, Patient 1 was diagnosed with acute peritonitis and bowel perforation and subsequently died on September 14, 2013 at 5:32 AM.Patient 1 was admitted to the facility on September 6, 2013, with diagnoses that included pulmonary embolism (blood clot in the lungs), Alzheimer's disease (a chronic, progressive disease causing loss of memory that affects thinking, language, judgment and behavior) and unspecified constipation. A review of the clinical record on September 19, 2013, showed the following documentation by facility staff on Patient 1's Progress Notes: On September 8, 2013, at 2:54 PM, LVN 4 (Licensed Vocational Nurse) documented, "Resident c/o (complaining of) stomach pain this afternoon, resident has had loose stools x (times) two today and yesterday, will hold Colace (stool softener medication)...refused lunch r/t (related to) stomach pain."A review of Patient 1's Progress Notes dated September 8, 2013, at 2207 (10:07 PM), LVN 3 documented, "Complained of gas pain on abdomen. Had episode of shaking." At 10:26 PM it was documented that Patient 1, "Refused dinner tray, offered snacks, and still refused." During an interview with LVN 3 on September 25, 2013, at 3:05 PM, LVN 3 stated that Patient 1 had refused her dinner and a snack on September 8, 2013. Patient 1 had also complained of abdominal gas pain, refusal of meals and shaking on September 8, 2013, during the PM shift. LVN 3 stated, "No, I did not call the doctor about it." LVN 3 also stated that she should have called the physician when Patient 1 complained of the abdominal pain, refusal of meals and shaking. Further review of the clinical record showed there was no documentation that the physician was notified of Patient 1's change of condition on September 8, 2013. Patient 1 continued to experience the abdominal pain, frequent diarrhea, refusal of meals and shaking throughout day of September 8, 2013. LVN 3 verified the finding during the record review on September 25, 2013. On September 9, 2013, at 1446 (2:46 PM), LVN 4 documented that she reported to MD 1 that Patient 1 had complained of abdominal cramping, and that Patient 1 had loose stools five times in two days. An order was received to hold Colace (a stool softener) and if loose stools continue, then collect stool for C-diff (Clostridium difficile is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon). Further documentation showed at 2:56 PM that Patient 1 had "Refused lunch r/t [related to] stomach pain." During an interview with LVN 4 on September 26, 2013, at 3:10 PM; she stated that on September 8, 2013, she did not notify the physician when Patient 1 was complaining of abdominal pain, diarrhea and refused lunch. She indicated that she just held the Colace medication due to the patient's diarrhea. LVN 4 then stated, on the following day, 24 hours after she identified the change of condition, on September 9, 2013, she notified the physician of Patient 1's change of condition. She also stated that Patient 1 had a significant change of condition on September 8, 2013 and the physician should have been notified then. A review of Patient 1's Progress Notes dated September 10, 2013, at 1557 (3:57 PM), LVN 4 documented, "Refused breakfast." Another review of Patient 1's Progress Notes dated September 10, 2013, at 2252 (10:52 PM), RN 2 (Registered Nurse), documented, "Res. [resident] c/o abd [abdominal] pain and abd distension. Resident c/o [complained of] no Bowel movement for two days." Further review of the clinical record showed there was no documentation that the physician was notified when the patient still continued having abdominal pain and abdominal distension. The DON was not able to show documentation that the registered nurse had called the physician when Patient 1 complained of abdominal pain, abdominal distension and had multiple episodes of diarrhea. September 11, 2013, at 12:35 PM, PT 1 (Physical Therapist), documented, "Patient levels varied due to abdominal pain..." September 12, 2013, at 1441 (2:41 PM), RN 1 documented, "0% meal consumed today." A review of the September 2013 BM (bowel movement) Record for Patient 1, documented that Patient 1 had multiple episodes of diarrhea from September 8, 2013 through September 12, 2013.A record review showed documentation by PT 1, dated September 12, 2013, at 9:35 PM. PT 1 documented, "...During the AM patient (Patient 1) presented as fatigued and tired. Patient reported that her tummy was sore and also her back hurts, reported same to nursing." Further review of the clinical record showed there was no documentation that the physician was made aware of the patient's condition when she was still complaining of abdominal pain and back pain. The DON verified this finding during the record review on September 26, 2013. During an interview with PT 1 on September 25, 2013, at 3:15 PM, she stated that on September 12, 2013, she felt, "That something was not right about Patient 1," and that the occupational therapist had reported to PT 1 that Patient 1, "Did not look good." PT 1 stated that sometime between 9:00 AM and 9:45 AM on September 12, 2013, PT 1 observed that Patient 1 could not lift her head up off her pillow and that Patient 1 stated, "My Tummy is sore." PT 1 then left Patient 1 to attend a stand- up meeting with the Director of Nurses (DON) and licensed staff. PT 1 stated she informed those present that Patient 1 "Did not feel well." PT 1 stated that later during the afternoon of September 12, 2013, PT 1 tried to sit Patient 1 up, but she became nauseous and decided to do exercises in the bed. Later in the PM shift, PT 1 again attempted to ambulate (walk) Patient 1. Patient 1 was able to stand up, but PT 1 stated she had, "Discomfort on her face." Patient 1 then pointed to her left lower abdomen and complained of pain. PT 1 stated that she reported the pain to a nurse, but could not remember which nurse. Review of a policy entitled, Pain Assessment and Management," revised October 2010, notes the following under "General Guidelines,": "...3. Pain management is a multidisciplinary care process that includes the following: a. assessing the potential for pain; b. effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. addressing the underlying cause of the pain; e. Conduct a comprehensive pain assessment...whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain." On this same policy under the heading "Reporting," "...Report the following information to the physician; 3. Prolonged, unrelieved pain despite care plan interventions." Further review of Patient 1's record showed a form entitled, "Nutritional Screening and Assessment," dated September 7, 2013, at 5:49 PM, and signed by the dietician. Documentation showed that, "Resident (Patient 1) current PO (by mouth) intake is less than optimal 25% or less most meals or refused. Resident currently has abdominal pain and that may be interfering with PO intake." A review of Patient 1's meal intake documentation on the CNA meal percentages form showed that Patient 1 refused meals on the following days: September 8, 2013- dinner September 9, 2013-lunch and dinner September 10, 2013-breakfast and dinner September 11, 2013-dinner September 12, 2013-breakfast and lunch. During an interview with LVN 4 and concurrent review of the clinical record on September 26, 2013, at 3:10 PM, she verified that Patient 1 had multiple refusals of meals. She indicated the refusal of meals was related to the abdominal pain and diarrhea and she stated that the doctor should have been notified. A review of the facility policy entitled, "Acute Condition Change - Clinical Protocol," revised December 2012, notes the following under, "Assessment and Recognition,": "...5. Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to the physician: for example, history of present illness." This policy further indicates under, "Cause Identification": "1.The nursing staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms." During an interview with the DON and concurrent clinical record review on September 26, 2013 at 3:30 PM, he stated according to facility policy and procedure, it was expected that the licensed nurse notify the physician immediately when the patient experiences a change of condition. The DON verified that the physician was not notified when Patient 1 had change of condition on September 8, 2013 and there was no follow up calls to the physician after September 9, 2013 when Patient 1 continued to experience abdominal pain, diarrhea/loose stool and had refusal of meals. Despite Patient 1's continued complaints of abdominal pain and frequent loose stools from September 8, 2013 through September 12, 2013, there was no evidence that the facility staff had made a follow up call to the physician after September 9, 2013, knowing the patient continued to experience abdominal pain, diarrhea/loose stool and refusal of meals. The DON verified this finding during the record review on September 26, 2013. A review of Patient 1's Progress Note documented by LVN 3, on September 12, 2013, at 9:00 PM, showed that at 6:00 PM Patient 1 was given a dose of Coumadin (a blood thinner) that was ordered to be held that day. Patient 1 was transferred to the acute care hospital on September 12, 2013 at 11:50 PM, because of the medication error. Review of the acute hospital documentation showed a form entitled, "Admission History and Physical," dated September 13, 2013, at 1:34 PM. Documentation by the physician showed, "Physical Exam": "Abdomen - diffusely tender abd [abdomen] on mild palpation (part of a physical examination in which an object is felt, usually with the hands of a healthcare practitioner, to determine its size, shape, firmness, or location), with distension, with generalized rebound tenderness, and decreased bowel sounds (sound made by the movement of the intestines as they push food through)." It was noted that Patient 1 had an elevated white blood cell count, "white count (WBC-white blood cell) of 13.57 (normal range is 4.80 - 11.80 bil/L (billion per liter),"(an elevated WBC count indicates infection). The principal problems noted were: "Acute Generalized peritonitis, bowel perforation, and Coumadin toxicity (too much blood thinner)." A discussion with family members about Patient 1's current clinical condition and poor prognosis for long term survival, concluded with a decision to place Patient 1 on "comfort care with DNAR/DNI (Do Not Attempt to Resuscitate/Do Not Intubate) orders." An interview was conducted with MD 1 on October 1, 2013, at 8:45 AM. MD 1 stated that she examined Patient 1 upon admission to the facility on September 6, 2013 and performed a History and Physical. Patient 1 did not complain of abdominal pain during the exam. MD 1 stated that she was only called one time by LVN 4, on September 9, 2013, that Resident 1 was complaining of abdominal cramps and diarrhea. Furthermore MD 1 stated that the facility staff should have called her immediately when Patient 1 continued to experience abdominal pain, diarrhea/ loose stool and had refusal of meals. After MD 1 was informed that Patient 1 continued to experience abdominal pain, abdominal distention, loose stools and refusal of meals from September 8 through September 12, 2013, MD 1 stated, "I should have been called immediately. I would have went and seen the patient."A review of the acute hospital discharge documentation conducted on September 30, 2013, showed that Patient 1's principal diagnosis was: acute peritonitis. Secondary diagnoses included abdominal pain, bowel perforation and Coumadin toxicity (toxic blood thinner level). Under the section "Hospital Course," the following was noted: "admitted for progressively worsening abdominal pain and elevated INR (International Normalized Ratio- is a laboratory measurement of how long it takes blood to form a clot). Was found to have generalized peritonitis secondary to bowel perforation and an INR of 13.3. Pt. [patient] was placed on comfort care measures in coordination with palliative care medicine. Pt. subsequently expired (died) at 5:32 AM, on September 14, 2013."The facility staff failed to notify MD 1 when Patient 1 had a significant change in condition that included multiple refusals of meals with the progression of significant abdominal pain, diarrhea/loose stools and shaking episode that had continued after September 9, 2013 when MD 1 had ordered to hold the Colace due to loose stools and abdominal cramping. This failure resulted in a delay in the identification and treatment of Patient 1's condition. It was not until Patient 1 was sent to the acute care hospital because of a medication error that Patient 1's condition was identified. Patient 1 subsequently died at the acute care hospital on September 14, 2013 at 5:32 AM with diagnoses that included acute peritonitis. These violations presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 240000096 |
Plymouth Village |
240012034 |
B |
24-Feb-16 |
V6LZ11 |
10341 |
REGULATION VIOLATION: Title 22 72529(a)(2) Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. The facility failed to protect one out of three sampled patients (Patient A) from theft and loss when the patient's wallet with $120 and two major credit cards, checks, an insurance card and California Identification card were stolen from her purse. This failure resulted in emotional distress for this patient. On October 2, 2014 at 4:20 PM, an unannounced visit was made to the facility to investigate an entity reported incident of a missing wallet. Review of the clinical record for Patient A indicated Patient A was admitted to the facility on August 29, 2014. A review of the patient's inventory of personal belongings did not reflect that a purse, wallet, money or credit cards had been brought with Patient A to the facility at the time of Patient A's admission. During an interview with the facility Social Service Designee (SSD) on October 2, 2014 at 4:25 PM, the SSD was asked about Patient A's missing wallet and money. The SSD stated the patient's family member had taken Patient A's purse home August 31, 2014 had brought it back and given the patient's purse to a licensed nurse [LVN 1] to keep in the medication room while the family member was on vacation. The SSD further stated the purse had been stored in the medication room because the facility did not have a designated safe place for the purse to be maintained. The SSD stated when the family member came back from vacation on September 15, 2014, she retrieved the purse from the licensed nursing staff (LVN 2) and left. The daughter returned fifteen minutes later and informed the licensed nurse that the patient's wallet was missing. The SSD reported there had been other items which belonged to the facility, such as facility IPADs, which had been in the medication room at the same time as the purse, which had also come up missing between September 8, 2014 and September 15, 2014.During a concurrent interview with the SSD and DON, they stated that the missing items were still being investigated but surmised it may have been an employee that stole the wallet, as only employees had access to the medication room and to Patient A's purse.A continued interview with the DON was conducted on October 2, 2014 at 4:50 PM. When asked who had keys to access the medication room, the DON stated that he was not aware of who other than nursing staff had keys to the medication room. A police report was filed for the missing wallet. The DON stated, "The locks should have been changed on everything after every DON changed so only I have a key with a spare in the administrator's office." The DON was not able to identify which staff had keys to the medication room or his office.A tour of the facility was conducted with the DON on October 2, 2014 at 4:50 PM, and the medication room was observed. The medication room was a small room which would allow only one or two people in it at one time. The medication room was located across from the nurses' station. The door to access the medication room contained a lock which required a key to open the door of the room. Once inside, several cabinets also required the same key to unlock them and access their contents.During an interview with Patient A on October 2, 2014 at 4:45 PM, Patient A was asked about her missing wallet. She stated her family member had the facility lock up her purse for her on September 3 or 4, 2014, Patient A's advised that the facility returned the purse to her family member on September 15, 2014, but her wallet and everything in it were missing at the time it was returned. She stated that $120.00 was missing that had been in her wallet, as well as her wallet and her credit cards. Patient A stated transactions had been charged on her credit cards since the incident, but she had been reimbursed for these transactions after her daughter had called and notified the credit card companies. She advised she had not been reimbursed the $120 from the facility, and wallet has not been recovered. Patient A advised she was upset by the incident and stated she was concerned it would happen again. During an interview with the facility Director of Staff Development (DSD) on October 15, 2014 at 3:33 PM, the DSD was asked what the protocol was for performance of an inventory for a patient's items. The DSD stated that on admission to the facility, a certified nurse aide (CNA) would complete an inventory of all items brought with the patient. If there were any other items brought after admission, the families were asked to check them in with staff to be added to the facility inventory list.The DSD further stated that a new protocol had been implemented, instead of items being kept in the medication room; the nurses were to have placed any items of value in the medication carts and were to count the items with a second nurse daily. This procedure had not been followed; however, there was no documented evidence of this protocol provided. When asked about Patient A's missing wallet, the DSD further stated Patient A's purse was not supposed to be in the medication room. The DSD stated the facility still does not know what happened to the patient's wallet and that the facility was continuing their investigation into the theft of Patient A's valuables. The DSD explained that when staff signs an item out to family members they were supposed to inventory it first and then inventory it again when it was signed back in. Patient A's family member had signed out the purse and taken it home after the patient was admitted to the facility. When the family member was going to go on vacation she brought the purse back in case Patient A needed it. The contents were not inventoried by staff when the daughter left the purse with them. The staff failed to follow protocol and did not inventory the contents of the purse when the family left it with the licensed nurse to lock in the medication room or before returning the purse to the daughter. A review of the interview by the SSD with LVN 1 dated September 18, 2015, indicated, "...I checked the purse inside. I did see a black wallet. I put it inside an O2 (oxygen) bag, labeled it with the resident's name. During a review of the interview documented by the SSD and signed by LVN 2 dated September 18, 2015, she had written, "On September 15, 2014, I was asked by the daughter [used name], to give purse back to her. I got it out of the med room, but I made the mistake of not checking inside of the purse. Fifteen minutes later the daughter ran down the hall screaming, stating the wallet was not in her mother's purse, accusing me of stealing the wallet...I overheard daughter state she did not remember who she gave it to..." During an additional interview with the SSD on October 15, 2014 at 4:15 PM, the SSD stated Patient A had not been reimbursed for the missing money or wallet. The SSD stated the patient had not yet asked for reimbursement.During an interview with a licensed vocational nurse (LVN 1) on October 15, 2014 at 4:44 PM, LVN 1 was asked about the policy for valuable items of patients stored at the facility. She stated that the staff would inventory everything with another nurse when it was requested to be stored by the patient. LVN 1 stated that the items were then stored in the medication room and kept locked up. When a patient would ask for their valuables, staff would simply give items to the patient, and the items were not re-inventoried. The patient was trusted with their own items. When the patient returned the item to be stored again, staff would lock the items back in the medication room, without performing any re-inventory of those items. LVN 1 stated the licensed nurses had not been counting valuables entrusted into their care on a daily basis. A review of a report of an investigation conducted by the facility indicated Patient A's family member had discovered that the patient's wallet was missing on September 15, 2014. The report indicated that there had been three transactions attempted on Patient A's major credit card reported by the daughter on September 15, 2014. There was no documentation found to indicate an inventory of the contents of the patient's wallet had occurred when the items were given to LVN for safe keeping on September "3 or 4," 2014.A voice message received from the facility DSD on October 17, 2014, indicated that the patient had requested to have a bill paid in lieu of being reimbursed for the wallet. The bill, totaling $150.00, was paid for Patient A.During a review of the facility policy and procedure entitled, "Personal Property," undated, the policy set forth the following: "5.The residents' personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. 6. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property." The facility policy and procedure entitled, "Safeguards for Cash Resources, Personal Property and Valuables of Residents," undated, indicated the following: "1. Every facility shall account for any cash resources, personal property and valuables entrusted to the care or control of the licensee or facility staff. The policy further indicated that no employee shall make expenditures from residents' resources and the staff "shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, "and that "Records of residents' cash resources and other valuables entrusted to the licensee for safekeeping shall include a copy of the receipt." The facility's failure to adequately safeguard and account for a patient's monies and valuables entrusted to the licensee's care, including the failure to maintain a detailed inventory of those valuables was a violation that had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000094 |
Providence Ontario |
240012268 |
B |
18-May-16 |
B10711 |
8204 |
Regulation Violation: 72527 Patients' Rights (a)Patients have the rights enumerate in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse.The facility violated the above mentioned regulation by failing to protect one sampled patient (Patient A) from verbal abuse by a Certified Nurse's Assistant (CNA 1) who cursed and yelled at Patient A. This had the potential for Patient A to experience emotional distress, and for another patient (Patient B), who witnessed CNA 1?s behavior, to feel ?uncomfortable.?A review of the "Nurses notes" for Patient A, dated October 23, 2014 at 5:00 PM, was completed on October 23, 2014. The following information was documented: "... report about allegation of resident [Patient A] stating that CNA [CNA 1] used inappropriate language to the resident [Patient A] early this morning. When I asked the resident [Patient A] what happened, she stated that," I don't have any problem with the CNA, I know I made a comment that she looks like she was on drugs, and then she came back to me and stated that, ?why are you talking s--t about me.? Asked the resident if she was okay, she stated that she was fine. After talking to the resident, CNA [CNA1] was sent home right away, MD (physician) aware.? A review of the interdisciplinary team (IDT) notes dated October 23, 2014, was completed on October 23, 2014. The following information was documented: "IDT review due to incident that occurred October 23, 2014, this resident (Patient A) had a problem with her CNA (CNA1)1] and reported that her CNA was speaking inappropriately with her. IDT recommendation: CNA [CNA1] was placed on Administrative leave pending further investigation. SOC filed (SOC 341- Report of Suspected Dependent Adult/Elder Abuse form), Police, Ombudsman and DHS (Department of Health Service now called California Department of Public Health ?CDPH) on file.? A review of the "Social Services Notes" dated October 23, 2014, was completed on October 23, 2014. The notes documented the following information: "SSD (Social Service Director) and Activity Director met with this resident?s [Patient A?s] roommate [Patient B], regarding incident that occurred October 23, 2014, with the resident [Patient A] and CNA [CNA1]. When the roommate was interviewed she stated, "My memory is not good, I just remember that when the nurse [CNA 1] came in talking she seemed frazzled, she told us that she was not going to be helping us. I don't really remember what she said, I just... it made me uncomfortable." During an interview conducted with the Director of Nursing (DON) on December 2, 2014 at 11:35 AM, the DON stated, "She (CNA1) was let go, we did not have a written investigation, it was all documented in the nurses notes.? The DON further explained during the interview that the Administration and Director of Staff Development (DSD) had decided to let CNA1 go because of the incident, as well as performance because she was late to work. The DON stated, ?But we ensure that the resident (Patient A) was informed that the particular CNA (CNA 1) will never be assigned to her after the incident. The resident said that she did just not like the attitude of the CNA and appreciated the action done on the situation."A review of the facility's document entitled, "Short Term Problems," the plan of care noted under "Approach/Plan, dated October 23, 2014, the following: ?Encourage resident (Patient A) to report further inappropriate statements. Employee placed under administrative leave until further investigation."During an interview with Patient A on April 7, 2015, at 4:40 PM, Patient A was asked if she remembered this incident that happened on October 23, 2014 between her and CNA 1. Patient A stated, "Yes."Patient A said, "I remember, she could have been a good CNA if she was trained better. I think she was just young and must be very tired because she was doing overtime. I remember talking to my roommate [Patient B] about her that she looks like she's on drugs, but she's not, she got back in the room and said, " nobody talks s__t to me like that, and she was shaking her head while talking, we call that rubber head, she was yelling at me. It scared my roommate. If it's only me I could have not reported, but what if I'm not here? She could be more rude, but it did not bother me, although that was not an excuse. I remember asking for ice after that and she told me, "I won't get it.? She was angry, so when I checked the ice she gave me, I poured the ice and checked first if there was nothing in there, but just like I said I did not want to report, especially if it will cost her job, but I had to for the sake of my roommates."During a review on April 7, 2015 of CNA 1's employee file, the file indicated that she was hired on August 7, 2014. Review of the ?Staff Abuse Training Acknowledgment Form? signed by CNA 1 and dated August 7, 2014, indicated that CNA 1 had received abuse training that covered the following:1. Abuse Training; 2. Inappropriate Conduct; 3. Policy & Procedure regarding resident grievances; 4. "Walk Away" Policy and Procedure; 5. Abuse Training: Staff Confidentiality Rights; 6. Duties of mandated reporter; 7. Policy & Procedures Regarding Prevention, Reporting, and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents. A review of the policy and procedure entitled ?Policy & Procedures Regarding Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents? dated February 2009 indicated; ?Prevention 3. Employee Education (a) Employees will be educated about the Facility?s ?Walk Away? policyduring orientation and annually thereafter, or more often as deemed necessary by the Administrator, the Director of Nurses, the Staff Developer or the Governing Body. This policy provides if an employee is frustrated in a situation with a resident, another employee, or visitor, he/she must walk away from the situation and seek assistance from a supervisor,...unless resident is in immediate danger, in which case employee will call out for immediate help from another employee.?A review on April 7, 2015 of the document entitled, "Change in Relationship Notice," in CNA 1?s employee file revealed the following information: ?date hired: 8/7/14, date of change: 10/27/2014, type of change: ?You were discharged on 10/27/14.? Under the section entitled, ?Comments Regarding Change in Relationship,? the following was listed: ?Failed to follow policy and procedure." A review of the facility's Policy and Procedure entitled, "Policies & Procedures Regarding Prevention, Reporting and Correction of Inappropriate Conduct including Abuse, Neglect and Mistreatment of Residents," dated February 2009 revealed the following language: "This facility recognizes that each resident has the right to be free from abuse (as defined below), neglect? and mistreatment. This facility works to ensure that its residents are not subject to such inappropriate conduct?by any employee? In this regard, the policies of this Facility include the following: II. Definitions: A) Abuse: As used in these policies and procedures, an abuse is defined according to the terms of state and federal law. Abuse includes... verbal abuse (oral, written or gestured language that includes disparaging and derogatory terms to residents or their families or within their hearing range C) Inappropriate Conduct: Inappropriate conduct includes abuse and all other related misconduct."The facility failed to protect Patient A from verbal abuse by CNA 1 who cursed and yelled at Patient A which had the potential for Patient A to experience emotional distress, and for another patient (Patient B), who witnessed CNA 1?s behavior, to feel ?uncomfortable.?This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 240000094 |
Providence Ontario |
240012509 |
B |
15-Aug-16 |
MALF11 |
4912 |
REGULATION VIOLATION: 483.25(h)(2) Accidents: (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility must ensure that- Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure that Patient B was free from injuries when she fell out of bed, when a Certified Nursing Assistant (CNA 2) did not ensure that the side rail used during care was locked in place. This failure resulted in Patient B falling out of bed and sustaining an abrasion to her elbow, bruises to her thigh, and experiencing pain to the right shoulder. Finding: During an interview with Patient B on May 26, 2016 at 3:10 PM, in the patient's room, she stated that she was being changed on May 16, 2016, when she fell out of bed. She stated, "The CNA [CNA 2] was changing me and did not put the side rails up, or was not sure it was all the way up, so when I tried to roll over to my left side, I fell and hit my right shoulder on the floor and had bruises and a left elbow abrasion." During an interview with CNA 2 on May 26, 2016 at 3:45 PM, he stated, "I was changing her [Patient B], I rolled her to the left side, and I didn't double check to see if the rail was locked. She fell on the floor and hit her right shoulder." During an interview with the Registered Nurse Supervisor (RN 1) on May 26, 2016 at 3:55 PM, she stated, "I was passing around in the nurse's station and the charge nurse told me that Patient B fell and that she already notified the doctor." When asked what the process was for providing care to the resident, she stated, "The side rails should be up when cleaning up the resident for safety." During an interview with the Director of Nursing (DON), on May 27, 2016 at 8:30 AM, she stated that the process for follow-up on an unusual occurrence was to notify the doctor right away, do an assessment of the resident and then order a "post-fall assessment." She stated that a post-fall Physical Therapy and Occupational Therapy assessment was ordered the next day on May 27, 2016. During an interview with the Physical Therapist (PT 1) on May 27, 2016 at 9:05 AM, he stated, "The post-fall screen report was not in the chart because it was not done. After an incident report is given to rehabilitation by the staff, and then we initiate a post-fall screen." When asked if the post-fall screen was done, he stated, "I forgot." During a review of the clinical record for Patient B, the "Rehab Status Post Fall Assessment", dated May 26, 2016, indicated that patient's post fall screen was not done until 10 days after the fall incident which occurred on May 16, 2016. During a review of the clinical record for Patient B, the "Admission Record" dated November 5, 2016, indicated that Patient B was admitted to the facility with diagnoses that included Paraplegia (paralysis of the lower part of the body), osteoarthritis (a condition that causes pain and stiffness of the joints), and multiple sclerosis (a disabling nerve condition that affects movement and coordination) During a review of the care plan for Patient B, titled "Falls," dated June 19, 2014, indicated "At risk for fall or injury due to generalized weakness and multiple medications." Interventions in the care plan included, "Side rails up while in bed to aid in bed mobility, repositioning and to define parameters of safety." A review of the "Interdisciplinary Team Progress notes," for Patient B dated May 17, 2016, indicated that, "Resident rolled out of bed when she was being changed and was turned to the side...Resident sustained abrasion to the left elbow and left thigh discoloration...Resident complained of pain to the right shoulder..." During a review of the "Minimum Data Sheet (MDS)," (an assessment tool for resident), dated April 24, 2016, indicated Patient B needed extensive assistance with one person physical assist during personal hygiene. A review of the "SBAR", (a communication to the physician when there was a change of condition), dated May 16, 2016, indicated pain location was "Right shoulder, intensity-sharp." An x-ray was done May 16, 2016, and findings were negative for a fracture (broken bone). The facility policy and procedure titled, "Therapy Policy," dated January 1, 2016, indicated, "Once notified of the post fall in the facility, therapy manager will assign a primary Physical therapist or Occupational therapist to do a status post fall screen...The screen will be done 24-48 hours from the date therapy became aware of the fall." The facility's failure to ensure that the side rail used for Patient B was securely locked in place before staff proceeded with care, resulted in Patient B falling out of bed and injuring her shoulder, elbow and thigh. The facility failure had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000096 |
Plymouth Village |
240012584 |
B |
19-Sep-16 |
1MWE11 |
11285 |
REGULATION VIOLATION: Patient Rights (a)(10) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures, which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. These policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. The facility violated the regulation by failing to: Protect one out of three sampled patients (Patient A) from abuse by licensed vocational nurses (LVN 1 and LVN 2) when Patient A was removed from bed to a wheelchair, and then removed from Patient A's room, but LVN 1 and LVN 2 failed to provide Patient A with access to a restroom upon Patient A's request. LVN 1 and LVN 2 secluded Patient A from other residents in the charting office by having Patient A remain in her wheelchair, despite requesting to return to bed, and LVN 1 verbally abused Patient A for using her call light repeatedly. This failure resulted in psychosocial harm to Patient A, and Patient A urinated in her pants after nursing staff denied Patient A's request to go back to her room and go to bed. A review of the face sheet, which contained patient demographic information, indicated Patient A was an 87-year-old female who was admitted to the facility on October 26, 2014. Patient A had diagnoses which included: dysphagia (difficulty swallowing), hypothyroidism (low thyroid hormone level), hypercholesterolemia (high cholesterol in the blood), macular degeneration of the retina (an incurable eye disease where the retina [part of the eye allow us to focus to see] deteriorates), viral pneumonia (a lung infection by a virus), muscle weakness, generalized pain, history of falls, and traumatic (physical injury) fracture (broken bone) of the hip. Patient A was described in the physician's history and physical as being "alert and oriented, but had fluctuating capacity to participate in making care decisions." During a phone interview with the Director of Nursing (DON), on September 9, 2015 at 2:00 PM, the DON stated, "A licensed vocational nurse (LVN 1) made Patient A sit in a wheelchair at the nursing station because Patient A kept using the call light requesting help to get up." The DON stated, "Patient A is alert, oriented, and sweet, can be needy, can make her needs known, and has occasional incontinence but can request to go to the restroom." The DON advised this incident occurred between 10:00 to 11:30 PM on September 7, 2015. The DON also stated CNA 1 and Patient A had been consistent [in their statements] about events that transpired between Patient A and LVN 1 and LVN 2. During an initial tour of the facility on September 9, 2015 at 4:45 PM, Patient A was observed sitting in a wheelchair in the facility's chapel. Patient A was well groomed. Patient A's room was located on a hallway four doors down from the nurses' station. The nurses' station and the charting room were located on another hallway near the main entrance, adjacent to the Director of Staff Development (DSD) office. A review of a written witness declaration by a certified nursing assistant (CNA 1) dated September 8, 2015, indicated (CNA 1) reported an alleged incident of abuse to the Social Services Designee (SSD) and the Director of Nursing (DON). CNA 1 wrote in a written declaration she witnessed Patient A being, "yelled at and treated badly," by two registry Charge Nurses (LVN 1 and LVN 2). During an interview with Patient A, on September 9, 2015, at 4:45 PM, Patient A stated, "I had used my call light and the nurse did not ask what I needed but put me in my wheelchair. I had to use the restroom and I ended up peeing in my pants. I asked a number of people to take me back to my room to go to bed but no one would." Patient A stated, "They all said they could not take me until the half hour was up and I had to guess [it was] about six people." Patient 1 stated, "I had not been treated this way before and LVN 1, the one who got me up, and then put me back in bed was the more aggressive of the two." During an interview with CNA 2, on September 9, 2015, at 5:05 PM, CNA 2 stated, "I heard Patient A say she was hurting. I went into Patient A's room to see if I could help. LVN 1 was in the room and told me she would take care of it. I checked on her in about fifteen minutes by the nurses' station and I said I could take her back to bed and was told, 'No,' by LVN 1. LVN 1 stated to Patient A, 'You are going to learn today that you can't be on the call light like that today." During an interview with CNA 1, on September 24, 2015, at 8:15 AM, CNA 1 stated, "I observed LVN 1 pushing Patient A really fast down the hallway and Patient A was in her pajamas. LVN 1 parked Patient A right in front of the nurses' station facing us. LVN 1 was talking very loud as she was pushing Patient A stating, 'I am not taking this tonight, I'm not dealing with this.' Patient A stated, 'I don't know what I did.' LVN stated, "You know what you did - don't play stupid with me." Patient A asked to go back to bed and LVN 1 stated, "Oh no, you're staying out here. You just keep hitting your call light." LVN 1's behavior was very threatening. Patient A started crying and LVN 1 put Patient A into the small [charting] office." During an interview with CNA 3, on November 14, 2015 at 4:30 PM, CNA 3 stated, "I was walking by the nurses' station and saw Patient A in the office with two nurses (LVN 1 and LVN 2). And after I walked by the nurses' station, I sat down to chart at the nurses' station, one of the nurse's (LVN 1) pushed out a desk [from the office] and Patient A said she needed help. I asked Patient A what she needed. Patient A said she wanted to go to bed. The Charge Nurse (LVN 1) said not to put her to bed right now. LVN 1 said Patient A kept pushing her call light and LVN 1 got her up out of bed. I wanted to help put Patient A to bed. I told her CNA (CNA 2) that I would help her but her CNA (CNA 2) said, 'No, because she was intimidated by LVN 1." A record review of the nurse's notes, dated September 7, 2015, at 9:17 PM, indicated Patient A was "alert, with forgetfulness. No complaints of pain or discomfort noted at this time. Patient A in bed at this time kept clean and dry and turned every two hours." A record review of the nurses' notes in the electronic health care record on January 13, 2016, indicated there are no nurses notes entered for Patient A after 9:17 PM on September 7, 2015. The next nurses' note entered was on September 8, 2015 at 7:57 AM for medication administration of insulin (medication for diabetes). A record review of the care plan, on January 13, 2016, indicated Patient A had, "High risk for falls related to (r/t) unaware of safety needs, legally blind/history (hx) of fall, gait/balance problems," and listed as a nursing intervention, "Be sure patient's call light is within reach and encourage the patient to use it for assistance as needed. The patient needs prompt response to all requests for assistance." A review of two facility's documents entitled, "Interview Record," dated September 8, 2015, indicated CNA 1 and CNA 2 recorded in two written declarations Patient A stated to LVN 1, "What did I do." LVN 1 stated to Patient A, "You know what you did. Patient A stated, "No, I don't know." LVN 1 said, "Don't play stupid, don't play that game with me," as LVN 1 walked to the office yelling at the same time. The documents also indicate that CNA 2 asked Patient A what was wrong and Patient A stated, "Can I just please go to bed." CNA 2 told Patient A just a minute and then LVN 1 yelled, "Don't take her back!" LVN 1 yelled at Patient A and grabbed the wheelchair pushing Patient A into the [charting] office. Patient A asked again and both Charge Nurses (LVN 1 and LVN 2) told Patient A, "You can go back to bed in twenty minutes." LVN 1 stated to Patient A, "You are up because you continue to push the call light." A review of the facility's document entitled, "Interview Record," dated, September 8, 2015, noted LVN 2 wrote in a written declaration, "We, no [LVN 1] got Patient A up. Patient A had her blanket/everything. [LVN 1] got her up because Patient A's on the light so much." A review of the facility's document entitled, "Interview Record," dated September 8, 2015, indicated Patient B, the roommate to Patient A stated, "I just heard them tell her to shut up." A review of the facility's document entitled, "Nursing Staffing Assignment and Sign-In Sheet," dated September 7, 2015, indicated LVN 1 signed in for a twelve-hour shift from 7:00 PM to 7:00 AM. LVN 1 was assigned to Rooms 34-47. LVN 1 was assigned to Rooms 20-47 from 11:00 PM to 7:30 AM. LVN 2 signed in for a seventeen-hour shift from 7:00 AM to 12:00 PM midnight. LVN 2 was assigned Rooms 20 to 33. A review of the facility's document entitled, "Committee Review," dated September 9, 2015 at 2:22 PM, indicated CNA 1 observed LVN 1 roughly rolled Patient A into the physician's office. CNA 1 observed LVN 1 loudly telling Patient A she had to stay up in wheelchair for twenty minutes because she pushes the call light too much. Patient A began to cry. After twenty to thirty minutes, LVN 1 assisted Patient A to her bed. A review of the facility's policy entitled, "Abuse and Neglect-Clinical Protocol," dated 2005, indicated under 3a, "Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish." A review of the facility's policy entitled, "Reporting Abuse to Facility Management," dated 2005, indicated under 2b, "Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance to describe residents, regardless of their age, ability to comprehend, or disability." In the same policy under 2e, "Mental abuse is defined as but not limited to humiliation, harassment, threats of punishment or withholding or treatment or services." A review of the facility's policy entitled, "Preventing Resident Abuse," dated 2005, indicated under 2i, "Monitoring staff on all shifts to identify inappropriate behaviors toward residents (e.g. using derogatory language, rough handling of residents, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their clothing/beds, etc.)." The facility failed to protect Patient A from abuse by licensed vocational nurses (LVN 1 and LVN 2) when LVN 1 removed Patient A from bed and took Patient A from her room in a wheelchair neglecting Patient A's request to use the restroom. LVN 1 and LVN 2 involuntarily secluded Patient A from other residents in the charting office by having Patient A remain in her wheelchair, despite Patient A's request to return to bed, and LVN 1 verbally abused Patient A. These violation(s) were determined to cause, or under circumstances likely to cause, significant humiliation, indignity, anxiety, or other emotional trauma and has a direct or immediate relationship to patient health, safety, or security. |
| 240000094 |
Providence Ontario |
240012634 |
B |
10-Oct-16 |
BG1211 |
4754 |
REGULATIONS VIOLATION: 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. The facility failed to provide safety precautions to Patient A. On May 19, 2016, Patient A was tired and had requested to be put back to bed. The CNA (certified nursing assistant) left Patient A in the wheelchair unattended. This failure resulted in Patient A to experience a fall on May 19, 2016, sustained a laceration (cut) to her right eyebrow, hematoma on her right side of face and required hospitalization. A review of Patient A's clinical record, reflected Patient A was admitted to the facility on March 9, 2016 with diagnoses, which included dementia (a disease of the brain which causes memory loss) and CVA (cerebral vascular disease - stroke in which blood flow is cut off to the brain causing damage) with left side weakness. A review of the history and physical, completed by the physician on March 12, 2016, indicated Patient A does not have the capacity to understand and make her own decision. A review of the Fall Risk Assessment dated March 10, 2016, indicated Patient A's fall risk score was 17. A score of 14 or more is considered a fall risk. A review of the Minimum Data Set (MDS-a facility comprehensive assessment tool) Functional status (the measure of a person's ability to perform activities of Daily Living (ADL's) independently) dated May 4, 2016, indicated Patient A was assessed to be total dependent (Full staff performance) in transfers, bed mobility, and locomotion (movement). A review of the care plan for "Falls" dated March 10, 2016, documented Patient A required close observation (Always in the line of sight) to minimize potential for falls. A review of the licensed nurse's progress notes and Physician/NP (nurse practitioner)/PA (physician's assistant) Communication for Changes in Condition, dated May 19, 2016 at 1:26 PM, reflected the following documentation, "Resident found on the floor on R (right) side, laceration to R (right) eye brow, alert, c/o (complain of ) pain to R (right) side of head." Patient A was transferred to the hospital at 1:30 PM for laceration to the R (right) eye brow. An interview with a Certified Nursing Assistant (CNA 1) on June 2, 2016 at 2:45 PM, she stated she was the CNA who assisted Patient A on May 19, 2016. CNA 1 stated Patient A was left alone outside by the beauty shop for approximately 20 minutes. Patient A was yelling and slipping off the wheelchair. Patient A was tired and requested to go to her room and be put back in bed. Patient A needs total assistance in transfers. CNA 1 stated she brought Patient A back to her room and left Patient A in a wheelchair unattended outside of her room. CNA 1 stated she did not put Patient A back to bed. CNA 1 stated, "I should have not left the resident by herself." Patient A was unable for interview during the investigation. During an interview with the Registered Nurse (RN 1) on June 2, 2016 at 4:45 PM, RN 1 stated she was working on the floor at the time of the incident when Patient A fell on May 19, 2016. She stated she called the doctor but decided to call 911 because of the size of the hematoma (bruise). RN 1 stated Patient A fell asleep in the w/c (wheelchair). RN 1 stated the resident (Patient A) should have been put to bed. A review of the facility's Interdisciplinary Team Progress Notes dated May 20, 2016, documented Patient A claimed that she was falling asleep prior to the incident." An interview with the Director of Nurses (DON) on June 2, 2016 at 5:25 PM, the DON verified Patient A had a high fall risk score of 17. She confirmed Patient A was at a high risk for falls. DON stated CNA 1 should have not left Patient A unattended. CNA 1 should have put the resident to bed right away especially when Patient A was tired and requesting to go to bed. A review of the facility policy and procedure titled, "Safety and Supervision of Resident" dated December 2007, indicated, "Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities." The facility failed to provide safety precautions to Patient A. On May 19, 2016, Patient A was tired and had requested to be put back to bed. The CNA (certified nursing assistant) left Patient A in the wheelchair unattended. This failure resulted in Patient A to experience a fall on May 19, 2016, sustained a laceration to her right eyebrow, hematoma on her right side of face and required hospitalization. These violations had a direct relationship to the health, safety or security of the patients. |
| 240000094 |
Providence Ontario |
240012656 |
A |
18-Oct-16 |
MALF11 |
5959 |
REGULATION VIOLATION Title 22, Chapter 3, Article 3, Section 72311?. Nursing Services-General
Licensed nursing personnel shall ensure that patients are served the diets as ordered by the attending licensed healthcare practitioner acting within the scope of his or her professional licensure.
The facility failed to have a system in place to identify residents who did not have an identification band and failed to ensure that physician orders for diets were followed. Patient A, who had a physician?s order to receive, "Nothing by mouth (NPO)," received and was fed a pureed (pudding consistency) diet, and developed aspiration (inhaling food or fluids into the lungs) pneumonia (a lung inflammation caused by foreign matter such as food entering the lungs).
During an unannounced visit, a recertification survey was conducted on May 23, 2016 through May 27, 2016.
During a record review of Patient A?s ?Admission Record,? the documents indicated Patient A was a XXXXXXXX year old male, admitted to the facility on XXXXXXXX 2016, with diagnoses to include: pneumonitis (inflammation of the lung tissue) and (difficulty swallowing. A review of Patient A?s physician?s orders, dated March 18, 2016, indicated the following: ?NPO (nothing by mouth) status.? Patient A?s ?Physician?s Order,? dated April 9, 2016, indicated Patient A had a gastrostomy tube (a feeding tube in the stomach used to provide nutrition to patients who cannot obtain nutrition by mouth, and are unable to swallow safely) feeding for Glucerna (a brand of formula for tube feeding).
A review of Patient A?s clinical record included an initial ?Speech Therapist (ST) Evaluation,? dated March19, 2016, which indicated the patient had, ??75%-99% impairment; primary non-oral nutrition: high risk of aspiration, requires supervision with oral intake due to aspiration risk and significant weight loss; trial oral intake via therapeutic feedings with SLP (Speech- language practitioner) only.? Under the section for goals dated March 19, 2016, the ST documented, The patient safely swallows ¬ tsp honey thick liquids using compensatory strategies from trained staff or care givers given verbal, tactile (touch) and visual instruction/cues). A ST evaluation dated April 8, 2016, indicated the goal was not met and recommended Patient A was to continue with NPO status due to aspiration risk.
During an observation on May 23, 2016 at 8:40 AM, Patient A was in his room with a meal tray at the bedside. Patient A did not have a name plate on his door or a wristband to identify him. The meal tray at his bedside had a meal tray card with Patient B?s name. Patient A was observed with a gastrostomy tube and a bottle of Glucerna (a brand of formula used for gastrostomy tube feeding) hung at his bedside. The bottle had a label with Patient C?s name on it.
During an interview on May 23, 2016, at 9:00 AM, with a Certified Nursing Assistant (CNA 1) she stated, ?I don?t usually work this hall so, I don?t know his name. I look at the name plate on the door. If it?s not there, I look at the wristband. Since he (Patient A) doesn?t have either one, I need to talk to the charge nurse. I don?t know how to identify him.?
A review of the facility policy entitled, ?Resident Identification,? undated, indicated the following: ?Upon admission, all residents will have a hospital identification bracelet made and applied to their wrists."
During an interview on May 23, at 9:00 AM, with a Licensed Vocational Nurse (LVN 1) when shown that the name on the tube feeding bottle did not match with Patient A?s name, she stated, ?He [used the name of Patient A] is getting the appropriate food, but it is not his (Patient A?s)name on it. [Used the name of Patient C] has his personal supply and it?s sent out weekly. I can?t speak for who hung it, but we have an ample supply of the formula for [used the name of Patient A] from our feeding cupboard. The tray belongs to [used the name of Patient B]. I don?t know why the tray is here. [Patient A] is on tube feeding.?
During an observation on May 24, 2016 at 8:20 AM, CNA 2 was feeding Patient A a food tray containing a pureed diet of apple juice, pureed donut and pureed egg.
In a concurrent interview with CNA 2, she stated, "I set him up and asked if he was hungry and began to feed him. Then I left to go get some pepper. His (Patient A?s) roommate told me he didn't think he was supposed to be fed. I went to go check to see if he should eat. I checked with LVN 2 who told me he was NPO, so I removed the tray. He ate about three bites of the donut, 1 bite of the egg and drank half of the apple juice. I didn't know he was NPO."
During an interview on May 24, 2016 at 8:45 AM, with LVN 2, she said, "CNA 2 approached me about Patient A [and asked] if he is supposed to get a tray. I checked the MAR (Medication Administration Record) and the diet list and he is NPO. I even checked with LVN 3 and she double checked the MAR and said he was NPO.?
A record review of a chest x-ray dated May 24, 2016, taken after Patient A was fed a pureed diet, indicated: Resident A had, ?patchy basilar infiltrates (fluid in the air spaces in the bottom of the lung) felt secondary to pneumonia.?
A ?Speech Therapy? bedside swallow evaluation, dated May 24, 2016, indicated Patient A?s ?Swallowing status is inadequate for oral intake?swallowing, coughing-occasionally occurred.?
The facility?s failure to follow the physician?s order for NPO status for Patient A when a CNA fed him a meal tray after he was identified on admission, and when assessed by the Speech Therapist, as being at high risk for aspiration, presented either (1) an imminent danger that death or serious harm to the patients or residents of the long term care health facility would result therefrom, or (2)substantial probability that death or serious physical harm to patients or residents of the long term care facility would result therefrom. |
| 240000059 |
Providence Del Rosa Villa |
240013175 |
B |
3-May-17 |
F78I11 |
6513 |
REGULATION VIOLATION:
72527(a)(10) 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:
(10) To be free from mental and physical abuse.
FINDINGS:
The facility failed to ensure Patient 1 was free from physical abuse when a Certified Nursing Assistant (CNA 1) responded to being hit by Patient 1, by hitting Patient 1 on the right hand during patient care which had the potential to cause emotional distress to Patient 1.
On February 24, 2017, at 10:00 AM, an unannounced visit was made to the facility to investigate an entity reported incident of possible physical abuse for Patient 1.
A review of Patient 1's face sheet indicated the patient was admitted to the facility on XXXXXXX 2012, with diagnoses which include: muscle weakness, dementia (brain disorder with memory problems, personality changes, and impaired reasoning) in other diseases classified elsewhere with behavioral disturbance, schizophrenia (a disorder with severely impaired thinking, emotions, and behaviors), bipolar disorder (an illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), major depressive disorder (disorder in which feelings of sadness, loss, anger, or frustration interfere with daily life for weeks or longer), and anxiety disorder (feelings of persistent anxiety).
During an interview with the Administrator (ADM), on February 24, 2017, at 10:00 AM, she stated two nursing assistant students went with the Certified Nursing Assistant (CNA 1) to change Patient 1. One student allegedly saw the CNA hit the patient. The other student did not see what had happened. The students went to report the incident to the Director of Staff Development (DSD). The Director of Nursing (DON) and the ADM were then notified. The CNA 1 was asked what had happened and stated Patient 1 was trying to hit CNA 1 and CNA 1 tried to stop the hit and did not use any force. She was removed from patient care immediately.
During an observation on February 24, 2017 at 10:15 AM, Patient 1 was lying in bed. Patient 1 responded to her name but could not answer appropriately to questions. There were no marks observed on top of the patient's right hand.
During a telephone interview with the Nursing Assistant Student (NAS 1), on February 24, 2017, at 11:28 AM, she stated CNA 1, NAS 2, and herself were changing Patient 1's underwear in her room. The NAS 1 further stated Patient 1 was calling CNA 1 names and hit CNA 1. She then witnessed CNA 1 hit the patient on top of her right hand.
During a telephone interview on March 9, 2017, at 12:52 PM, NAS 2 stated she did not see CNA 1 hit Patient 1. She witnessed Patient 1 hit CNA 1. She bent down to pick up a black bag, she heard a second "popping noise", and when she got back up, CNA 1 told her and NAS 1 "You are not supposed to do that," but NAS 2 did not know what CNA 1 meant.
During an interview with the DSD, on February 24, 2017, at 11:00 AM, she stated NAS 1 witnessed CNA 1 hit the patient on top of the right hand. She further stated the last in-service CNA 1 received regarding abuse training was at the end of October 2016, when CNA 1 was hired. She further stated almost every day she educated staff about how to handle patient behaviors and actions to take during abuse re-training.
During an interview with the DON, on March 9, 2017, at 10:20 AM, when asked about the facility's "Walk-Away" policy, she stated it is a policy where if the patient is acting up, having an inappropriate behavior, or a CNA cannot handle the patient's behavior, the staff can walk away from the situation. The staff should inform a change nurse and not just leave the patient alone.
During an interview with the ADM, on March 9, 2017, at 10:30 AM, she stated after her investigation that she could not determine for certain if CNA 1 hit the patient, or it was a tap, or it was a "reflex" on Patient 1's right hand. She further stated after talking to CNA 1, CNA 1 did not decide to use the "Walk Away" policy.
A review of the facility's investigative [untitled] document dated February 15, 2017, provided by the DSD, reflected that the DSD conducted an interview with CNA 1, which indicated, "[Name of CNA 1] stated that yes patient did hit her and that she attempted to stop the hit. 'I did not use any force.'"
During further review of the facility's investigation note, a signed statement from NAS 1 indicated, "...I saw CNA [1] slap patient (Patient 1) back on the top of right hand."
A review of the signed statement from NAS 1, on February 15, 2017, indicated that CNA 1 told NAS 1 and NAS 2 "Ya'll [You all] don't do that, but she's one of the troubled one's that gives us a hard time."
During a telephone interview with NAS 1, on March 23, 2017, at 4:02 PM, she stated when CNA 1 made the comment that they should not do "that," CNA 1 was referring to hitting the patient. NAS 1 further stated the patient was still agitated after being hit, but had calmed down before they left the patient's room.
The facility policy and procedure titled, "Walk-Away" Policy and Procedures, undated, indicated, "...any staff member who becomes frustrated when assisting a patient, visitor or other staff members must walk away from the situation, absent an emergency, and request assistance so as to prevent a patient from being subject to inappropriate conduct which includes, but is not limited to...physical abuse..."
The facility policy and procedure titled, "Abuse Prevention", dated December 31, 2015, indicated, "Policy: Each patient has the right to be free from verbal, sexual, physical, and mental abuse ...Patients must not be subjected to abuse by anyone, included, but not limited to, facility staff, other patients..."
Based on the information obtained, the facility failed to ensure the patient's right to be free from abuse, which caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients.
The violation was determined to cause or under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to the patient. |
| 250000092 |
PALM SPRINGS HEALTHCARE & REHABILITATION CENTER |
250009589 |
B |
16-Nov-12 |
4KDK11 |
5435 |
W&I 15610.30 (a) "Financial Abuse" of an elderly or dependent adult occurs when a person or entity does any of the following: (1) Takes, secretes, appropriates, or retains real or personal property of an elderly or dependent adult to a wrongful use or with intent to defraud, or both.The facility failed to ensure facility staff did not take a signed, blank personal check written by Patient A, whereby staff attempted to cash the check. An unannounced visit was made to the facility on June 30, 2008, at 4 p.m., for the purpose of investigating a complaint. On June 30, 2008, a review of Patient A's record indicated, Patient A, a 93 year old, was readmitted to the facility on May 21, 2008, with diagnosis that included Alzheimer's disease (memory loss) with chronic agitation.The record for Patient A was reviewed on July 29, 2008. Patient A was admitted to the facility on May 21, 2008, with diagnoses that included Alzheimer with chronic agitation. A review of the Minimum Data Set (MDS), an assessment tool, dated June 5, 2008, indicated Patient A had a short-term and long-term memory problem, and had impaired cognitive skills. Patient A was identified as having limited ability to making concrete request, sometimes able to respond adequately to others, had a behavior of repetitive anxious complaints and repetitive physical movements. Patient A was dependent on staff for activities of daily living. Further review of the record indicated there was no documentation indicating an incident regarding Patient A writing a five hundred dollar check to the housekeeper. There was no documented evidence that the facility provided intervention to prevent the incident from reoccurring. There was no care plan written regarding the patient's behavior of writing checks to facility staff. An interview was conducted with the Administrator in Training (AIT) on June 30, 2008, at 4 p.m. The AIT stated CNA 1(Certified Nursing Assistant) had been arrested by the police for attempting to cash a check from Patient A. She stated Patient A gave CNA 1 a signed blank check. She stated CNA 1 wrote an amount of seven hundred dollars on the check. She stated CNA 1 gave the check to her friend, in an attempt to cash the check at the bank. She stated the bank personnel identified the patient's name on the check and knew that the patient required a conservator to sign the checks. The AIT stated the bank personnel called the police and detained the CNA 1 and her friend.On June 30, 2008, at 4:20 p.m., Patient A was interviewed. Patient A stated she wanted CNA 1 to have the check because the facility did not pay CNA 1 enough. Patient A stated the CNA "always did extra stuff for her." During an interview conducted with the AIT on July 29, 2008, at 11:40 a.m., she stated Patient A also wrote a check to a housekeeper for the amount of five hundred dollars, prior to the incident on June 26, 2008. She stated she was not sure of the exact date of the incident. She stated she did not document the incident in the patient's record. She stated there was no investigation or in-service done to inform staff not to accept any checks from the patient. There was no intervention done to prevent the patient from writing additional checks to any facility staff. The AIT further stated the patient's checks were given to the family after the second incident on June 26, 2008. The AIT was unable to explain why Patient A continued to have checks in her possession after the first incident of writing a check to a facility staff.On July 29, 2008, at 12:20 p.m., the Administrative Staff 1 was interviewed. She stated she was unaware regarding the patient writing a five hundred dollar check to the housekeeper. She stated there was no in-service done to the facility staff after the first incident of the patient writing the five hundred dollar check to a housekeeper. In an interview conducted with the AIT on August 6, 2008, at 9:10 a.m., she stated she notified the housekeeping supervisor via phone. She stated the housekeeping supervisor was unable to remember which staff received the five hundred dollar check from the patient. The AIT stated she also talked to the housekeeper and the housekeeper informed her that it was CNA 2 that received the five hundred dollar check from the patient. The AIT stated the incident was not investigated.A review of the facility policy and procedure titled, "Abuse and Neglect Prohibition", documented, "Prevention 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect, or misappropriation of resident property is at risk for occurring." Review of the facility policy titled, "Discipline: Location Non-Supervisory", indicated, "32. Employees may not accept gifts or gratuities from residents/patients, families, or visitors."The facility failed to ensure Patient A was free from financial abuse from CNA 1 who took a blank signed, personal check from Patient A and attempted to cash it. The facility failed to provide interventions after identifying resident's previous behavior of writing personal checks to facility staff. The facility failed to ensure their policy and procedure related to abuse and accepting gifts and gratuity from residents was followed. The violation of this regulation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Patient A. |
| 250000039 |
PREMIER CARE CENTER FOR PALM SPRINGS |
250010514 |
B |
06-Mar-14 |
C5J111 |
8363 |
483.1(b) Abuse F223 The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility failed to ensure Resident 1 a resident was free from verbal and physical abuse while getting assistance from staff with peri-care (changing of brief) on August 22, 2013 from Certified Nursing Assistant 1 (CNA1). A record review was conducted on August 22, 2013. The record indicated Resident 1 was admitted to the facility on February 15, 2013 with a diagnosis of cognitive deficits (decreased thinking capacity) due to cerebral vascular disease (stroke). Resident 1?s MDS (Minimum Data Set- a Documented report of resident status) indicated on June 13, 2013 Resident 1?s cognitive status was 3- severely impaired- never/rarely able to make decisions. Resident 1?s mobility status on the same record indicated upper and lower extremity impairment. Resident 1 depended on staff for completion of his personal care. A review was conducted of a report phoned into the Department by the administrator (ADM) on August 20, 2013, 5:16 p.m. the report indicated, ?(Certified Nursing Assistant) CNA 2 reported that another CNA (CNA 1) physically and verbally abused a resident? CNA 1 has been suspended. The administrator stated, ?The facility?s investigation has indicated the following: CNA 3 [Name Withheld], observed CNA 1 slap the resident?s hand and flick him on the lips, when the resident became combative. He (the ADM) stated CNA 3 reported CNA 1 also called the Patient 1 a derogatory name in Tagalog (Filipino language). The ADM stated the resident understands Tagalog. The ADM stated CNA 3 told CNA 2 about the incident and CNA 2 reported the abuse allegation to facility management staff. The ADM stated CNA 3 did not immediately report the witnessed abuse by CNA 1 to the resident until later on in the investigation?? A review was conducted of a written report sent to the Department on August 26, 2013 at 7:09 a.m. The report indicated, ?At approximately 8 a.m. on Tuesday August 20, 2013, CNA 2 reported an allegation of physical and verbal abuse on a Patient 1, during the night shift by another CNA?CNA 2 stated CNA 3 told her that the alleged abuser, CNA 1 slapped patient 1 on the hand and cursed at him in Tagalog. The curse word allegedly used was ?puntang ina,? which translates to ?your mother is a whore?? CNA 1 stated she was changing the brief of Patient 1, and Patient 1 was being combative...Patient 1 called CNA 1 puntang ina and CNA 1 stated back to him ?my mother is not a ?puta,? and took her index finger, lightly pressed it to his lips, and told him not to speak that way? The report further indicated, ?The facility recognizes that CNA 1 should have handled the situation differently, especially as it relates to her placing her finger near (Patient 1?s face). ..She should have responded without using the same language as (Patient 1) or her finger to quiet him. An interview was conducted with CNA 3 on August 22, 2013; at 10:45 a.m. CNA 3 acknowledged she was assisting with peri-care with CNA 1 when she observed CNA 1 tell (Resident 1) in Tagalog my mother is not a ?Mother F?ker.? She stated, ?CNA 1 put her fingers to his lips to keep him (patient 1) quiet. CNA 3 further stated,? I could see her having a hard time.? CNA 3 stated, (incident happened) ?Between 11 p.m. and 1 a.m.? An interview was conducted on August 22, 2013, at 11:50 a.m. with CNA 1. CNA 1 stated, ?I slapped the hand of the resident (Resident 1) because he twisted my fingers.? She stated, ?He just stared at me when I slapped his hand and (I) told him do not do that to me.? CNA 1 further stated,? I told the nurse [Name withheld] I was burned out a previous day before?almost every day I told him this,? CNA 1 stated, (the incident) ?Happened sometime? around 11:30 p.m.? An interview was conducted with CNA 2 on August 22, 2013, at 2:30 p.m. CNA 2 stated CNA 3 came up to her during her shift and needed to talk with her. She stated, ?She (CNA 3) told me that CNA 1 grabbed two of her fingers to hit Patient 1 in the mouth?she also hit him with the same two fingers on the hand. CNA 3 told me Patient 1 and CNA 1 were cussing at each other?she definitely said they were cussing (saying more than one swear word) and CNA 1 hit him (Resident 1). I asked her (CNA 3) if she was going to report it. She said I don?t know.? CNA 2 further stated,? I asked CNA 3 if this (information) was correct as to what she was reporting to me and then she demonstrated (the action of hitting someone) to me as to how CNA1 was seen hitting Patient 1. CNA 2 stated, ?I told her if she was not going to say something I was going to say something.? CNA 2 stated, (the incident) ?Happened at the beginning of the shift.? An interview was conducted with the night shift supervisor (RN 1) on August 27, 20113, at 12 noon. RN 1 acknowledged she worked the shift the alleged incident occurred. RN 1 stated, ?I asked CNA 2 if she had any proof since she only heard this from CNA 3. I asked her to tell CNA 3 to get me a picture?she has a cell phone or get me a video of the kind of abuse they were talking about? moments later CNA 2 came back to me and shook her head. ? The surveyor asked what type of alleged abuse was described? RN 1 did not answer. RN 1 stated,? I took CNA 2?s answer (shaking her head) as no?that CNA 3 did not see abuse because she did not come up to me.? RN 1 further stated, ?CNA 3 never mentioned a word about any incident that night and early next morning.? RN 1 stated, (the incident) ?happened around 4:45 a.m.? RN 1 stated, ?The incident happened in the B wing and it should have been reported to the B wing charge nurse.? An interview was conducted with the B wing Charge Nurse (CN1) on September 5, 2013, at 11a.m. CN1 stated, ?I work on B and C wing. Patient 1 was within my wing. Anyone on that side could have reported to me and no one mentioned anything." A review of the facility policy and procedure titled, ?Abuse Prohibition Program,? dated, April 2013, indicated, under ?Protection? If the suspected perpetrator is an employee: remove employee immediately from the facility? All staff members (CNA 1, CNA2, CNA 3, RN1 and CN1) acknowledged CNA 1 worked her entire shift of 11 p.m. to 7 a.m. The policy indicated under ?Investigation?A licensed nurse shall immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination should be recorded in the resident?s record. The investigation shall consist of: 1. An interview with the person(s) reporting the incident; 2. An interview with the resident(s); 3. Interview with any witnesses to the incident, including the alleged perpetrator? 4. A review of the resident?s medical record; 5. An interview with staff members? 6. An interview with other residents to whom the accused employee provides care? 7. An interview with staff members having contact with the accused 8. A review of circumstances surrounding the incident.? RN 1 stated, on August 27, 2013, at 12 noon, ?I asked CNA 2 if she had any proof since she only heard this from CNA 3. I asked her to tell CNA 3 to get me a picture?she has a cell phone or get me a video of the kind of abuse they were talking about? moments later CNA 2 came back to me and shook her head.? The surveyor asked what type of alleged abuse was described. RN 1 did not answer. RN 1 stated,? I took CNA 2?s answer (shaking her head) as no?that CNA 3 did not see abuse because she did not come up to me.? (Staff waited till the end of shift to report and investigate the incident of abuse.) The policy further indicated, ?It is the policy of this facility that each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to facility staff?? The facility failed to ensure Resident 1 was free from verbal and physical abuse by CNA 1 on August 22, 2013. The facility failed to implement their abuse policies and procedures by failing to: 1. Immediately remove a staff member from all resident areas accused of verbal and physical abuse. 2. Ensure the immediate safety of the resident and promptly examine the resident for injury. These violations had a direct relationship to the health, safety, or security of residents. |
| 250000091 |
PROVIDENCE ORANGE TREE |
250010528 |
B |
14-Mar-14 |
CH9P11 |
9177 |
72315 - Nursing Services(h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. The facility failed to identify Resident 1's poor eating habits which directly contributed to a continued weight loss, and decline in nutritional status. This failure presented an imminent danger to Patient 1's health status, and was a direct proximate cause of the hospitalization of the resident.An unannounced visit was made to the facility on November 2, 2012, at 9:15 a.m., to initiate an investigation of a complaint. Review of the record indicated Patient 1 was admitted to the facility on March 3, 2012, with diagnoses that included high blood pressure and dementia (a progressive, irreversible decline in mental function). The "Social Services Notes" dated March 5, 2012, indicated Patient 1 "was admitted to ....(facility's name)from home..." The admission Minimum Data Set (MDS- an assessment tool) dated March 14, 2012, indicated Patient 1 was "Independent- no help or staff oversight at any time" to eat. The quarterly MDS dated June 14, 2012, indicated Patient 1 needed "Supervision- oversight, encouragement or cueing" while eating. Review of the form titled "Yearly Weight Chart--2012" indicated Patient 1's admission weight on March 3, 2012, was 153.2 pounds (lbs.). The form titled "Yearly Weight Chart--2012" indicated Patient 1's monthly weights were: March 12, 2012-146 lbs. (loss of 7.2 lbs.) March 19, 2012-150.2 lbs. (gain of 3.8 lbs.) March 20, 2012-146.6 lbs. (loss of 3.6 lbs.) March 24, 2012-149.8 lbs. (gain of 3.2 lbs.) March 26, 2012- 147.8 lbs. (loss of 2 lbs.) This was a total of a 5.4 lb. weight loss or 3.5 % of Patient 1's admission weight, during the month of March 2012. Additional recorded monthly weights indicated the following: April 25, 2012- 150.4 lbs. (gain of 2.6 lbs.) May 23, 2012- 148.6 lbs. (loss of 1.8 lbs.) June 23, 2012-149.8 lbs. (gain of 1.2 lbs.) July 25, 2012-146.4 lbs. (loss of 3.4 lbs.) August 25, 2012-142.4 lbs. (loss of 4 lbs.) September 28,2012-138.0 lbs. (loss of 4.4 lbs.) This was a total of a 15.2 lbs. weight loss in six months or 9.93% of Patient 1's admission weight. Further recorded weights indicated: October 23, 2012-131.8 lbs. (loss of 6.2 lbs.) October 26, 2012-125.2 lbs. (loss of 6.6 lbs.) This was a total of a 28 lbs. weight loss in seven months. Resident 1 had a 16.7% weight loss during the six month period, from April through October 2012. The form titled "Resident Transfer Record" dated October 26, 2012, indicated Resident 1 was transferred to a hospital emergency room. The form indicated "Resident has been losing weight..."On November 2, 2012, the hospital record of Patient 1 was reviewed. Patient 1 was admitted to the hospital on October 26, 2012 with diagnoses that included weight loss and dysphagia (difficulty swallowing). The hospital physician's "History and Physical Report," dated October 26, 2012, indicated, "She was brought by the patient's family since...She has lost weight, about 30 pounds, in the last few months..." The hospital form, completed by the emergency room physician, indicated "Exam...appears malnourished" (a condition resulting from inadequate consumption of foods especially proteins, inadequate intake of essential vitamins, minerals). The form also indicated "Assessment/Plan (Problem List)...Dehydration, Dysphagia, Weight loss...Hypokalemia (low potassium)..." The results of the hospital blood tests for Patient 1, dated October 27, 2012, at 7:05 a.m., indicated Patient 1's pre-albumin level ( a test used to assess nutritional status) was 7.6. The hospital reference range (normal range) was 17.6-36.0.The "American Family Physician Journal," dated April 15, 2002 indicated a pre- albumin of 7.6 (Patient 1's test result) "..Dictates the need for aggressive nutritional support." The hospital physician's progress notes, dated November 2, 2012, indicated that Patient1 had a gastrostomy tube (a tube inserted through the abdomen into the stomach, and used to administer liquid nutrition) placed in the hospital. An interview and concurrent record review was conducted with the facility's Registered Dietitian (RD), on December 11, 2012, at 10:40 a.m. The RD stated she initiated the form titled "Nutrition Approach" on March 3, 2012. The form indicated Patient 1 was a "Risk for unintended weight loss...weigh q (every) month. The form indicated Patient 1's admission weight was 153.2 lbs. The form titled "Yearly Weight Chart-2012" was reviewed with the RD. The RD was asked how she calculated the percentage of Patient 1's weight loss. She stated that she "Usually use the resident's admission weight (153.2 lbs.), but with her I didn't, because I used the 149.8 lb. weight."This weight was recorded on March 24, 2012; twenty-one days after Patient 1 had been admitted.The RD stated it was "Up to me to review weights every month and address the weights in the "Resident Care Conferences" (a meeting attended by staff to discuss resident care), and at the "Weekly Weight Meetings." The RD stated she reviewed the Director of Nurses (DON) weight log book and the form titled "Resident Consumption Log" ( a form used by CNAs (Certified Nursing Assistant) to document how much food a resident eats). The "Resident Care Conferences," dated March 20, 2012, June 19, 2012, and September 18, 2012, were reviewed. The RD was unable to find documentation that Patient 1's weight loss had been addressed. The RD was asked if she had assessed why Patient 1 was having weight loss. She stated, "I don't know. It's not my job (to assess the resident). It's the nurse's job. They would always call me if they need me." The RD stated she did recommend Resident 1 be given a liquid nutritional supplement in March and in October 2012. During an interview with CNA 1 on December 11, 2012, at 9:35 a.m., she stated that she had provided care for Patient 1 one to two days a week since patient 1's admission on March 3, 2012. CNA 1 stated Patient 1 "Was never a good eater, (was) a very picky eater," and ate the "food her family provided." CNA 1 stated Patient 1 refused to drink the "nutrition drinks" the facility provided. During an interview with CNA 2, on December 11, 2012, at 11:10 a.m., she stated that she had provided care for Patient 1 one to two days a week since July 2012. CNA 2 stated Patient 1, "All the time ate a little and slow." CNA 2 stated she "offered snacks, she refused" (them), and "Since I started taking care of her, (she) refused her special drinks." An interview and concurrent record review was conducted with the DON on December 11, 2012, at 12:10 p.m. The DON was asked how a resident's food intake was monitored. She stated it was "All (staff) our jobs" to monitor how much a resident ate. The DON stated nurses assess the residents' nutritional status i.e., intake, weight loss, receiving any nutritional supplements, likes and dislikes of foods, and then use the information to develop a plan of care for the resident. The DON reviewed Patient 1's record and was unable to find documentation that a care plan had been developed, implemented, and/or revised to address Patient 1's observed and documented poor food and nutritional supplement intake, and Patient 1's weight loss for the months of April, May, June, July, August, and September 2012. The DON stated residents were weighed weekly when first admitted and then monthly thereafter as long as their weight was stable. The DON stated if a resident's weight was not stable, they would be weighed more frequently as needed. The DON stated weights would be logged in a book that was brought to the weekly weight meetings for review. The DON stated weights were also logged on the form titled "Yearly Weight Chart" in the residents chart. Patient 1's form titled "Yearly Weight Chart-2012" was reviewed with the DON. Patient 1's documented weights on the form were compared to the weight log book brought to the weekly weight meetings. The DON was unable to locate patient 1's weight of 149.8 used by the RD for weight loss calculation. There was no documentation of the 149.8 lb. weight located in the log book brought to the care conferences. Patient 1's weights were reviewed with the DON. The DON stated "Maybe we should monitor people better if they have a weight loss like that." The facility policy and procedure titled "Policy and Procedure for Weekly Weight Meeting" undated, indicated "1. Identify residents...who are at risk for weight loss secondary to...poor eating habits..." The undated facility document titled "Nutritional Assessment Protocol", indicated "Nursing staff will notify the R.D. of any Resident assessed to be "at risk nutritionally...poor appetite..." Phone call attempts to contact Resident 1's primary physician, in order to discuss the resident's weight loss were made on December 12, December 13, and December 19, 2012. The physician failed to return any of the calls. Therefore, the facility failed to identify Patient 1's poor eating habits which directly contributed to a continued weight loss, and decline in nutritional status.The above violation had a direct relation to Patient 1's health, safety, or security. |
| 250000091 |
PROVIDENCE ORANGE TREE |
250011146 |
B |
03-Dec-14 |
FIQR11 |
10676 |
Code of Federal Regulations ? 483.25 (F309) Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.On November 21, 2013, at 1:30 p.m., an unannounced visit was conducted for a complaint investigation. Subsequent visits were made to the facility. Resident A's record was reviewed. Resident A was, a 91 year old resident, was admitted to the facility on June 1, 2012, with diagnoses that included leukocytosis (white blood count higher than normal), renal insufficiency (kidney problems), anemia (low blood [hemoglobin] count), cardiac arrhythmia (irregular heart rhythm), diabetes, and gastro esophageal reflux disease (stomach reflux). The "Resident Care Plan Conference Review" dated October 15, 2013, indicated, "Resident is in stable condition...Stated Resident/RP (Responsible Party) Goals: 'Yes honey. My care is very good here.'" The "Social Services Notes" dated October 2, 2013, indicated, "Quarterly Note: Res(ident) likes up in electric w/c (wheelchair). Resident is A/O (alert and oriented) x 3 (person, place, and time). With episodes of confusion. But able to make needs and concerns known...Resident attends activity of choice and promenade daily. Resident interacts and socializes well with staff and peers. Overall condition stable..." The Physician Order dated October 27, 2013, at 10:28 a.m., indicated, "As per son request send resident to (acute hospital's name) ER (Emergency Room) for evaluation secondary resident increasing weakness." The "Nurses' Progress Notes" dated October 27, 2013 (Sunday), at 12:30 p.m., indicated, "Resident's son stated resident is getting weak and he will (would) like for the resident to be sent at the hospital for an evaluation. Resident told this RN (Registered Nurse - RN 1), that she feels weak but has no pain. Just generalized weakness. This RN explained to resident's son that resident refused to eat for past 2 days and also she got a flu vaccine few days ago and could be that the reason why she is feeling weak. Resident's son stated that he wants something done now and send resident to hospital..." The Nurses' Progress Notes did not contain documented evidence prior to October 27, 2013, at 12:30 p.m. (October 25 through October 27, 2013), indicating Resident A had increased weakness, and/or change in condition that would require evaluation and/or assessment, and reporting to the physician. The "Food Consumption Log" for October 2013 was reviewed and indicated: "October 24, 2013 - poor intake for breakfast, lunch, and dinner; October 25, 2013 - poor intake for breakfast, lunch, and dinner; October 26, 2013 - poor intake for breakfast, lunch, and dinner; and October 27, 2013 - refused breakfast." On November 21, 2013, at 2:10 p.m., a phone interview was conducted with RN 1. RN 1 stated she recalled, on a Sunday (cannot recall the date), the son came to visit and was upset and complained to the RN that the patient was weak with infection and threw up. RN 1 stated the patient "was fine" and was clean, no emesis. RN stated the patient (Resident A) was alert and oriented x 3 and told her that she was okay. RN 1 called the physician to inform of the son's concerns and ordered to transfer the resident to the acute hospital. RN 1 stated she took the resident's vital signs and that they were "fine." On February 5, 2014, at 2:55 p.m., Resident A (residing in another facility) was interviewed. Resident A stated she recalled being taken to the hospital. The resident stated prior to going to the hospital, she was having some difficulty swallowing, something bothering her lower throat. Resident A stated she gagged "a little", but not vomiting. She stated she had to cough something out in a basin. The resident stated, because of this problem, she was unable to eat, but now felt better and was able to eat. The resident stated she was "practically unconscious...about out of it..." when she was transferred to the hospital. On February 5, 2014, Resident A's record was reviewed. The resident's Emergency Department (ED) record and inpatient records were reviewed. The ED record indicated the resident was triaged on October 27, 2013, at 2:39 p.m., and indicated, "Chief Complaint: generalized weakness..." The Emergency Physician Notes, dated October 27, 2013, at 2:46 p.m., indicated: "HPI (History of Present Illness) Paragraph: Patient with Weakness Generalized for 2 day(s). The Onset is acute. The symptoms are Mild, weak, One Episode, few days per episode(s). Symptoms improved with rest. Additional Symptoms or Pertinent History also involve decreased ambulation...Patient states exacerbating Factors that occur are movement..." ...Assessment / Plan (Problem List)...Weakness, Pneumonia, Urinary Tract Infection, elevated troponin (a cardiac enzyme)..." The History and Physical dictated October 27, 2013, at 5:33 p.m., indicated: "...The patient states her symptoms started almost a week ago. At baseline, she is able to transfer herself independently from her bed to the bedside commode, as well as into her chair. She does not need help to get back into bed....She states her symptoms of generalized weakness and overall sleepiness started about a week ago and have progressed ever since... The "Discharge Summary" dated November 6, 2013, indicated, "Final Diagnoses: Sepsis Secondary to Urinary Tract Infection and suspected aspiration pneumonia, candida esophagitis (an infection of the esophagus), anemia (low blood [hemoglobin] level)..." On February 20, 2014, at 2:20 p.m., Certified Nursing Assistant (CNA) 1, who was assigned to the resident on October 27, 2013, 6:30 a.m. to 3 p.m. shift, was interviewed. CNA 1 recalled Resident A was transferred to the hospital. CNA 1 stated the resident usually got up and ate, but that day, she did not want to get up. CNA 1 stated the resident usually was up in her electric wheelchair, and was able to go to the toilet herself. CNA stated, "She's usually the first one to line up for Promenade (an exercise activity offered by the facility)." CNA 1 stated she did not go that day. CNA 1 stated the resident "seemed confused." CNA 1 stated the resident was able to transfer herself from the wheelchair to the toilet, just needing assistance pulling her pants up, but was not able to that day. On February 20, 2014, at 2:30 p.m., CNA 2, who was assigned to the resident on October 2, 2013, 6:30 a.m. to 3 p.m. shift, was interviewed. CNA 2 stated Resident A was able to transfer independently herself from chair to the toilet, able to do things on her own, but would need assistance pulling her pants up. CNA 2 stated, a few days prior to being sent out to the hospital (unable to recall how many days), the resident appeared weaker than usual. CNA 2 stated the resident was weak, "like she's tired." The CNA stated the resident was still able to go to the bathroom (toilet), but required more assistance. On February 20, 2014, at 3:10 p.m., Licensed Vocational Nurse (LVN 1), who was assigned to Resident A on October 25 and 26, 2013, 3 to 11 p.m. shift, was interviewed. LVN 1 could not recall Resident A having a change in condition. LVN 1 reviewed Resident A's record and stated, if the resident had a change in condition, he would have documented it in the resident's record. LVN was unable to find documented evidence the resident's condition changed on October 25 and 26, 2013, during his shift. On February 21, 2014, at 2 p.m., LVN 2, who was assigned to Resident A on October 25, 2013, 5:30 a.m. to 2 p.m., was interviewed. LVN 2 stated the resident usually was up in her electric wheelchair during the daytime, always in "Promenade". She stated she had a Nurses' Note entry on October 25, 2013, at 3:30 p.m., informing the Director of Nursing (DON) that the resident was not eating well. LVN 2 stated the resident did not want to get up that day and appeared "more weak." LVN 2 did not notify the physician of the resident's condition.On February 21, 2014, at 2:15 p.m., CNA 3, who was assigned to Resident A on October 25, 2013, 6 a.m. to 3 p.m. shift, was interviewed. CNA 3 recalled being assigned to Resident A on her last day to work that week. CNA 3 stated, "She (Resident A) was really just tired...Didn't want to get up...Didn't want to get her coffee..." CNA 3 stated the resident was usually up in her wheelchair around 6:30 a.m. CNA 3 stated the resident usually was up in her electric wheelchair and wheeled herself around the facility. On February 21, 2014, at 3 p.m., CNA 4, who was assigned to Resident A on October 25, 2013, 3 to 11 p.m. shift, was interviewed. CNA 4 stated Resident A usually needed one person stand-by assist with transfers to the toilet. CNA 4 stated the resident would hold on to the grab bar and transfer herself. The CNA stated the resident was usually up in her electric wheelchair, but in her shift, would have the electric wheelchair charged. CNA 4 stated she recalled the resident was "really tired" during the last few days she was in the facility. She stated the resident's condition would require to be reported to the charge nurse. CNA 4 could not recall if she reported the change in the resident's condition to the charge nurse. On February 21, 2014, at 3:20 p.m., an interview was conducted with the DON. Discussed with the DON that several staff members indicated they observed Resident A's increased weakness and "feeling tired." The DON stated this was considered a change in condition and needed to be assessed and/or evaluated by the licensed nurse, then reported to the physician. The facility's policy titled, "Change of Conditions and Reporting Changes in Condition" was requested and provided by the DON. The DON stated the policies were last reviewed on January 2014. The policy indicated, "...Assess the resident's condition: limited movement...notify the Attending Physician promptly...Follow up nursing assessment and monitoring until the condition has stabilized or at least 72 hours.... ...What is a change of condition? Any sudden or marked change in...Appetite (refusing meals, decreased appetite)...Movement (limited...)...Change in Level of Functioning..." The facility failed to identify Resident A's change in condition; and conduct an assessment to evaluate the need for treatment and/or service to improve or maintain the resident's well-being. This failure resulted in the delay in treatment of potential acute conditions. This violation had direct or immediate relationship to the health, safety, or security of patients. CA00380758 - Orange Tree Nursing Center |
| 250000110 |
PALM GROVE HEALTHCARE |
250011511 |
B |
30-Jun-15 |
EJU611 |
6759 |
42 CFR 483.13(c) ?Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility?s identification of residents, whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis.?Misappropriation of resident property? means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident?s belongings or money without the resident?s consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation regarding resident financial abuse.Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse.The facility failed to ensure for Resident C: 1. The safe keeping and security of the resident?s trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident?s trust funds, affecting Resident C. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents? funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM ?admitted to ?padding? the paychecks? of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to ?mismanaging? resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the resident's trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM?s employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled ?Abuse Prevention? in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents? family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility?s investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator?s (ADM 2?s) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM?s work.The following discrepancies were found for Resident C:According to the facility?s ?Summary of SOC? ledger, Resident C did not have a share of cost (SOC), from April 2012 to August 2012, however a total of $6,173.00, was withdrawn from the resident?s trust account and the ?Resident Trust Withdrawal Report? indicated the amount had been used towards a SOC.An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, ?They (facility management) really trusted her? some of the checks were not legitimate? or fraud? or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later.? AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents? money.The facility policy and procedure titled, ?POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND,? indicated the following: ??3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator?c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings? Under ?DISBURSEMENTS?, the policy indicated: ??b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported? 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident?s signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents.? The policy further indicated under:?RESIDENTS MONEYS OR VALUABLES:? 2. Should be adequately safeguarded and accurately accounted for anddocumented? 4. Upon discharge should be surrendered in exchange for a signed receipt? 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health.?During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM?s work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility?s failure to safeguard the resident?s trust fund accounts and prevent financial abuse, had a direct or immediate relationship to the resident?s health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011512 |
B |
30-Jun-15 |
EJU611 |
6862 |
42 CFR 483.13(c) ?Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility?s identification of residents, whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis.?Misappropriation of resident property? means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident?s belongings or money without the resident?s consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation regarding resident financial abuse.Based on interview and facility record review, the facility failed to ensure three residents were free from financial abuse.The facility failed to ensure for Residents G, H, and N: 1. The safe keeping and security of the resident?s trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident?s trust funds, affecting Residents G, H, and N. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents? funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM ?admitted to ?padding? the paychecks? of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to ?mismanaging? resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM?s employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled ?Abuse Prevention? in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents? family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility?s investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator?s (ADM 2?s) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM?s work.Review of the residents? Detail Inquiry revealed: For Resident G ? No receipts for ?cash for shopping? totaling $150.00 withdrawn from resident?s trust fund on May 15, 2012. For Resident H - Additional SOC was withdrawn totaling $ 413.00 from resident?s trust fund. The resident?s SOC had already been paid. For Resident N ? A withdrawal totaling $87.79 for ?personal items? without receipts was withdrawn from resident?s trust fund.An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, ?They (facility management) really trusted her? some of the checks were not legitimate? or fraud? or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later.? AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents? money.The facility policy and procedure titled, ?POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ??3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator?c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings? Under ?DISBURSEMENTS?, the policy indicated: ??b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported? 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident?s signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents.? The policy further indicated under:?RESIDENTS MONEYS OR VALUABLES:? 2. Should be adequately safeguarded and accurately accounted for anddocumented? 4. Upon discharge should be surrendered in exchange for a signed receipt? 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health.?During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM?s work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility?s failure to safeguard the residents? trust fund accounts and prevent financial abuse had a direct or immediate relationship to the residents? health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011513 |
B |
30-Jun-15 |
EJU611 |
7022 |
42 CFR 483.13(c) ?Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility?s identification of residents, whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis.?Misappropriation of resident property? means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident?s belongings or money without the resident?s consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation regarding resident financial abuse.Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse.The facility failed to ensure for Resident K: 1. The safe keeping and security of the resident?s trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident?s trust funds, affecting Resident K. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents? funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM ?admitted to ?padding? the paychecks? of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to ?mismanaging? resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM?s employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled ?abuse prevention? in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents? family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility?s investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator?s (ADM 2?s) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM?s work.The following discrepancies were found for Resident K:Review of the Detail Inquiry of Resident K?s trust account, revealed Resident K had additional SOC withdrawn from the resident?s trust fund totaling $5061.00 for 2012, and an additional $267.00 for 2013. The withdrawals indicated the amount was used for SOC, however the resident?s actual SOC had also been withdrawn.On July 27, 2013, a withdrawal of $275.00 was noted as ?Personal Items?. There were no receipts or descriptions stating what personal items were purchased. This combined total of $5603.00, was withdrawn from the resident?s funds and unaccounted for. An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, ?They (facility management) really trusted her? some of the checks were not legitimate? or fraud? or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later.? AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents? money.The facility policy and procedure titled, ?POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ??3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator?c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings? Under ?DISBURSEMENTS?, the policy indicated: ??b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported? 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident?s signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents.? The policy further indicated under:?RESIDENTS MONEYS OR VALUABLES:? 2. Should be adequately safeguarded and accurately accounted for anddocumented? 4. Upon discharge should be surrendered in exchange for a signed receipt? 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health.?During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM?s work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility?s failure to safeguard the resident?s trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident?s health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011514 |
B |
30-Jun-15 |
EJU611 |
6804 |
42 CFR 483.13(c) ?Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility?s identification of residents, whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis.?Misappropriation of resident property? means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident?s belongings or money without the resident?s consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation resident financial abuse.Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse.The facility failed to ensure for Resident O: 1. The safe keeping and security of the resident?s trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident?s trust funds, affecting Resident O. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents? funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM ?admitted to ?padding? the paychecks? of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to ?mismanaging? resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM?s employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled ?abuse prevention? in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents? family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility?s investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator?s (ADM 2?s) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM?s work.The following discrepancies were found for Resident O:Resident O ? Had no SOC, but a total of $3,498.00, was withdrawn from the resident?s trust fund and indicated the amount had been used towards a SOC.On May 6, 2013, a withdrawal in the amount of $2102.00, was noted as Share of Cost. Two additional withdrawals, titled Share of Cost, were made on June 6, 2013, and July 4, 2013, in the amounts of $698.00 each.An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, ?They (facility management) really trusted her? some of the checks were not legitimate? or fraud? or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later.? AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents? money.The facility policy and procedure titled, ?POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ??3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator?c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings? Under ?DISBURSEMENTS?, the policy indicated: ??b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported? 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident?s signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents.? The policy further indicated under:?RESIDENTS MONEYS OR VALUABLES:? 2. Should be adequately safeguarded and accurately accounted for anddocumented? 4. Upon discharge should be surrendered in exchange for a signed receipt? 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health.?During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM?s work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility?s failure to safeguard the resident?s trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident?s health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011515 |
B |
30-Jun-15 |
EJU611 |
6558 |
42 CFR 483.13(c) ?Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility?s identification of residents, whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis.?Misappropriation of resident property? means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident?s belongings or money without the resident?s consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation regarding resident financial abuse.Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse.The facility failed to ensure for Resident S: 1. The safe keeping and security of the resident?s trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident?s trust funds, affecting Resident S. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents? funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM ?admitted to ?padding? the paychecks? of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to ?mismanaging? resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM?s employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled ?abuse prevention? in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents? family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility?s investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator?s (ADM 2?s) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM?s work.The following discrepancies were found for Resident S:In 2012, Resident S had an additional SOC withdrawn from the resident?s trust fund totaling $2,051.00. An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, ?They (facility management) really trusted her? some of the checks were not legitimate? or fraud? or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later.? AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents? money.The facility policy and procedure titled, ?POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ??3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator?c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings? Under ?DISBURSEMENTS?, the policy indicated: ??b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported? 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident?s signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents.? The policy further indicated under:?RESIDENTS MONEYS OR VALUABLES:? 2. Should be adequately safeguarded and accurately accounted for anddocumented? 4. Upon discharge should be surrendered in exchange for a signed receipt? 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health.?During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM?s work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility?s failure to safeguard the resident?s trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident?s health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011516 |
B |
30-Jun-15 |
EJU611 |
6902 |
42 CFR 483.13(c) ?Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility?s identification of residents, whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis.?Misappropriation of resident property? means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident?s belongings or money without the resident?s consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation regarding resident financial abuse.Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse.The facility failed to ensure for Resident W: 1. The safe keeping and security of the resident?s trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident?s trust funds, affecting Resident W. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents? funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM ?admitted to ?padding? the paychecks? of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to ?mismanaging? resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM?s employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled ?abuse prevention? in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents? family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility?s investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator?s (ADM 2?s) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM?s work.The following discrepancies were found for Resident W:Resident W was admitted to the facility on July 6, 2012 and discharged April 2, 2013, with a balance of $2,266.53. The ?Resident Trust Aging? form had Resident W?s name handwritten with $2266.53 written next to it. There was no evidence of a withdrawal from the account in this amount or a check written to the resident or anyone in this amount. There was also no receipt or signature to show that the resident was given any money upon discharge.An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, ?They (facility management) really trusted her? some of the checks were not legitimate? or fraud? or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later.? AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents? money.The facility policy and procedure titled, ?POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ??3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator?c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings? Under ?DISBURSEMENTS?, the policy indicated: ??b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported? 4. BANK RECONCILIATION? a. All purchases properly supported by invoices. Resident?s signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents.? The policy further indicated under:?RESIDENTS MONEYS OR VALUABLES:? 2. Should be adequately safeguarded and accurately accounted for anddocumented? 4. Upon discharge should be surrendered in exchange for a signed receipt? 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health.?During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM?s work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility?s failure to safeguard the resident?s trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident?s health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011529 |
B |
30-Jun-15 |
EJU611 |
6541 |
Class B Citation 42 CFR 483.13 (C) An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation regarding resident financial abuse. Based on interview and facility record review, the facility failed to ensure four residents were free from financial abuse. The facility failed to ensure for Residents A, B, D, and R: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident's trust funds, affecting Residents A, B, D, and R. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents' funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM "admitted to 'padding' the paychecks" of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to "mismanaging" resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM's employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled "Abuse Prevention" in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents' family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility's investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator's (ADM 2's) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM's work.Review of the Detail Inquiry of the Residents' Trust Fund accounts revealed: Resident A - Had no SOC, but a total of $390.00 was withdrawn from the resident's trust fund and indicated the amount had been used towards a SOC. Resident B - Additional SOC was withdrawn from the resident's trust fund for $298.00 and cigarette purchases without receipts, or receipts not coinciding with date of purchase for $263.46, totaling $561.46. Resident D - An additional SOC for $168.00 and a withdrawal of $250.17 for "personal items" without receipt's, totaling $418.17 was withdrawn from the resident's trust fund.Resident R - Additional SOC was withdrawn totaling $607.00 from resident's trust fund.An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, "They (facility management) really trusted her... some of the checks were not legitimate... or fraud... or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later." AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents' money.The facility policy and procedure titled, "POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ..."3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator...c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings... Under "DISBURSEMENTS", the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported... 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident's signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated under:"RESIDENTS MONEYS OR VALUABLES:... 2. Should be adequately safeguarded and accurately accounted for anddocumented... 4. Upon discharge should be surrendered in exchange for a signed receipt... 5. Within Thirty (30) days following death, except coroner case (sic -spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health."During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM's work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility's failure to safeguard the residents' trust fund accounts and prevent financial abuse, had a direct or immediate relationship to the residents' health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011534 |
B |
30-Jun-15 |
EJU611 |
7457 |
Citation Class B 42 CFR 483.13(c) Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. "Misappropriation of resident property" means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation regarding resident financial abuse.Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident F: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident's trust funds, affecting Resident F. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents' funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM "admitted to 'padding' the paychecks" of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to "mismanaging" resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM's employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled "Abuse Prevention" in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents' family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility's investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator's (ADM 2's) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM's work.The following discrepancies were found for Resident F:Resident F had a share of cost of $1003 from November, 2012 through January, 2013.Review of the Detail Inquiry of Resident F's account revealed: On November 7, 2012, a withdrawal titled SOC was made in the amount of $720.00. On November 26, 2012, two withdrawals titled "SOC" were made in the amounts of $720.00 and $323.50. A total of $1763.50 was withdrawn and titled SOC during November 2012, $760.50 over the resident's Share of Cost due for November. On December 5, 2012, Resident F's SOC of $1003.00 was withdrawn in addition to another withdrawal, also titled SOC, in the amount of $650.00, which was over the amount of SOC due for the month of December. In January, 2013, Resident F had an additional $750.00 withdrawn from the resident's trust fund that is unaccounted for. A total of $2160.50, was withdrawn from the resident's account, from November 2012, to January, 2013, and labeled as Share of Cost, even though the SOC had already been withdrawn. An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, "They (facility management) really trusted her... some of the checks were not legitimate... or fraud... or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later." AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents' money.The facility policy and procedure titled, "POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ..."3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator...c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings... Under "DISBURSEMENTS", the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported... 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident's signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated under:"RESIDENTS MONEYS OR VALUABLES:... 2. Should be adequately safeguarded and accurately accounted for anddocumented... 4. Upon discharge should be surrendered in exchange for a signed receipt... 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health."During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM's work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility's failure to safeguard the resident's trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident's health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011536 |
B |
30-Jun-15 |
EJU611 |
6958 |
Citation Class B 42 CFR 483.13(c) Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. "Misappropriation of resident property" means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation resident financial abuse. The facility failed to ensure for Resident J: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident's trust funds, affecting Resident J. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents' funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM "admitted to 'padding' the paychecks" of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to "mismanaging" resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM's employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled "Abuse Prevention" in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents' family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility's investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator's (ADM 2's) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM's work.Review of the Medi-Cal Eligibility report, December 18, 2013, revealed that Resident J had no SOC from her admission in April 2012 through October 2013. Review of the Detail Inquiry of Resident J's trust account revealed that from November, 2012, through October, 2013, a total of $9397.00 was withdrawn from the resident's account and titled "SOC." Also, on July 27, 2013, a withdrawal in the amount of $955.00 for "personal items" was withdrawn from resident's trust fund, without any receipts or notation of the items purchased. A total of $10,542.00 was withdrawn from the resident's trust account, without evidence of where the money went. An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, "They (facility management) really trusted her... some of the checks were not legitimate... or fraud... or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later." AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents' money.The facility policy and procedure titled, "POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ..."3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator...c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings... Under "DISBURSEMENTS", the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported... 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident's signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated under:"RESIDENTS MONEYS OR VALUABLES:"... 2. Should be adequately safeguarded and accurately accounted for anddocumented... 4. Upon discharge should be surrendered in exchange for a signed receipt... 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health."During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM's work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility's failure to safeguard the resident's trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident's health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011541 |
B |
30-Jun-15 |
EJU611 |
7111 |
Citation Class B 42 CFR 483.13(c) Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. "Misappropriation of resident property" means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation resident financial abuse.Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident M: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident's trust funds, affecting Resident M. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents' funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM "admitted to 'padding' the paychecks" of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to "mismanaging" resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM's employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled "Abuse Prevention" in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents' family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility's investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator's (ADM 2's) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM's work.The following discrepancies were found for Resident M:On July 16, 2012, an additional $409.00 was withdrawn from the account and labeled as Share of Cost. On August 10, 2012, an additional $413.00 was withdrawn from the account and labeled as Share of Cost. On September 13, 2012, an additional $100.00 was withdrawn from the account and labeled as Share of Cost. During 2013, Resident M had no SOC, but a total of $1,254.28 was withdrawn from the resident's trust fund and indicated the amount had been used towards a SOC. A total of $2176.28 was withdrawn from the resident's account and documented as a share of cost, however the resident's Share of Cost had already been paid. An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, "They (facility management) really trusted her... some of the checks were not legitimate... or fraud... or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later." AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents' money.The facility policy and procedure titled, "POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ..."3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator...c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings... Under "DISBURSEMENTS", the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported... 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident's signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated under:"RESIDENTS MONEYS OR VALUABLES:... 2. Should be adequately safeguarded and accurately accounted for anddocumented... 4. Upon discharge should be surrendered in exchange for a signed receipt... 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health."During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM's work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility's failure to safeguard the resident's trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident's health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011547 |
B |
30-Jun-15 |
EJU611 |
7168 |
42 CFR 483.13(c) -Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis."Misappropriation of resident property" means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation regarding resident financial abuse.Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse.The facility failed to ensure for Resident E: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident's trust funds, affecting Resident E. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents' funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM "admitted to 'padding' the paychecks" of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to "mismanaging" resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM's employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled "Abuse Prevention" in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents' family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-Cal requires a resident to pay for medical goods and services before Medi-Cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility's investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator's (ADM 2's) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM's work.The following discrepancies were found for Resident E: Resident E had a monthly share of cost, ranging from $1229 to $1274, deducted from his account for the year 2012. Additional withdrawals from his trust account were listed as SOC, however the resident's SOC was already paid. Review of the "Detail Inquiry" for Resident E, revealed the following- on May 31, 2012 a withdrawal of $302; on June 29, 2012, a withdrawal of $535; on July 16, 2012, a withdrawal of $435; and on September 13, 2012, a withdrawal of $167.13. All of these withdrawals, totaling $1439.13, were listed as SOC withdrawals from the resident's trust fund.There was no documentation of the resident owing additional SOC, nor any information of where the money actually went.An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, "They (facility management) really trusted her... some of the checks were not legitimate... or fraud... or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later." AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents' money.The facility policy and procedure titled, "POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ..."3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator...c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings... Under "DISBURSEMENTS", the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported... 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident's signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated under:"RESIDENTS MONEYS OR VALUABLES:... 2. Should be adequately safeguarded and accurately accounted for anddocumented... 4. Upon discharge should be surrendered in exchange for a signed receipt... 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health."During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM's work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility's failure to safeguard the resident's trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident's health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011550 |
B |
30-Jun-15 |
EJU611 |
7646 |
Citation Class B 42 CFR 483.13(c) Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. "Misappropriation of resident property" means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation resident financial abuse.Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident Q: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident's trust funds, affecting Resident Q. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents' funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM "admitted to 'padding' the paychecks" of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to "mismanaging" resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM's employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled "Abuse Prevention" in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents' family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility's investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator's (ADM 2's) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM's work.The following discrepancies were found for Resident Q:In 2012, Resident Q - Had additional SOC withdrawn from the resident's trust fund totaling $7733.97.From March 2012 to November 2012, Resident Q's Share of Cost was $10 a month. Review of the "Detail Inquiry" regarding Resident Q's account, revealed the following: On May 7, 2012, an additional SOC withdrawal, in the amount of $1600.00, was documented. On June 25, 2012, an additional SOC withdrawal, in the amount of $632.97, was documented. On June 29, 2012, an additional SOC withdrawal, in the amount of $756.00, was documented. On July 13, 2012, an additional SOC withdrawal, in the amount of $1098.00, was documented. On August 10, 2012, an additional SOC withdrawal, in the amount of $940.00, was documented. On September 10, 2012, an additional SOC withdrawal, in the amount of $1263.00, was documented. On September 13, 2012, an additional SOC withdrawal, in the amount of $402.00, was documented. On October 16, 2012, an additional SOC of $840.00, was documented. In 2013, Resident Q - A total of $202.00 was withdrawn from the resident's trust fund. The withdrawals were listed as "personal items," but there were no receipts for the items purchased.An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, "They (facility management) really trusted her... some of the checks were not legitimate... or fraud... or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later." AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents' money.The facility policy and procedure titled, "POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ..."3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator...c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings... Under "DISBURSEMENTS", the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported... 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident's signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated under:"RESIDENTS MONEYS OR VALUABLES:... 2. Should be adequately safeguarded and accurately accounted for anddocumented... 4. Upon discharge should be surrendered in exchange for a signed receipt... 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health."During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM's work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility's failure to safeguard the resident's trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident's health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011551 |
B |
30-Jun-15 |
EJU611 |
6930 |
42 CFR 483.13(c) -Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis."Misappropriation of resident property" means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation resident financial abuse.Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse.The facility failed to ensure for Resident I: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident's trust funds, affecting Resident I. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents' funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM "admitted to 'padding' the paychecks" of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to "mismanaging" resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM's employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled "Abuse Prevention" in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents' family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility's investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator's (ADM 2's) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM's work.The following discrepancies, in the amount of $1184.00, were found for Resident I:Review of the Detail Inquiry for Resident I's account, revealed a withdrawal dated August 16, 2012, for "personal items," totaling $754.00. Another withdrawal, dated July 27, 2013, for "personal items," totaling $250.00, was also noted. There were no receipts or comments regarding what personal items were purchased. Also, Resident I did not have a Share of Cost, but a total of $180.00 was withdrawn and indicated the amount had been used towards a SOC.An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, "They (facility management) really trusted her... some of the checks were not legitimate... or fraud... or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later." AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents' money.The facility policy and procedure titled, "POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ..."3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator...c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings... Under "DISBURSEMENTS", the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported... 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident's signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated under:"RESIDENTS MONEYS OR VALUABLES:... 2. Should be adequately safeguarded and accurately accounted for and documented... 4. Upon discharge should be surrendered in exchange for a signed receipt... 5. Within Thirty (30) days following death, except coroner case (sic) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health."During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM's work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility's failure to safeguard the resident's trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident's health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011556 |
B |
30-Jun-15 |
EJU611 |
6912 |
42 CFR 483.13(c) -Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis."Misappropriation of resident property" means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation resident financial abuse.Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse.The facility failed to ensure for Resident L: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident's trust funds, affecting Resident L. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents' funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM "admitted to 'padding' the paychecks" of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to "mismanaging" resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM's employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled "Abuse Prevention" in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents' family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility's investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator's (ADM 2's) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM's work.The following discrepancies were found for Resident L:For 2012, the resident had no SOC, but a total of $840.00 was withdrawn from the resident's trust fund and indicated the amount had been used towards a SOC. For 2013, the resident had no SOC, but a total of $1,048.02 was withdrawn from the resident's trust fund and indicated the amount had been used towards a SOC. A total of $1,888.02 was withdrawn from the resident's trust fund and listed as SOC, even though the resident didn't have an SOC. An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, "They (facility management) really trusted her... some of the checks were not legitimate... or fraud... or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later." AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents' money.The facility policy and procedure titled, "POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ..."3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator...c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings... Under "DISBURSEMENTS", the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported... 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident's signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated under:"RESIDENTS MONEYS OR VALUABLES:... 2. Should be adequately safeguarded and accurately accounted for anddocumented... 4. Upon discharge should be surrendered in exchange for a signed receipt... 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health."During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM's work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility's failure to safeguard the resident's trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident's health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011557 |
B |
30-Jun-15 |
EJU611 |
6869 |
42 CFR 483.13(c) -Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis."Misappropriation of resident property" means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation resident financial abuse.Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse.The facility failed to ensure for Resident P : 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident's trust funds, affecting Resident P. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents' funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM "admitted to 'padding' the paychecks" of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to "mismanaging" resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM's employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled "Abuse Prevention" in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents' family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility's investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator's (ADM 2's) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM's work.The following discrepancies were found for Resident P:Resident P - Had no SOC, but a total of $4,665.00 was withdrawn from the resident's trust fund and indicated the amount had been used towards a SOC.Share of Cost withdrawals in the amount of $833.00, were withdrawn on March 5, 2013, April 15, 2013, May 6, 2013, June 6, 2013, and July 4, 2013. An additional withdrawal, labeled Share of Cost, was withdrawn on August 6, 2013, in the amount of $500.00. An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, "They (facility management) really trusted her... some of the checks were not legitimate... or fraud... or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later." AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents' money.The facility policy and procedure titled, "POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ..."3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator...c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings... Under "DISBURSEMENTS", the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported... 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident's signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated under:"RESIDENTS MONEYS OR VALUABLES:... 2. Should be adequately safeguarded and accurately accounted for anddocumented... 4. Upon discharge should be surrendered in exchange for a signed receipt... 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health."During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM's work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility's failure to safeguard the resident's trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident's health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011558 |
B |
30-Jun-15 |
EJU611 |
7226 |
42 CFR 483.13(c) -Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis."Misappropriation of resident property" means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation regarding resident financial abuse. Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse.The facility failed to ensure for Resident T: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident's trust funds, affecting Resident T. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents' funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM "admitted to 'padding' the paychecks" of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to "mismanaging" resident trust funds. ADM 1 stated that he noticed the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM's employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled "Abuse Prevention" in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents' family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility's investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator's (ADM 2's) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM's work.The following discrepancies were found for Resident T:Resident T had a share of cost for July and August, 2012, listed as $944 per month, however Medi-Cal had paid the full amount that was billed, and Resident T did not have to pay. Review of the Detail Inquiry of the resident's funds revealed two withdrawals listed as an SOC withdrawal, one in the amount of $434, on July 16, 2012, and one in the amount $804 on August 10, 2012.Resident T was responsible for a share of cost of $944 in September. On September 10, 2012, a withdrawal of $1060 was listed as SOC, and on September 13, 2012, a withdrawal of $80 was also listed as SOC, ($196 over the resident's SOC). BOM withdrew a total of $1434, between July and September 2012, from Resident T's account, without explanation of where the money went. An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, "They (facility management) really trusted her... some of the checks were not legitimate... or fraud... or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later." AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents' money.The facility policy and procedure titled, "POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ..."3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator...c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings... Under "DISBURSEMENTS", the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported... 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident's signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated under:"RESIDENTS MONEYS OR VALUABLES:... 2. Should be adequately safeguarded and accurately accounted for anddocumented... 4. Upon discharge should be surrendered in exchange for a signed receipt... 5. Within Thirty (30) days following death, except coroner case (sic-spelling is correct) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health."During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM's work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility's failure to safeguard the resident's trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident's health, safety, and security. |
| 250000110 |
PALM GROVE HEALTHCARE |
250011575 |
B |
30-Jun-15 |
EJU611 |
6821 |
Citation Class B 42 CFR 483.13(c) Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. "Misappropriation of resident property" means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 42 CFR 488.301- An unannounced visit was conducted on October 9, 2013, to investigate a complaint allegation resident financial abuse.Based on interview and facility record review, the facility failed to ensure a resident was free from financial abuse. The facility failed to ensure for Resident U: 1. The safe keeping and security of the resident's trust fund account. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate and implement a check and balance protocol to prevent widespread financial abuse of resident's trust funds, affecting Resident U. On October 9, 2013 at 8:55 a.m., an interview was conducted with Administrator (ADM 1). ADM 1 stated that the former Business Office Manager (BOM) was in charge of handling residents' funds from 2008 through August of 2013. The BOM also was able to withdraw monies from resident accounts, with the co-signature of the facility administrator. ADM 1 stated that in August 2013, he noticed the payroll was incorrect and the BOM "admitted to 'padding' the paychecks" of a family member, who also worked in the facility. In October 2013, discrepancies were identified in resident trust funds, and during an interview with BOM, she admitted to "mismanaging" resident trust funds. ADM 1 stated that he noticed that the cosigning signature was not his, but that of the prior administrator (ADM 2). The facility notified the local police department and contacted an auditing firm to review the resident trust funds and confirmed there were discrepancies regarding the residents trust accounts. A State auditing agency conducted an investigation beginning in 2013. The State Auditors identified a discrepancy in excess of $97,000 in resident trust funds from January 1, 2012 through December 31, 2012.A review of the former BOM's employee file revealed she was hired in September 2002. The file indicated the former BOM read and signed policy titled "Abuse Prevention" in 2002, 2007, and 2010. There were no reference checks conducted prior to her employment at the facility. An interview was conducted on October 9, 2013, at 12:45 p.m., with the current facility Account Biller (AB). The AB stated every quarter there was a statement for deposits and withdrawals sent to the residents' family, plus monthly statements related to share of cost (SOC is a monthly amount Medi-cal requires a resident to pay for medical goods and services before Medi-cal begins to pay for care in the facility), and a quarterly statement that showed a history of deposits and withdrawals for each resident account. The AB said that withdrawals needed to be authorized with a staff witness to withdraw monies or purchase items.Review of documentation regarding the facility's investigation, dated October 17, 2013, revealed ADM 1 reviewed a few checks from resident trust accounts that were made out to BOM, with a signature that appeared to be a rubber stamp of the previous Administrator's (ADM 2's) signature. The checks were endorsed on the back by BOM and deposited into a personal account. ADM 1 stated there was no oversight for the BOM's work.The following discrepancies were found for Resident U:Resident U was admitted to the facility on August 30, 2012 and discharged on March 7, 2013. Review of the Share of Cost ledger revealed that she did not have a SOC liability. Review of the Detail Inquiry for Resident U revealed that a total of $5217.00 was withdrawn from the resident's trust fund and indicated the amount had been used towards a SOC. An interview was conducted with the AB on February 20, 2014, at 2:30 p.m. The AB stated, "They (facility management) really trusted her... some of the checks were not legitimate... or fraud... or posted erroneously, the receipts for purchased items should have been posted the same month as the purchase, not a month later." AB stated there was no documentation indicating BOM sent quarterly statements to families because the families would have inquired about the residents' money.The facility policy and procedure titled, "POLICIES AND PROCEDURES HANDLING PATIENT TRUST FUND," indicated the following: ..."3. A custodian shall be designated by the Facility/Administrator to handle petty cash withdraws, withdraws by checks, and to make deposits to the account. All checks will be signed by the custodian and administrator...c) Recordings and postings to the trust fund ledgers should be done daily.d) Postings should be reconciled with the Control account Immediately after postings... Under "DISBURSEMENTS", the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported... 4. BANK RECONCILIATION a. All purchases properly supported by invoices. Resident's signature required to acknowledge receipt of the items purchased/charged. b. Bank balance to reconcile with control/ledger account. c. Individual ledgers to reconcile with Patient Trust Fund control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated under:"RESIDENTS MONEYS OR VALUABLES:... 2. Should be adequately safeguarded and accurately accounted for anddocumented... 4. Upon discharge should be surrendered in exchange for a signed receipt... 5. Within Thirty (30) days following death, except coroner case (sic) are surrendered to the responsible party or executor or administrator in exchange for a signed receipt. 6. Of dead residents without a representative or known heirs, are given to the County Public Administrator and a copy of notice is given to the department (sic) of Health."During an interview with ADM 1 on October 9, 2013, at 8:55 a.m., he stated there was no oversight regarding BOM's work. During an interview conducted with the current Administrator (ADM 3) on July 7, 2014, at 1:30 p.m., ADM 3 stated a form should have been filled out authorizing staff to purchase items for the residents.The facility's failure to safeguard the resident's trust fund accounts and prevent financial abuse had a direct or immediate relationship to the resident's health, safety, and security. |
| 250000072 |
PALM TERRACE CARE CENTER |
250011700 |
B |
03-Sep-15 |
KGNU11 |
5015 |
Class "B" Citation HSC 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. HSC 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report a patient-to-patient altercation, which resulted in two allegations of abuse during one incident between Patients 1 and 2, to the California Department of Public Health (CDPH) immediately, or within 24 hours. On May 19, 2015, at 8 a.m., Patient 1 reported to facility staff an allegation of abuse of Patient 1 by Patient 2. On May 19, 2015, at 8:30 a.m., Patient 2 reported to facility staff an allegation of abuse of Patient 2 by Patient 1. The facility reported the alleged abuse to CDPH on May 21, 2015, at 1:50 p.m. (53 hours and 50 minutes after the facility became aware of the allegations of abuse).On May 19, 2015, at 8 a.m., facility staff heard yelling and observed Patient 1 falling to the floor. Facility staff asked Patient 1 what had happened, and Patient 1 reported that Patient 2 had "punched" her.On the same day, at 8:30 a.m., Patient 2 was interviewed by facility staff and reported that Patient 1 had "swung" to hit Patient 2. On May 28, 2015, the records for Patients 1 and 2 were reviewed. The records indicated Patients 1 and 2 were in adjacent rooms.On May 28, 2015, at 3:20 p.m., an interview was conducted with Registered Nurse 1 (RN 1). RN 1 saw Patient 1 on the floor with both of her feet facing the door of the bathroom on May 19, 2015, at approximately 8 a.m. Patient 1 stated that Patient 2 had hit her (Patient 1). RN 1 stated that she spoke to Patient 2 next. Patient 2 stated that Patient 1 "swung" her hands at Patient 2 in the bathroom, and the swinging motion caused Patient 1 to fall. On May 28, 2015, at 4:20 p.m., an interview and concurrent observation of the adjacent rooms, which had been occupied by Patients 1 and 2, was conducted with the Administrator. A connecting bathroom was shared between the two adjacent rooms. The Administrator stated a Certified Nursing Assistant (CNA) was directly across the hall from the doorway of Patient 1's room when the CNA heard a "commotion." The CNA saw Patient 1 falling to the floor. On May 28, 2015, at 3:40 p.m., an interview was conducted with the Administrator. The Administrator stated he was the abuse coordinator for the facility and had reported the incident to CDPH on May 21, 2015, at 1:50 p.m. The Administrator verified he had not yet submitted a written report to CDPH. On May 29, 2015, the facility policy, titled "Elder/Dependent Adult Abuse," indicated, "The facility will fully protect the rights of each patient... against any and all forms of physical, verbal... mental abuse... The facility will report all 'alleged', known, or suspected incidents of physical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm, pain or mental suffering... to the office of the state survey and certification agency... immediately or as soon as possible but no later than within 24 hours of such knowledge... The initial report... may be made by telephone immediately or as soon as possible but must be followed up by a written report utilizing the form titled "Report of Suspected Dependent Adult/Elder Abuse" (SOC 341...) within two (2) working days of the first knowledge of an instance of alleged or known abuse...." [The policy did not indicate all incidents of alleged abuse would be reported to the Department immediately, or within 24 hours.] On May 29, 2015, the facility policy, titled "Unusual Occurrence Reporting," was reviewed. The policy indicated, "Our facility will report the following events to appropriate agencies... Allegations of abuse... Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident... A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency... within forty-eight (48) hours of reporting the event or as required by federal and state regulations...." [The policy did not indicate a written report within 48 hours of the event.] The facility failed to report the patient-to-patient altercation on May 19, 2015, which resulted in two allegations of abuse during one incident between Patients 1 and 2, to the California Department of Public Health (CDPH) immediately, or within 24 hours. The facility initially reported the alleged incidences of abuse to the CDPH office on May 21, 2015, at 1:50 p.m. (53 hours and 50 minutes after the facility became aware of the allegations of abuse). These failures placed all patients at the facility in potential danger due to the risk for further abuse. These violations had a direct relationship to the health, safety, or security of the patients. |
| 250000072 |
PALM TERRACE CARE CENTER |
250011707 |
A |
10-Sep-15 |
EEJQ11 |
9002 |
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. An unannounced visit was conducted at the facility on January 22, 2014, to investigate an entity reported incident that indicated a resident (Resident A) fell off his bed while receiving care from Certified Nursing Assistant (CNA) 1. The report indicated Resident A fractured his right femur (thigh bone) as a result of the fall. It was determined that the facility failed to ensure Resident A's care was provided in an environment free from accidents when CNA 1 did not ask for help while providing care to the resident who required two persons to turn and reposition the resident while he was in bed. This failure resulted in Resident A falling off his bed, sustaining a right femur fracture that required admission to the hospital for surgical repair, and an avoidable seven day stay in the hospital. Resident A's record was reviewed on January 22, 2014. The record indicated the resident, an 82 year old male, was admitted to the facility on October 30, 2012, with diagnoses that included cerebral vascular accident (stroke) with unspecified hemiparesis (paralysis of one side of the body), dysphagia (difficulty swallowing), and left above the knee amputation. Review of Resident A's Minimum Date Set (MDS, an assessment tool), dated December 11, 2013, and indicated the resident had short and long term memory problems with severely impaired cognitive skills for daily decision making.Resident A's "Activities of Daily Living Assistance (Section G)" of his annual MDS, dated March 18, 2013, indicated under bed mobility, that the resident was totally dependent on staff to change his position and required at least two people to physically assist him with positioning his body and turning from side to side. The MDS quarterly assessments, dated June 19, 2013, September 18, 2013, and December 13, 2013, remained the same for Resident A's bed mobility. The record indicated Resident A had fall risk assessments completed at admission on October 30, 2012, December 7, 2012, March 11, 2013, June 4, 2013, and September 4, 2013. On each of the fall assessments the resident had scored 14. The assessment form indicated a total score of ten or above represented a high risk for falls. There were no falls listed on the MDS assessment dates of March 18, 2013, June 19, 2013, September 18, 2013, and December 13, 2013. A care plan for falls was located in Resident A's record. There was nothing in the fall care plan to indicate two people would be required to turn and position the resident while receiving care to prevent falls.A physician's order, dated October 30, 2012, was located on the record that indicated the resident should have a low air loss mattress with bolsters (air filled pillows built into the air mattress) on his bed and have one quarter side rails (side rails located at the head of the bed covering one fourth the length of the bed), up to be used by Resident A for mobility.Observation of the resident's bed on January 22, 2014, revealed a low air loss mattress with bolster was in place. When the bed rails were in the raised position, they were level with the top of the mattress.A review of the facility's form, entitled, "Advanced SBAR (S-situation, B-background, A-assessment, R-recommendation) Change of Condition, dated January 18, 2014, indicated Resident A had a witnessed fall with injury. The form listed other factors involved with the fall as, "CNA lost grip resident fell to floor." Review of a facility form entitled, "Licensed Nurses' Progress Notes," located a late entry written for January 18, 2014. The document indicated that the Licensed Nurse (LN) was called to (Room number omitted) and saw the resident (Resident A) on the floor on his back. The LN wrote, "Apparently resident was being changed by CNA. CNA lost grip of resident, fell to floor... C/O (complained of) bilateral (both sides) hip pain, noted an abrasion to center of lower back."After the fall on January 18, 2014, Resident A's physician was notified. The physician ordered a "stat" (immediate) x-ray of the right and left hips. On January 19, 2014, x-rays of Resident A's hips and pelvis were completed by a private portable x-ray service. The results indicated comminuted (bone is splintered) proximal (nearest to the head) right femur fracture. The physician was notified of the x-ray results, and Resident A was transferred from the facility to an acute care hospital emergency room by ambulance on January 19, 2014. LN 1 was interviewed on January 22, 2014. She stated that at about 8:30 p.m. on January 18, 2014, CNA 1 had been cleaning Resident A after the resident had a bowel movement. LN 1 said that CNA 1 had been cleaning Resident A without the help of another staff. She said the resident was lying on his left side. LN 1 stated that CNA 1 had asked the resident to grab and hold onto the left (quarter) side rail, which he did. She said that CNA 1 was on the right side of the bed and held Resident A up with one hand while he cleaned the resident with the other hand. LN 1 stated that the CNA said the resident started to roll on his back, and he told Resident A that he was not done yet and continued cleaning the resident. CNA 1 told LN 1 that the resident shifted himself back on his left side and fell off the bed landing on his right side.In an interview conducted with LN 2 on January 22, 2014, she stated that CNA 1 was changing Resident A's brief alone on the evening shift of January 18, 2014. LN 2 said that Resident A had been turned towards the left while the CNA was cleaning the resident. The LN said that CNA 1 had placed his hand on the resident's right side but lost his grip on Resident A, and the resident fell off the bed. LN 2 further stated, "I told him (CNA 1) that the patient (Resident A) should be in the middle of the bed when cleaning (the resident) not at the edge of the bed."The acute care hospital record was reviewed on January 29, 2014, and indicated that Resident A was admitted to the hospital on January 19, 2014. On January 21, 2014, the resident had a CT (computerized tomography - an x-ray commonly known as a "cat scan") with findings that indicated: "...1. Complex fracture of the proximal (nearest to the patient's head) right femur. 2. A comminuted (bone is splintered) oblique (slanted) fracture was seen in the right subtrochanteric (below the neck of the femur) region with a mild impaction and displacement of the distal (farthest away from the head) fracture fragments..." After the CT scan, Resident A underwent major surgery with an open reduction with internal fixation (ORIF, a surgical procedure to repair fractured long bones) on January 21, 2014, of his right femur fracture. Resident A had been admitted to a medical floor from January 19, 2014, until January 21, 2014, prior to his surgery. After surgery he was transferred to the Definitive Observation Unit, a higher level of care in the hospital, until January 27, 2014, when he was discharged from the hospital.On March 4, 2014, a telephone interview was conducted with CNA 1. He stated that Resident A was a large person and heavy (recorded weight of 166 pounds on January 7, 2014). CNA 1 further stated that on the evening shift of January 18, 2014, he (CNA 1) had turned Resident A on his left side to clean the resident after a bowel movement. The CNA said, "The resident was about to roll back, and I kept him from rolling towards me." The CNA further stated, "I needed to go back to my routine work. He (Resident A) was on his left side and went over the bed. I lost grip of him. I had my gloves on." In addition CNA 1 stated that the Nursing Supervisor had told him the resident (Resident A) should be in the middle of the bed when changing him. The CNA further stated, "He was close to the edge. He was on the air mattress bed. The best way to describe it (is) the air mattress is as high as the bed rails." On March 4, 2013, a review of the facility form, entitled "Safety Instructions: Nursing and Therapy Departments," indicated, "Obey all safety rules and practice safe judgement at all time in order to prevent illness, injury, or any similar events in the workplace." Therefore, the facility failed to ensure Resident A's care remained in an environment free from accidents when CNA 1 did not ask for help while providing care to the resident who required two persons to turn and reposition the resident while he was in bed. The failure resulted in Resident A falling off his bed, sustaining a right femur fracture that required admission to the hospital for surgical repair, and an avoidable seven day stay in the hospital.The violation of the above regulation presented either imminent danger or serious harm would result or a substantial probability that death or serious harm would result. |
| 250000092 |
PALM SPRINGS HEALTHCARE & REHABILITATION CENTER |
250011714 |
B |
16-Sep-15 |
2LVN11 |
11566 |
483.13 (b) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. 483.13 (c)(1)(i) The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to promote care in a manner, and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for one resident (Resident A), that resulted in fear and emotional harm for the resident when: 1. Registered Nurse 1 (RN 1) yelled at Resident A, for refusing medication, and 2. RN 1 entered Resident A's room without knocking or permission, despite having been instructed to stay away from the resident by the Administrator. On March 4, 2014, at 9:30 a.m., an unannounced visit was made to the facility to investigate one complaint regarding abuse of a resident by a registered nurse. The record for Resident A was reviewed and indicated Resident A was admitted to the facility on February 26, 2014, with diagnoses that included intravenous (through the vein) antibiotic therapy, diabetes (abnormal blood sugar levels), and enteritis (inflammation of the intestines).Review of the resident's MDS (Minimum Data Set - an assessment tool), indicated Resident A scored 15 out of a possible 15 on the BIMS (Brief Interview for Mental Status). This score demonstrated that Resident A had no cognitive or memory problems.On March 4, 2014, at 10 a.m., Resident A was observed in her room, sitting up in bed, and was well groomed. Upon interview with Resident A at that time, she was pleasant, articulate, able to recall events easily, and knowledgeable about her diagnosis and treatment. Resident A stated on February 27, 2014, at approximately 4:45 p.m., RN 1 entered Resident A?s room to test the resident?s blood sugar level with results of 82 mg/dl (milligrams/deciliter). RN 1 then began to administer Resident A?s medication to her. The resident wanted to make sure she received the correct medication so she asked RN 1 to identify each pill. When RN 1 handed Resident A the aspirin medication Resident A refused it, along with her medication for diabetes. Resident A told RN 1 that since her blood sugar was only 82 mg/dl (normal blood sugar range for a diabetic before meals per the American Diabetes Association, (2007), was 70-130 mg/dl), she should not take the medication. Resident A informed RN 1 that she was nauseated and not eating, so taking the medicine could result in adverse consequences such as hypoglycemia (low blood sugar which if severe can lead to coma). Resident A stated that when she refused the medication, RN 1 yelled at her loudly and stated, "Well, I'm not gonna treat you anymore! Who do you think you are telling me how to do my job? I'll never treat you again!" Resident A stated that RN 1 screamed so loud and the RN took away the rest of Resident A?s pills, and didn't treat Resident A for the rest of the shift. RN 1 and Resident A's daughter, who was visiting Resident A at that time, then began to have a verbal confrontation in front of Resident A. Around 5 p.m., Resident A then requested medication for nausea. RN 1 informed her she could not find the medication. Resident A stated she was retching for two hours, and her daughter and RN 1 began another verbal confrontation because RN 1 would not medicate Resident A. The Administrator arrived and went with RN 1 to get Resident A?s nausea medication. Then the Administrator stayed with Resident A until she was calm, and promised Resident A she would not have further contact with RN 1. At approximately, 8 p.m., Resident A stated she began asking for her medication for sleep. She stated she asked the nurse for medication five times. Resident A stated she was upset, crying, and having thoughts that RN 1 might return to her room and put something in the resident?s intravenous line (IV- in the vein) to hurt her. Resident A was comforted by Licensed Vocational Nurse 1 (LVN 1), who came in to check on her throughout her shift. Resident A stated that she did not receive her medication for sleep until after 1 a.m., by a nurse from the next shift.Resident A then stated in a tearful voice, "I have never been so upset or treated so badly. Can you believe she just didn't treat me? She just held off my medicine. It just isn't right!" Resident A stated on the evening of March 1, 2014, she looked up and saw RN 1 standing at her bedside looking down at her, after the Administrator assured her that RN 1 would not be caring for her. She told RN 1 she was not supposed to be in her room. RN 1 then left and did not come back. Resident A stated she was so upset and scared that she called her daughter, and her daughter called the facility and asked LVN 1 to check on Resident A that night because Resident A was so scared. On March 4, 2014, Resident A?s record was reviewed. Review of the Nurse?s Notes dated March 1, 2014, at 9 p.m. documented ??(name of daughter) called at 9:50 a.m., stating she does not want (name of RN 1) to even be near pt (patient/resident), pt stated to (name of daughter) she is scared & worried about what (name of RN 1) can or might do to her (Resident A), reassured pt & daughter pt will be safe?? (This documentation supports the fact that Resident A contacted her daughter following RN 1 entering Resident A?s room). On March 4, 2014, at 11:30 a.m., in a concurrent interview with the facility Administrator and Director of Nursing (DON), the Administrator stated RN 1 probably entered the room on March 1, 2014, to hang an IV medication. The Administrator stated that he had instructed RN 1 to stay away and not interact with Resident A. The Administrator did not know why RN 1 was in the resident?s room. The DON interjected stating that the RN from the oncoming shift (11 p.m to 7 a.m.) usually arrived early and could have administered Resident A?s IV medication due at 10 p.m. The DON further stated RN 1 didn?t need to administer the medication to Resident A. On March 6, 2014, at 5:10 p.m., in a telephone interview with RN 1, she confirmed Resident A's blood sugar level was 82 mg/dl on February 27, 2014. RN 1 stated Resident A requested medication for nausea and it was offered P.O. (by mouth). RN 1 stated the resident refused the P.O. medication and requested the medication be given through the IV line due to her nausea. RN 1 stated she went to look for the IV medication order for nausea, but did not locate one. The resident then refused her aspirin and diabetic medication. RN 1 stated when she came out of the resident's room, she was met by Resident A's daughter who approached her in a ?threatening manner.? RN 1 tried to calm the daughter down by telling her she was an RN. RN 1 stated she located the IV medication for nausea and when the Administrator arrived to the station at approximately 6 or 7 p.m., he accompanied her to medicate Resident A. The exact time of medication administration could not be verified since RN 1 did not document the medication administration on the medication administration record (MAR). On March 10, 2014, at 10:35 a.m., a second interview was conducted with RN 1. She stated that she was not sure if she raised her voice at the resident or daughter. She stated her voice was soft, so when people do not understand her she speaks louder so they can understand.RN 1 stated it may have seemed that she was yelling, but she was just trying to be heard. RN 1 stated she did not remember what she said to Resident A when the resident refused her medication. RN 1 then stated she did not give the medication for sleep because the Administrator told her the resident felt drowsy. She was just being cautious, but did not document an assessment, or explain to the resident why the medication was not given. RN 1 stated that she was the only RN on duty, and had to administer Resident A?s IV medication. She stated she did not think about how Resident A would react. RN 1 stated she was very busy and just did what she had to do automatically. RN 1 further stated she did not think about other options, did not remember to knock before entering Resident A?s room, and did not remember how the resident reacted to seeing her (RN 1) in the room. On March 13, 2014, at 4:43 p.m., during a telephone interview with LVN 1, she stated she could hear screaming from Resident A?s room and went to find out what was going on. She stated she found RN 1 and Resident A's daughter screaming at each other in front of Resident A. Resident A was experiencing dry heaving (retching without vomiting) and RN 1 was not doing anything about it. LVN 1 state Resident A's daughter approached LVN 1 and exclaimed (referring to RN 1), "She won't help me!" LVN 1 went to the "E Kit (emergency medications)" and located the Phenergan IV (medication used to treat nausea and/or vomiting). LVN 1 stated Resident A's daughter and RN 1 then engaged in a screaming match; the daughter wanted RN 1 to help Resident A. LVN 1 stated the Administrator arrived and accompanied RN 1 to the medication room to get Resident A?s medication for nausea. LVN 1 stated Resident A expressed fear of RN 1 to LVN 1, and the resident needed constant reassurance throughout the shift that everything was ok. LVN 1 further stated she had received a call from Resident A?s daughter later that evening with a request to check on the resident and make sure she was not scared.On March 17, 2014, at 3:55 PM, in a telephone interview with Certified Nursing Assistant 1 (CNA 1), she stated she witnessed the incident on February 27, 2014, when RN 1 was yelling at Resident A?s daughter, and she also heard her yelling at Resident A over something to do with medication. CNA 1 also remembered a second incident with RN 1 yelling at Resident A. CNA 1 stated she did not know what it was about and could not remember the date it occurred. CNA 1 further stated after each incident the resident expressed being scared and fearful of RN 1.On May 14, 2014, at 2:35 p.m., a follow-up interview was conducted with the complainant. The complainant stated on the evening of March 1, 2014, she received a telephone call from Resident A informing her that RN 1 had entered Resident A's room and frightened her. The complainant stated Resident A was scared, crying, and afraid that RN 1 had added something to her IV bag. The complainant called the facility and requested LVN 1 to check on Resident A, and keep RN 1 away from the resident. On May 14, 2014, at 2:40 p.m., a follow-up telephone interview was conducted with Resident A. The resident stated the way she was treated by RN 1 needed to be corrected. Resident A stated she felt people who need help should get it, and vulnerable people should not have to beg for assistance and go through what happened to her. Resident A further stated something should be done to help the people that are in that position now. Therefore, the facility failed to promote care in a manner and environment that maintains or enhances each resident?s dignity and respect in full recognition of his/her individuality for one resident (Resident A). This failed practice resulted in emotional harm and fear to Resident A when RN 1 yelled at her for refusing medication, and entered Resident A?s room without knocking or obtaining permission, despite RN 1 having been instructed to stay away from the resident by the Administrator. The above violation of the regulation had a direct relationship to the physical health, safety, and psychosocial well-being of Resident A. |
| 250000087 |
PROVIDENCE MT. RUBIDOUX |
250011835 |
B |
06-Jan-16 |
3YTK11 |
3474 |
"B" Citation 483.13 (c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. 482.13 (c)(2)The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (according to the State survey and certification agency). The facility failed to ensure a Charge Nurse (CN 1) reported an allegation of abuse by a Certified Nursing Assistant (CNA 1) toward Patient A to the facility Administrator immediately. On April 15, 2015, at 9:30 a.m., an unannounced visit was made to the facility to investigate an entity reported incident of CNA 1 pinching Patient A on the upper arm resulting in a bruise to the patient's arm on April 3, 2015. On April 15, 2015, at 11:20 a.m., an interview was conducted with CNA 1, who stated he was called to Patient A's room on April 3, 2015. The patient was in the bathroom and, while attempting to get out of the bathroom door, backed her wheelchair up against one of the beds in the room. Patient A's arm was stuck between the bed and wheelchair when CNA 1 came in to assist her. CNA 1 stated the resident became upset and hit him twice when he was attempting to move her. CNA 1 stated he told the Charge Nurse about the incident immediately after leaving the patient's room. During an interview conducted with Patient A on April 15, 2015, at 11:33 a.m., she stated CNA 1 grabbed her wheelchair while she was coming out of the bathroom on April 3, 2015. She stated she did not know why CNA 1 grabbed her. The patient was unable to speak English and spoke through an interpreter. On April 15, 2015, the facility policy and procedure titled, "Policies and Procedures Regarding Prevention, Reporting, and Correction of Inappropriate Conduct, Including Abuse, Neglect, and Mistreatment of Residents," was reviewed. It included: "E. Facility Reporting... 2. Any employee who reasonably suspects, observes, becomes aware through personal observation, or obtains knowledge from reports made by residents, other employees or visitors, that a resident may have been subject to inappropriate conduct, have suffered physical abuse and/ or have an injury of an unknown source, must immediately report such information directly to the Administrator, the Director of Nurses, or the Shift Supervisor. The Shift Supervisor must in turn immediately report this to the Administrator or the Director of Nurses. This is required regardless of whether or not the employee believes abuse, neglect or other inappropriate conduct occurred." On April 15, 2015, at 11 a.m., an interview was conducted with the facility Administrator, who stated he was notified on April 5, 2015, of the April 3, 2015, statements by Patient A that CNA 1 pinched her. He stated the Charge Nurse was notified of the incident by CNA 1 after it occurred, but the Charge Nurse did not report the allegations until two days later. He stated he did not know any reason he was not informed of the incident after she learned of it by the Charge Nurse. The Charge Nurse's failure to report the allegation of abuse to Patient A by CNA 1 had a direct relationship to the health, safety, or security of all patients in the facility. |
| 250000087 |
PROVIDENCE MT. RUBIDOUX |
250011968 |
B |
20-Jan-16 |
IIQW11 |
4400 |
Class "B" Citation F223 483.13(b), 483.13 (c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECULUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility failed to ensure Resident 1 was free from verbal and mental abuse when Certified Nursing Assistant (CNA) 1 refused to assist the resident to use a bedpan and instructed the resident to soil himself. On September 16, 2015, an unannounced visit was made to the facility to investigate an entity reported incident that CNA 1 verbally and mentally abused Resident 1 by telling the resident to "Shit on yourself" after Resident 1 requested a bedpan. On September 16, 2015, at 10:04 a.m., an interview was conducted with Resident 1. The resident dictated his statement to the surveyor due to the resident's diagnosis of Muscular Dystrophy (loss of fine motor movement). Resident 1 initialed and signed the dictation to authenticate his statements. During the interview, Resident 1 stated he pushed his call button to summon a nurse to help him use the bedpan. He stated that, after about 30 minutes, CNA 1 came into the room and asked him what he wanted. Resident 1 told CNA 1 he needed to have a bowel movement. The CNA replied, "I am with the family of another resident, what are you going to do, write me up?" Resident 1 stated he protested to CNA 1, who told him, "Then go shit yourself." Resident 1 stated when CNA 1 returned and put the resident on a bedpan, he left him on the bedpan for 45 minutes. After that time, Licensed Vocational Nurse (LVN) 1 came into the room and helped the resident off the bedpan. In the written documentation provided by LVN 1, she documented Resident 1 was very upset and asked LVN 1 not to have CNA 1 come into his room again. Additionally, LVN 1 documented Resident 1 wanted to speak with Registered Nurse (RN) 1. Furthermore, LVN 1 documented RN 1 had referred LVN 1 to RN 2 for assistance with filling out the report on CNA 1. A record review was conducted for Resident 1 on September 16, 2015. The resident was admitted to the facility on August 11, 2015. An Initial History and Physical dated August 13, 2015, indicated Resident 1 was alert and oriented and had the capacity to understand and make his own decisions. During an interview conducted with the Director of Nursing on September 16, 2015, at 8:40 a.m., she stated the incident was substantiated by a facility investigation. The Social Services Director (SSD) documented in her progress notes dated September 10, 2015, SSD was made aware by nursing staff that Resident 1 had incident with CNA 1 on the night of September 9, 2015. Resident 1 stated he had his call light on because he had to go to the bathroom. Resident 1 stated when CNA 1 came in, CNA 1 told Resident 1 he had a lot to do, then CNA 1 told Resident 1, "You can go ahead and shit on the bed. What are you going to do, write me up?" Resident 1 stated CNA 1 finally did put Resident 1 on the bedpan around 8 p.m., but did not get off until 8:45 p.m., when LVN 1 assisted him off the bedpan. Resident 1 stated he informed RN 1, RN 2, and LVN 1, on duty of the issues with CNA 1. A record review of the personnel file for CNA 1 was conducted on September 16, 2015. CNA 1 had documentation dated May 23, 2014, he attended Staff Abuse Training. Additionally, there was documentation CNA 1 was terminated on September 14, 2015. On September 16, 2015, the facility policy and procedure titled, "Reporting Abuse to Facility Management," dated April 2011, was reviewed. The policy indicated, "...Policy Interpretation and Implementation...1. Our facility does not condone resident abuse by anyone, including staff members..." A second policy titled, "Preventing Resident Abuse," dated December 2006, was reviewed. The policy indicated, "...Policy Interpretation and Implementation...2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following:...i. Monitoring staff on all shifts to identify inappropriate behaviors toward residents (e.g., using derogatory language, rough handling of residents, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their clothing/beds, etc.);..." The violation of this regulation has a direct or immediate relationship to the health, safety, or security of the patient. |
| 250000087 |
PROVIDENCE MT. RUBIDOUX |
250011969 |
B |
20-Jan-16 |
SR9211 |
6943 |
42 CFR 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.The facility failed to provide services to ensure Resident 1's highest practical physical condition by failing to consistently monitor the resident for signs and symptoms of hypoglycemia. The facility failed to have a policy which defined "alternate schedule" blood sugar monitoring and post dialysis assessments. The facility failed to communicate with the dialysis center regarding monitoring blood sugar levels during dialysis, and resident's status and response to dialysis treatments.As a result, Resident 1 experienced two episodes of profound hypoglycemia and became unresponsive. The resident required treatment with Glucagon (a medication given by injection to increase blood sugar levels in diabetics with hypoglycemia (low blood sugar) who are unable to take a quick-acting source of sugar by mouth).Resident 1 was admitted to the facility on June 19, 2014, at 6:15 p.m., with diagnoses including type 2 diabetes and end stage renal disease. Resident 1 received hemodialysis treatments three days per week.Physician admission orders dated June 19, 2014, indicated staff should administer 10 units of Lantus (long acting insulin) each morning at 6 a.m. Blood sugar testing was ordered, "BID (twice daily) alternate schedule." No specific times or directions were noted regarding an "alternate schedule." Additionally, the physician ordered regular insulin to treat elevated blood sugar levels, per sliding scale with parameters given, and indicated staff was to call the physician if blood sugar values were less than 60 or greater than 450. Glucagon was ordered for "blood sugars less than 60, resident unresponsive due to hypoglycemia, call MD." Resident 1's record contained two blood sugar test logs. One, labeled "Blood Glucose Testing Record, Month - June 2014," contained testing times on the form designated at 6:30 a.m. and 11:30 a.m., and 4:30 p.m. and 9 pm. The second log labeled, "After Meals Blood Glucose Testing - Month June 2014," listed test times as 9 a.m., 2 p.m., and 7 p.m. Resident 1's record reflected the first blood sugar test (result = 112) was performed on June 20, 2014 at 4:30 p.m., 21 hours after admission. The next test was at 9 p.m., result = 118.Resident 1 was hospitalized from June 21, 2014, to June 28, 2014, for treatment of a rectal bleed. Upon his readmission to the facility, his blood sugar testing orders remained BID, alternate schedule.On June 29, 2014, at 6:30 a.m., a blood sugar test result was 60. Lantus insulin was administered at 6 a.m. No 11:30 a.m. test result was recorded. A nursing note indicated at 2 p.m., the resident's wife reported her husband was "clammy, wet, and non-verbal." His blood sugar was 29. Resident 1 was given Glucagon, and 10 minutes later he was alert and able to eat.The Food Consumption Log for June 29, 2014, indicated Resident 1 ate a fair breakfast and lunch, between 50 and 75 percent. At 4 p.m., the resident's blood sugar level was 71, and at 7 p.m., it was 106. On June 30, 2014, the treating physician documented completion of the resident's history and physical. There was no indication the blood sugar values were reviewed by the physician. There was no indication an assessment for the use of Lantus was conducted. On July 1, 2014, Lantus insulin was administered at 6 a.m. At 6:30 a.m., Resident 1's blood sugar test result was 60, and at 11:30 a.m. the test result was 73. The nursing notes indicate, at 1:15 p.m., Resident 1 went for dialysis treatment.The July 1, 2014, nursing notes indicated Resident 1 returned to the facility at 6:30 p.m. At 7:20 p.m., Resident 1 was found unresponsive. He became cyanotic and CPR was initiated. Blood sugar testing was completed and the results indicated Resident 1's blood sugar was "low" (less than 20, per the testing machine instruction sheet). Following administration of Glucagon, the resident's blood sugar rose to 31 and then 70. Resident 1 remained unresponsive. Paramedics arrived and continued efforts to revive him.Resident 1 was pronounced dead at 7:56 p.m.Summary:Table of blood sugar test results:June 28, 2014 7: 05 p.m., readmitted no test performed June 29, 2014 6:30 a.m.result 60, 2 p.m.result 29, glucagon given4:30 p.m.result 71, 7 p.m.result 106 June 30, 2014 11:30 a.m. result 75, 4:30 p.m.result 71.July1, 20146:30 a.m.result 60,11:30 a.m. result 737:20 p.m.result "Low," glucagon given, (unresponsive) No time -Recheck result 31 No time -2nd recheck result 707:39 EMS notified / at scene, recheck, result-110. (EMS note) There was no time when the resident had an elevated blood sugar level requiring additional insulin, per the physician ordered sliding scale parameters.A review of Resident 1's clinical record revealed no initial care plans for diabetes, dialysis, hypoglycemia (glucose at or below 70 mg/ dL., American Diabetes Association) or hyperglycemia. A care plan for low blood sugar was developed on June 29, 2014, after Resident 1 experienced profound hypoglycemia that required treatment. The care plan directed "monitor BS for 72 [hours]." No strategies, time frames, or directions for frequency were listed on the care plan. No changes were made to the existing blood sugar monitoring schedule.During an interview on February 2, 2015, the Medical Records representative stated the facility used a communication form to share information between the facility and the dialysis center. The representative and the director of nursing (DON 1) were unable to find a communication form for Resident 1. The DON 1 stated she did not know what occurred at dialysis and, "maybe they have a record." During an interview on July 8, 2015, the director of nursing (DON 2) indicated the facility had no policy regarding an "alternate schedule" for blood sugar testing. DON 2 stated, "They just follow doctor orders." DON 2 stated the facility had no set times when an alternate schedule testing should be done. The facility failed to adequately monitor Resident 1 for signs and symptoms of hypoglycemia. Resident 1 did not have a care plan for diabetes, and had an inadequate care plan for hypoglycemia.The facility failed to conduct post dialysis assessments and to maintain communication with the dialysis center regarding the resident's status and response to treatments.The facility failed to have policy and procedures for any periodic blood sugar testing schedules ordered by the physician. The facility failed to prevent two episodes of acute hypoglycemia that occurred within 48 hours of each other and which required Glucagon treatments.The above violations jointly, separately, or in any combination, had a direct or immediate relation to the health, safety, and security of residents. |
| 250000091 |
PROVIDENCE ORANGE TREE |
250012038 |
B |
24-Feb-16 |
35CW11 |
8465 |
Class B Citation (F223)Code of Federal Regulations 483.13 (b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. An unannounced visit was made to the facility on February 18, 2015, to investigate an entity reported incident. It was determined that the facility failed to ensure one female resident (Resident A) was free from sexual abuse from a male employee (Certified Nurses Aide 1). On February 18, 2015, at 10 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident A informed CNA 2 (Certified Nurse Aide) on February 16, 2015, that she (Resident A) had a relationship with CNA 1 for approximately four or five months. Resident A indicated the relationship was "consensual" and consisted of kissing.The DON indicated during an interview she conducted with CNA 1, he admitted to kissing Resident A on the cheek and an "open mouth" kiss. The DON stated the facility was unaware of the relationship between Resident A and CNA 1.CNA 1 was suspended on February 16, 2015, and then terminated on February 18, 2015. An interview was conducted with Resident A on February 18, 2015, at 10:45 a.m. She stated since October 2014, CNA 1 had been assisting her with her care needs. Resident A stated during the night shift on February 15, 2015, CNA 1 told her "she was very special", and got "touchy". The resident stated CNA 1 kissed her and attempted to clean her genital area, stating he wanted to please her "down there". Resident A stated, "He tried to reach me down there, but I was too dry, so he wet his fingers and tried again, that's when I told him to stop. I didn't report the kissing until after he tried to penetrate me with his finger." Resident A indicated she needs assistance to get to the bathroom, and during the night shift she will wear an incontinent pad. A psychologist assessed Resident A on February 17, 2015, and documented Resident A admitted to being "touched in an inappropriate way by a male staff member... expressed relief that she had done the correct behavior in reporting abuse to staff... continued psychotherapeutic intervention is needed...". The psychologist described Resident A's mood as "Depressed, Anxious...Feels worthless..." A record review was conducted on February 18, 2015. Resident A, a 38 year old female was admitted to the facility on November 6, 2014, with diagnoses including injury to the brain and hemiplegia. The physician documented on November 8, 2014, the resident has the capacity to understand and make decisions. The Minimum Data Set (MDS- an assessment tool) dated November 18, 2014, indicated Resident A can understand others and has the ability to make herself understood. There are no problems with short or long term memory and there are no problems with cognitive skills for daily decision making. Resident A needs extensive assist with one person physical assist for toileting and personal hygiene. The resident uses a wheelchair for mode of transportation.A care plan was developed for Resident A on January 12, 2015, for "Hypersexual behavior- approaching male resident to get in her bed..." A review of the Social Service Director's (SSD) notes dated January 12, 2015, indicated Resident A was counseled regarding asking a male resident to join her in her bed. The SSD counseled the resident regarding the inappropriateness of her behavior. A phone interview was conducted on February 18, 2015, at 2 p.m., with CNA 1. He stated he worked the night shift on February 16, 2015, and was assigned to care for Resident A. He indicated he checked on Resident A because she needed a "diaper change", and he also administered peri-care (cleansing procedure of the outer female genitalia after urinating or defecating) because "It's part of the care". He stated he purchased personal wipes for Resident A, and explained that he would touch her private parts to check if Resident A was soiled. CNA 1 indicated he was not trained to physically touch the residents, stating, "I did this on my own."CNA 1 admitted kissing Resident A on the mouth and forehead more than twice. On February 18, 2015, at 2:24 p.m., an interview was conducted with the Director of Staff Development (DSD). The DSD was asked to explain the process of how the CNAs are trained to assess if a resident has soiled their incontinent pad. The DSD stated if the residents are alert but incontinent (unable to control bladder), the CNAs should ask the residents if their disposable brief needs to be changed. The CNAs can look under the disposable brief by removing the velcro from the brief to observe a soiled diaper. The CNAs are not taught to physically touch the resident's peri area. The DSD indicated Resident A is continent and wears disposable briefs during the night shift and needs assistance to go to the bathroom. The CNAs are taught to "ask, look and visually check." A review of the CNA flow sheets for February 2015, revealed that Resident A did not have any documented incontinent episodes throughout all shifts through February 15, 2015. A review of the police report dated February 16, 2015, documented "I was dispatched to the (name of this facility and address) reference a possible past sexual assault involving patient and employee at the facility... O3 (identified as DON) statement: a patient O1 (identified as Resident A) informed O3 that a male staff member O2 (identified as CNA 1) touched her inappropriately between 02-15-15 2300 hours (11 p.m.) and today's date 0700 (7 a.m.)... O2 placed his hand underneath O1's diaper/underwear and began to fondle her vagina... O2 has fondled her vagina in the past... O1 and O2 have been sexual in nature, kissing ... O1's statement: ... O1 and O2 were engaged in mutual "french kissing" ...used his own money and purchased O1 over the counter medication wipes and he treated O1 by applying the wipes to her vagina area ... O2 reached underneath her diaper and began to fondle her vagina. O1 told him she was "dry" and felt non-lady like... O2 walked to the bathroom doused his hands in water and returned and again attempted to penetrate O1's vagina with his fingers at which point she told him "No"... Next, I talked to O2... O2's statement: ...He admitted to purchasing medicated vaginal wipes... O1 and O2 became intimate and kissed on several occasions... O2 said parts of his job responsibilities are to provide baths to persons to include cleaning their anuses, penis', and vagina's... He did check O1's diaper to determine if it was saturated and needed to be replaced... he left the room being her diaper did not need to be changed..." An interview was conducted with CNA 2 on February 20, 2015, at 1:30 p.m. CNA 2 indicated that she had been assigned to care for Resident A on a regular basis for two months. She stated she worked the day shift. CNA 2 revealed that Resident A developed a trust and rapport with her that included jokes, laughter and inquiring about family members. CNA 2 indicated Resident A had anxiety issues, such as moving her hands a lot, and would get "loud and would yell about anything." Resident A informed CNA 2 that she "liked" CNA 1 because "he was nice to her." On the morning of February 16, 2015, CNA 2 was preparing Resident A for her shower when the resident told CNA 2 that a male CNA on the night shift had kissed her and attempted to "stick his hand inside her underwear and play with her. It didn't feel good." CNA 2 stated the resident told the male CNA to stop because she didn't like it. The male CNA asked Resident A, "Why aren't you getting wet... he said he was going to try every night because he wants to make her feel good."CNA 2 stated Resident A admitted the "male" CNA was (CNA 1's name omitted). CNA 2 immediately informed the nursing supervisor.A review of the facility policy and procedure, dated 2014, titled, "(name of corporation omitted) Abuse Prevention and Reporting Policy", indicates ..." 2... All employees are informed of the California state law which defines "abuse of an elder or dependent adult" as any of the following:... treatment with resulting... mental suffering... c. Sexual Abuse - Sexual harassment, sexual coercion, and sexual assault are examples."The facility failed to ensure one female resident was free from sexual abuse from a male employee. The violation of this regulation has a direct relationship to the health, safety, or security of the resident. |
| 250000091 |
PROVIDENCE ORANGE TREE |
250012056 |
B |
09-Mar-16 |
GOKV11 |
8274 |
HSC 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. HSC 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. On November 4, 2015, an unannounced visit was made to the acute hospital for the investigation of an alleged incident of sexual abuse that was suspected to have occurred at the Skilled Nursing Facility. Based on interview and record review, it was determined the facility failed to report to the California Department of Public Health (CDPH) immediately, or within 24 hours, an alleged incident of sexual abuse for one Patient (Patient 1). Failure to notify the California Department of Public Health (CDPH) had the potential to place all the patients in the facility at risk for harm from sexual abuse. On November 4, 2015 the acute hospital records for Patient 1 were reviewed. The document titled, ?History and Physical,? and dated November 1, 2015, indicated Patient 1 had been admitted to the hospital on November 1, 2015. It further indicated, ?After arrival in the ER (Emergency Room), patient apparently had some vaginal bleeding (unclear if this was related to her self- removal of the Foley catheter) however she also had ?white substance? in her pubic hair according to the ER staff along with a dirty sock with the name ?Mark?on it. There was concern for sexual abuse so the ER extensively pursued options of getting an evaluation for rape, but since patient was not willing to consent, transfer was held and physician was called to admit the patient for further evaluation?? An interview was conducted with the Quality/Risk Manager (QRM) and Social Services Director (SSD) of the acute hospital. When asked about their policy of reporting allegations of abuse, the QRM stated that suspected allegations of abuse that occur at a facility other than their own are reported to the Ombudsman, Adult Protective Services and the Police department.A review of the document titled, ?CONFIDENTIAL REPORT,? dated November 1, 2015, faxed to the Ombudsman by the acute hospital?s Social Worker (SW), indicated, ?Pt (patient) with dementia came to ER from nursing facility, presenting with blood in diaper and a white discharge around her vaginal area. Per nursing staff, pt cries when asked if she was hurt, however when asked specifically by the police officer in the presence of the Social Worker, pt denied being hurt by anyone.? A review of a document titled, ?Emergency Department Record,? date November 1, 2015, indicated, ?While changing patient?s gown and diaper, blood was notice and white fluid noted near vaginal area. A sock with the name ?Mark? was also found in patient?s bed. Sock is noted to be damp with fluid on it as well. Pt stated ?someone grabbed me.? Pt started crying and saying she wants to go home?? A review of document titled, ?SS (Social Services )-Narrative,? dated November 2, 2015, indicated, ??While in ER Pt reported being grabbed and hurt by someone and there was blood and white discharge in her vaginal area, however, it was reported that Pt did pull out her F/C (Foley catheter). It was also noted that there was a sock found in Pts bed that was soiled with the name ?Mark? on it?? A review of the hospital?s ?Pathology Report,? dated November 2, 2015, indicated the specimen was a pubic hair with foreign material. In section, ?Diagnosis,? it indicated, ??No spermatozoa or other foreign material are identified.? An interview was conducted with Patient 1 at the hospital on November 4, 2015, Patient 1 was asked if anyone had hurt her at the Skilled Nursing Facility. Patient 1 stated, ?No.? Patient 1 was asked if anyone had touched her inappropriately. Patient 1 stated, ?No.? On November 4, 2015, an unannounced visit was conducted at the facility for the further investigation of the alleged incident of sexual abuse for Patient 1. Patient 1's facility record was reviewed. Patient 1 was re-admitted to the facility on October 31, 2015, with diagnoses that included fracture of shaft of right tibia (shin bone), fracture of right fibula (lower leg bone), anemia, type II diabetes mellitus (chronic condition that affects the way the body processes blood sugar), dementia (a decline in mental ability), bipolar disorder (episodes of mood swings) and major depressive disorder (persistent feeling of sadness). An interview was conducted with the facility Administrator (AD) and the Director of Nursing (DON). The AD and the DON were asked about Patient 1. The AD stated Patient 1 was a fall risk and a confused patient. He stated the physician (MD 1) called him and told him about the specimen the hospital was processing. The AD further stated he would look into it. The DON stated she called the hospital on Monday just to ?Clarify concerns.? The AD and DON were asked why the allegation was not reported. The AD stated they did not feel it was true. The AD further stated it was only because of MD 1?s call that he did the investigation. The AD was asked when staff was interviewed, had anyone heard screaming. The AD stated, ?No, nothing like that.? When asked about the sock found with Patient 1, both the AD and DON stated they were not aware of the sock or how the patient had gotten it. The AD stated he asked the DON to call the hospital and stated, ?Rape seemed so far out of the picture.?Review of a document faxed to the Department on November 5, 2015, by the facility Administrator indicated, ?November 01, 2015 (physicians name) asked me why his patient, (Patient 1) had been transferred to the hospital. He said he had not been notified by our nurses. He then told me that (Name of hospital) was concerned because she did not come in ?good shape.? Also a sock with another patient?s name on it was with her belongings?The allegation of a potential rape from the hospital was never discussed.? A review of a document on November16, 2015, titled, ?SBAR,? (Situation, Background, Assessment, and Recommendation) dated November 1, 2015, indicated by a check mark, ?Reported to:? (MD 1?s name) was handwritten in. A mark next to the box, ?MD on,? hand written was the date November 1, 2015, and time 1:00 p.m. On November 19, 2015, an interview was conducted with a Registered Nurse Supervisor (RNS) at the facility. The RNS was asked about the alleged incident. The RNS stated she had heard rumors but stated there were enough witnesses around. The RNS further stated the DON was fully aware of the situation. She stated again, she had only heard rumors, but that it was checked out and everything was, ?Ok.? On November 19, 2015, a phone interview was conducted with MD 1. MD 1 was asked about the events surrounding Patient 1?s hospitalization. MD 1 stated the hospital ER nurses aroused the allegations. A white matter found near Patient 1?s vaginal bleeding was sent out to the lab. MD 1 stated he called the facility AD and told him to ?Look into it.? MD 1 stated the allegation was huge. MD 1 was asked what did the AD do, MD 1 stated the AD talked to the staff and got a better history. When asked when he had contacted the AD, MD 1 stated the same night the patient came into the ER. MD 1 stated he told the AD, ?To figure it out.? MD 1 stated the AD got all the information he needed.A review of the facility?s policy and procedure titled, ?ABUSE PREVENTION AND REPORTING POLICY,? undated indicated, ?Our facility policy is to report known or suspected instances of elder abuse, including all allegations, to the Abuse Coordinator. In addition, California law mandates that all employees in a long-term healthcare facility must report known or suspected instances of elder or dependent abuse immediately, or as soon as possible by telephone to the Long-Term Care Ombudsman, California Department of Public Heath, and the local Police Department?? Therefore, it was determined the facility failed to report to the California Department of Public Health (CDPH) immediately, or within 24 hours, an alleged incident of sexual abuse for one Patient (Patient 1). The failure of the facility to report the alleged sexual abuse placed all patients at the facility in potential danger to their health, safety, and security. |
| 250000087 |
PROVIDENCE MT. RUBIDOUX |
250012161 |
B |
07-Apr-16 |
WK1211 |
8455 |
483.25 (h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On September 23, 2015, at 12 noon an unannounced visit was made to the facility to investigate two complaints. It was determined that the facility failed to ensure one patient's (Patient 1) environment remained free from accident hazards when he fell from his bed because the bedrail had not been locked in place in the up position on September 6, 2015. This failure caused Patient 1 to sustain a broken nose and head laceration from the fall that required him to be transported to the emergency department of the acute hospital via 911 in a paramedic staffed ambulance for further evaluation and treatment of a head injury. Twice on September 23, 2015, observations were made of the patient in his room. Patient 1 was lying in bed, the head of his bed was raised, and side rails were raised and padded. The height of his bed was observed and was in a high position. An interview was conducted with Patient 1's roommate (Patient 2) on September 23, 2015. Patient 2 stated his roommate had a habit of kicking the side rail of the bed. When Patient 2 was asked about Patient 1's recent fall, Patient 2 stated he heard Patient 1 kicking the side rail. He further stated, "Once the kicking stopped," he thought his roommate had gone to sleep. He then stated he heard noises coming from the floor and when he looked, he saw the bed side rail down and his roommate on the floor. Patient 1's record was reviewed. Patient 1 was admitted to the facility on March 31, 2008, with diagnoses that included Huntington's chorea (disease that causes the progressive breakdown of nerve cells in the brain), convulsions (a sudden, violent, irregular movement of a limb or of the body), schizophrenia (a severe brain disorder in which people interpret reality abnormally), dissociative anxiety (disruption in awareness, memory, or identity with no known physiological basis) and somatoform disorder (mental illnesses that cause bodily symptoms, including pain). A review of the form, "Charge Nurses' Evaluation" notes, entry date September 6, 2015, at 7 a.m., indicated, "Pt (patient) found on floor, 2 lacerations to L (left) side of head, cut above L eyebrow bleeding, pt bleeding from nose...pt is awake...called requested ambulance transfer to acute hospital, concern for head injury..." A review of the patient's "Fall Risk Assessment," located three quarterly assessments, dated September 18, 2014, December 15, 2014, March 16, 2015, and an annual assessment dated June 15, 2015, in the record. All assessment dates indicated a total score of 16. Directions on the assessment indicated, "When the resident's total score is greater than or equal to 14, care plan this fall risk with interventions to decrease such a risk." A review of the "Care Plan for Fall Risk," with an intervention date of November 4, 2013, indicated, "Minimize hazards in resident's (patient's) environment, including...locking moveable equipment..." Section "5" indicated, "Provide assistive interventions as necessary, including..." No interventions were marked except two handwritten interventions, one of which indicated, "side rails up when in bed..." Section "7" indicated, "Have SR (side rail) padded." The care plan titled, "Fall Risk," dated June 2015, indicated, "SR up as ordered...padded SR to prevent injury..." Further review of the Patient 1's record located an "Order Summary Report," (Physician's orders) that indicated, "Both side rails up while in bed..." The order was dated March 20, 2014. Additional review of the patient's record located a "Short Term Care Plan," dated September 6, 2015. The "Short Term Care Plan" indicated, "5. Make sure bed rails are secure." A review of the "Interdisciplinary Team Meeting," dated September 6, 2015, indicated, "Resident (Patient 1) found on the floor on his back next to his bed. Sustained laceration to L eyebrow and back of the head. Resident sent out to hospital for further evaluation." A review of the "Emergency Provider Report," from the acute hospital, dated September 6, 2015, indicated laceration management to the left face, the wound length 1.000 cm (centimeter -0.39 inch). The skin repair was noted as skin adhesive (a glue used to connect the edges of skin for wound closure). A review of the "History and Physical," from the acute hospital indicated, "This is a 73-year old male who sustained a fall in the nursing home today, was transferred to the ER for further evaluation. The patient was found to be encephalopathic (generalized brain dysfunction) with evidence of hypernatremia (an elevated concentration of sodium in the blood); therefore, stabilized and referred for admission and management...The patient is referred for further management of electrolyte abnormalities and further medical management...CT (computerized tomography - a computer scan that takes data from several X-ray images of structures) of the head without contrast (a dye used for better visualization of certain x-rays) shows...nasal fracture..." The "Interdisciplinary Team Meeting," document dated September 16, 2015, after the patient returned from the hospital indicated, "Continue bed in lowest position, and continue SR pads for seizure precaution, SR up in place to keep LAL (low air loss mattress- special mattress to help prevent bed sores) in place."This same "Interdisciplinary Team Meeting," indicated on the back of the document, "Resident (Patient 1) was heard kicking the side rail @ (at) time of incident. Roommate called staff when patient was seen on the floor. Patient was last seen during routine morning medication pass at 6:30 a.m., and all precautions were observed." No date was noted on this entry. On September 23, 2015, an interview was conducted with the Director of Nurses (DON). When asked about Patient 1's fall, she stated Patient 1's son spoke with her and the Administrator. She stated she told the son the facility would conduct an investigation and inform him of their findings. When asked about the findings of the investigation, the DON stated it was possible that the last staff member to care for the resident might not have locked the side bed rails completely.During a second visit to the facility, Patient 1 was observed lying in bed. The bed was noted in low position with a LAL mattress. No bed rails were observed. A mat was observed on the floor next to the bed. Attempts were made to interview the patient. Patient 1 was called by his name three times with no response. Patient 2 in Bed A stated, "He doesn't talk." On October 27, 2015, the height of Patient 1's bed was measured by the Maintenance Supervisor (MS). The MS was asked if the bed was in the lowest position, he stated, "Yes." The height of Patient 1's bed in the lowest position measured 19 inches from the top of the mattress to the floor. The bed was observed to have a LAL mattress in place. The MS was then asked to take the measurement of the LAL mattress. It measured 8.5 inches. The MS was then asked to measure Bed C. The MS was asked what position Bed C was in; the MS stated the "Normal," or "Regular," position. Bed C in the "Normal," position from the top of the mattress to the floor was measured by the MS at 27 inches. Bed C was observed to have a thinner, non-therapeutic mattress. Review of the facility policy and procedure titled, "Falls and Fall Risk, Management," revised December 2007, indicated, "Based on previous evaluations...the staff will identify interventions related to the resident's (patient's) specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling..." Therefore, the facility failed to ensure one patient's (Patient 1) environment remained free from accident hazards when the patient fell from his bed because the bedrail had not been locked in place in the up position. This failure caused Patient1 to sustain a broken nose and head laceration from the fall that required him to be transported to the emergency department of the acute care hospital via 911 in a paramedic staffed ambulance for further evaluation and treatment of a head injury. The violation of the above regulation had a direct or immediate relationship to the health, safety, or security of patients. |
| 250000087 |
PROVIDENCE MT. RUBIDOUX |
250012202 |
B |
19-Apr-16 |
OHLX11 |
4454 |
Class B Citation Code of Federal Regulations ? 483.13 (b), (F223) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. On December 17, 2015, an unannounced visit was conducted at the facility to investigate a complaint of verbal abuse of a patient by a staff. During the course of the investigation, it was determined that the facility failed to provide for Patient A an environment free from verbal abuse and intimidation from Certified Nursing Assistant 1 (CNA 1) and CNA 2. On December 17, 2015, Patient A, Patient B, CNA 3, CNA 4, CNA 5, CNA 6, Director of Staff Development (DSD), Director of Nursing (DON) and Administrator were interviewed. Patient A was observed in bed, unable to move without assistance and slow to speak. Patient A stated on Tuesday, December 15, 2015, CNA 1 and CNA 2 were both in his room at one point. Patient A stated when he told CNA 1 that his clothes were in the wrong closet CNA 1 responded "Shut up and (expletive) off!" Patient A stated CNA 2 then "Put the call light on the floor." Patient A stated the call light was left on the floor until CNA 3 came in and he asked her to pick it up. Patient A stated he told CNA 4 about CNA 1 and CNA 2. Patient A further stated he told the whole story to CNA 5 the following day, Wednesday, December 16, 2015. Patient A's record was reviewed. Patient A, a 55 year old male, was admitted to the facility on XXXXXXX with diagnoses that included Cerebrovascular Accident (CVA - stroke) with left side weakness. Patient A's History and Physical dated September 10, 2015, indicated Patient A had the capacity to understand and make decisions. Patient A's Minimum Data Set (MDS - an assessment tool) dated October 5, 2015, indicated Patient A had a Brief Interview for Mental Status (BIMS - screener for mental and cognitive status) score of 15 (a score of 13-15 means cognitively intact). The MDS also indicated Patient A required extensive assistance with activities of daily living (includes moving in bed, transferring, personal hygiene, bathing and toileting.) Patient B was Patient A's roommate. Patient B stated "Yes, I heard it." Patient B further stated "The (skin color) nurses said shut up and (expletive) off!" Patient B stated the incident happened on Tuesday (December 15, 2015). Patient B's record was reviewed. Patient B's History and Physical, dated October 15, 2015, indicated Patient B had the capacity to understand and make decisions. The MDS dated October 26, 2015, indicated Patient B had a BIMS score of 15. CNA 3 confirmed that she did pick up Patient A's call light from the floor when Patient A asked her to pick it up on Tuesday. CNA 4 stated Patient A told her about the call light and that "The lady (CNA 1) doesn't change my diaper." CNA 4 stated she told the nurse yesterday but could not remember the nurse's name. CNA 5 stated Patient A informed her that on Tuesday when he told CNA 1 and CNA 2 that his clothes were in the wrong closet "They (CNA 1 and CNA 2) told him to be quiet and (expletive) off." CNA 5 stated Patient A told her about the incident on Wednesday. CNA 5 stated "No I didn't report it...I didn't want to point fingers." The DSD stated she did not receive any report about what happened to Patient A. The DSD confirmed CNA 1 and CNA 2 worked and were assigned to Patient A's station on December 15, 2015. CNA 1 and CNA 2's employee files were reviewed with the DSD. CNA 1 had training on different types of abuse, abuse prevention and reporting on September 15, 2015. CNA 2 had the same abuse training on October 14, 2015. The Administrator stated the he was the facility's abuse coordinator. The Administrator stated what happened to Patient A was not reported to him. The DON stated "It should have been reported." The facility "Preventing Patient Abuse" policy and procedure dated December 2006, indicated "Our facility will not condone any form of resident abuse and will continually monitor...to assist in preventing resident abuse...The facility's goal is to achieve and maintain an abuse-free environment..." Therefore, it was determined that the facility failed to provide an environment free from verbal abuse, and intimidation for Patient A from CNA 1 and CNA 2. This failure had the potential for severe psychological harm for Patient A. This violation had direct or immediate relationship to the health, safety, or security of patients. |
| 250000091 |
PROVIDENCE ORANGE TREE |
250012258 |
A |
27-Oct-16 |
MZXH11 |
14839 |
483.25 (j) SUFFICIENT FLUID TO MAINTAIN HYDRATION The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. On September 23, 2015, an unannounced visit was made to the facility to investigate two complaints. It was determined that the facility failed to ensure one patient (Patient 1) was provided sufficient fluid intake to maintain proper hydration and health. This failure resulted in the patient being admitted to the acute hospital for severe dehydration with elevated laboratory values that indicated dehydration and a free water deficit of approximately 5 liters. The severe dehydration, elevated blood sodium levels, and free water deficit made it necessary for Patient 1 to start hemodialysis (procedure to remove fluid and waste products from the blood) due to his renal (kidney) failure. A resident on hemodialysis is required to use three to four hours out of his day three times per week to complete each dialysis treatment. The skilled nursing home resident must also travel to and from a dialysis clinic by medical transport van. This can take up to an hour each way. Depending on what time treatment is scheduled, the resident's medication and/or meal times must be altered so the resident can receive this vital treatment. Patient 1's clinical record was reviewed. Patient 1, age 64 was admitted to the facility on September 13, 2015, with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness or partial paralysis) following cerebrovascular disease affecting left dominant side (a stroke that caused paralysis on the left side of the body), type II diabetes mellitus (a condition that affects the way the body processes blood sugar), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), hypertension (high blood pressure), and chronic kidney disease (disease of the kidneys leading to renal failure). A review of Patient 1's history and physical dated September 16, 2015, indicated, "This resident (Patient 1) has the capacity to understand and make decisions." A review of Patient 1's Minimum Data Set (MDS - a comprehensive assessment tool) dated September 25, 2015, section titled, "Brief Interview for Mental Status," (BIMS) score section was blank. A BIMS score is a reflection of a patient's mental status. A review of Patient 1's, "Physician Admission Orders," dated September 13, 2015, indicated Patient 1 was, "NPO," (nothing by mouth) but was not on any fluid restriction related to kidney disease. In section, "Enteral Feeding: G-tube (delivery of a nutritionally complete fluid, directly into the stomach or small intestine) with Nephro (tube feeding used for kidney patients) at 35cc (cubic centimeter - the equivalent to a milliliter)/hr (per hour) to start @ 12 noon to provide 840cc in 24 hours, infuse until volume 840cc is completed...flush tube/cc 100 H20 (water) Q shift (every shift) or 6 hours." Review of Patient 1's care plan titled, "DEHYDRATION," dated September 14, 2015, indicated a dehydration potential assessment score of 10 (no indication of how the score was determined or the implication of the score was found). The document further indicated by a check mark, "Will be free from signs and symptoms of dehydration daily until next review...BUN (Blood Urea Nitrogen - a kidney function test)/Creatinine (kidney function test)/electrolytes levels will be within normal limits until next review." In section, "Approach Plan," the following interventions were indicated by a check mark to, "Monitor for signs and symptoms of dehydration...Monitor I&O (intake and output) per protocol...Monitor intake only...Monitor output only..." A care plan initiated for Patient 1 on September 15, 2015, was reviewed. In the section titled, "Goals," it indicated, "Patient will be adequately nourished and hydrated during stay..." In section, "Interventions," it indicated, "TF (tube feeding) rate and H20 flushes to be adjusted as appropriate...NSG (nursing) to observe for s/s (signs and symptoms) of fluid imbalance (dehydration or fluid overload)." A review of Patient 1's document titled, "NURSING CARE NOTES," and the telephone order document both dated September 15, 2015, indicated, "RD (Registered Dietician) recommend: 1). DC (discontinue) previous TF, change to Nephro to 45cc/hr to provide 900cc/1620kcal via g-tube per enteral pump (g-tube pump) in 24 hrs. or until dose of 900cc is met. 2). D/C previous H20 flushes and change to H20 flushes 200cc Q shift..." To provide Patient 1 with 600cc per day of water via flushes in addition to 657cc of free water in the Nephro tube feeding. Review of Patient 1's form titled, "ANNUAL WEIGHT CHART 2015," indicated the date of admission was September 13, 2015, with admission weight of 143.4 lbs. The document further indicated on September 22, 2015, the patient's weight was 136.2, a seven pound weight loss. Patient 1's form titled, "NUTRITION ASSESSMENT AND REVIEW," with an entry date of September 22, 2015, was reviewed. The form indicated, "IDT wt 136.2- down 7.2 # (sic) in 1 wk. GT (g-tube) was increased 9/15 - not enough time for increase in weight to be noticeable..." Documentation entry was signed by RD 2. A review of Patient 1's, "PHYSICIAN'S PROGRESS RECORD," dated September 18, 2015, indicated, "Mucous membranes dry...skin dry..." On September 25, 2015, Patient 1 was transferred from the facility to the acute hospital for hyperglycemia (excess sugar in the blood) and shortness of breath. Patient 1's acute hospital emergency department record was reviewed on November 19, 2015, and indicated Patient 1 was admitted to the acute hospital emergency department on September 25, 2015, for respiratory failure (not enough oxygen passes from the lungs into the blood) and in acute and chronic kidney disease with hypernatremia (high level of sodium level in the blood which coincides with dehydration or not having enough fluids). Hypernatremia is a sodium concentration in the blood of greater than 145. Hypernatremia is demonstrated by a deficit of total body water (TBW) relative to total body sodium content. It is caused by water intake being less than water losses. A major symptom is thirst; other clinical symptoms are primarily neurologic (chemical or electrical abnormalities of the brain, spinal cord or other nerves), including confusion, neuromuscular excitability, seizures, and coma. Hypernatremia occurs with severe volume loss. A review of Patient 1's hospital, "History and Physical," (H&P) dated September 25, 2015, indicated, "Chief Complaint: Respiratory failure and found to be in acute on (sic) chronic kidney disease with hypernatremia." Section, "HISTORY," of the H&P indicated, "...His (Patient 1) laboratory data showed severe hypernatremia with sodium of 157, (test to evaluate sodium level in the blood, normal level 137-145; high levels coincide with dehydration or not having enough fluids), as well as acute on (sic) chronic renal failure with a BUN of 220 (normal level 9.0-20.0; high levels may be due to dehydration or not having enough fluids) and creatinine of 12.7 (normal level of 0.7 to 1.3; high levels may be due to dehydration or not having enough fluids)." It further indicated, "Subsequently, a Foley catheter was inserted and he was aggressively hydrated (intravenously) with 3L (liters or 3000cc) of NS (normal saline used to hydrate) boluses and maintenance fluid of 150cc/hr, with very little urine output..." In section, "IMPRESSION," of the same H&P for Patient 1, it indicated, "3.Oliguric (decreased urine output) acute kidney injury on (sic) chronic kidney disease-most likely secondary to ischemic (restriction in blood supply to tissues)/septic (infected with bacteria) acute tubular necrosis (kidney disorder involving damage to the tubule cells of the kidneys) and severe dehydration...5.Hypernatremia, the patient has a free water deficit of approximately 5L (5000cc)." It further indicated, "...Continue Foley and monitoring of strict I&Os." A phone interview was conducted with the Director of Nursing (DON) on November 19, 2015. The DON was asked about the monitoring of I&O's for Patient 1. The DON stated the I&Os were under the previous policy, that with admission to the facility on a G-tube, I&Os would not be monitored unless the patient had a Foley catheter. When asked if this patient had a Foley catheter, the DON stated it was discontinued before admission to the facility. The DON further stated for G-tube only, the facility does not monitor I&O's. In a phone interview with the DON on November 23, 2015, the DON was asked how a patient with a G-tube was monitored to ensure they received adequate hydration if no I&O's were documented. The DON stated they monitored input by the documentation on the MAR (Medication Administration Record) the administration of the tube feedings and water flushes. When asked about the monitoring of output, the DON stated the Certified Nurses Assistants (CNA) documented output on the ADL (Activities of Daily Living) sheet by noting the number of times the patient had urinated. When asked how the facility monitored patients for dehydration, the DON stated patients were assessed by licensed staff daily for signs and symptoms of dehydration. When asked what signs and symptoms the staff looked for, the DON stated the staff would look for dry mouth and mucus membranes and at skin turgor (the degree of elasticity in the skin to determine fluid loss or dehydration). A review of the facility ADL documentation for Patient 1 indicated the number of continent (able to control the bladder) and/or incontinent (unable to control the bladder) episodes per day, per shift, but not the volume of output. A phone interview was conducted with the DON on November 24, 2015. The DON was asked if Patient 1 was on a physician ordered fluid restriction. The DON stated, "No." A phone interview was conducted with the facility's Registered Dieticians (RD 1 and 2) on November 24, 2015. RD 1 was asked about Patient 1's fluid intake and how much he should have received daily. RD 1 stated she considered Patient 1's chronic kidney disease, cirrhosis (chronic liver damage) and possible fluid shift when determining his intake. She stated she did not want to begin with too much fluid. She said she wanted to maintain fluid balance. RD 1 was asked if Patient 1 was on a physician ordered fluid restriction. RD 1 confirmed Patient 1 was not on any fluid restrictions. RD 2 was asked about the formula used to determine the appropriate fluid intake for a patient. RD 2 stated they calculated 25-30cc/kg of fluid by counting the free water in the tube feeding and the water flushes. When asked how they would monitor for dehydration, RD 2 stated they would monitor by looking at labs and nursing notes for signs and symptoms of dehydration. RD 2 further stated Patient 1 was sent out to the hospital before they could check his tolerance. RD 2 stated they chose to check his tolerance before increasing his fluid intake due to his chronic kidney disease and cirrhosis When RD 2 was asked again about the calculations for fluid intake, RD 2 stated it would be between 1600-2000cc of fluid per day. RD 2 stated he was receiving, "Very close to 1600cc's." A calculation was done to evaluate necessary fluid intake for Patient 1. Based on the general guideline for determining baseline daily fluid needs the patient's body weight in kg (2.2lbs = 1kg) multiplied by 30cc. Patient 1's admission weight was 143.4 lbs. (65.1 kg). By multiplying 65.1 and 30cc the patient's total daily fluid need was calculated at 1953cc a day. The facility administered 900cc of tube feeding (657cc of the 900cc was free water) as indicated on Patient 1's document titled, "Nutrition Assessment and Review, dated September 9, 2015. Plus 600cc of H20 flushes a day for a total of 1500cc of fluid per day. That was a 453cc difference from the calculated need of 1,953 cc per day. Patient 1 was in the facility for 12 days. Twelve days at a 453cc deficit a day equaled 5432cc. Per the acute hospital records, Patient 1 was found to have a, "Free water deficit of approximately 5L" (5000cc). A review of the University of Michigan's Hospital and Health Centers, "Patient Food and Nutrition Services Enteral Products Quick Reference For Adults," indicated the free water content for Nepro was 725ml per liter of enteral formula. The patient was ordered 900cc of Nepro thus receiving 652.5cc of free water per day. On December 9, 2015, an interview was conducted with CNA 1. CNA 1 was asked how episodes of incontinence were documented on the facility ADL (activities of daily living) sheet. When asked if the number listed on the ADL sheet was the number of times the patient was found wet or the number of times the diaper had been changed regardless of the patient being found wet. CNA 1 stated it was the number of diaper changes. On December 9, 2015, an interview was conducted with CNA 2. CNA 2 was asked how she documented episodes of incontinence on the facility ADL sheet. CNA 2 stated it was the number of times the diaper was changed and did not signify if the patient was wet or dry. A review of the facility's policy and procedure titled, "HYDRATION," undated indicated, "The facility shall provide each resident with sufficient fluid intake to maintain proper hydration for optimum functioning of various body systems." It further indicated, "Each resident will be provided an amount of fluid as indicated to prevent dehydration and maintain health...Resident suspected of or exhibiting signs of dehydration or consuming less that their fluid needs will need of further assessment and evaluation. The signs and symptoms may include but not limited to: Dry skin...Dry mucous membranes...Decreased urine output..." A review of the facility policy and procedure titled, "RECORDING INTAKE AND OUTPUT," dated March 1993 indicated, "To monitor intake and output to assure adequate hydration...Each nursing assistant and licensed nurse records the amount consumed and the amount voided..." Therefore, it was determined that the facility failed to ensure Patient 1 was provided sufficient fluid intake to maintain proper hydration and health. This failure resulted in the Patient being admitted to the acute hospital for severe dehydration, elevated blood serum levels that indicated dehydration, and a free water deficit of approximately 5 liters. The severe dehydration, elevated blood serum levels, and free water deficit required Patient 1 to start hemodialysis (procedure to remove fluid and waste products from the blood) due to his renal (kidney) failure. The above violation presented either an imminent danger of death or serious harm or substantial probability of death or serious physical harm to the patient. |
| 250000091 |
PROVIDENCE ORANGE TREE |
250012389 |
B |
20-Jul-16 |
RZUZ11 |
5697 |
483.15 (a) DIGNITY AND RESPECT OF INDIVIDUALTY The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. On February 19, 2016, at 8:15 a.m., an unannounced visit was made to the facility to investigate two complaints. It was determined that the facility failed to ensure two patients (Patients A and B) were provided care that maintained respect and dignity when: Patient A was observed with a dried brown matter in her hair, across her forehead, on her clothing, bedding, and privacy curtain. Patient B was made to wait an extended period of time in soiled briefs before assistance was provided which resulted in the patient sitting in his own waste until a facility staff member came to change him. These failures had the potential to impact the residents' self-esteem and self-worth. At 9:45 a.m. on February 19, 2016, Patient A was observed. The patient was wearing a diaper which appeared to be filled with fluid. A dried brown matter was observed in the patient's hair, across her forehead, on her hands, and under her fingernails. The dried brown matter was on the patient's clothing, smeared on the bed linens, blanket, the right side bed rail and the privacy curtain. Attempts were made to engage Patient A in conversation, but the patient did not respond. The patient attempted to cover herself with the soiled linens and had a look of embarrassment on her face. The call light was observed hanging down near the ground on the right side of the bed, out of reach of Patient A. Facility staff was observed going in and out of Patient A's room without staff attending to Patient A's needs in spite of the obvious odor of bowel movement in the room. During a second observation at 9:58 a.m., Patient A was in the same condition as seen earlier except the brown matter was now on the patient's legs and her pillow. The patient remained alert. Attempts were made to interview her again, but Patient A was unable to respond to questions. A certified nursing assistant (CNA 1) was observed walking into Patient A's room carrying a clear plastic bag of what appeared to be clean linens. CNA 1 was asked when the last time the patient had been changed or attended to. CNA 1 stated the patient was changed at 6:30 or 7 a.m. CNA 1 further stated she was the last one to change Patient A. CNA 1 was asked how often patients were to be checked. The CNA stated every two hours. When asked if Patient A had been checked since 6:30 or 7 a.m. this morning CNA 1 stated, "No." CNA 1 further stated she was not able to tend to the patient sooner due to being short staffed. CNA 1 said she had two more patients to care for than normal. Patient A's clinical record was reviewed. Patient A, age 69, was admitted to the facility initially on May 15, 2010, with diagnoses that included cerebral infarction (stroke), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), bipolar disorder (disorder associated with episodes of mood swings) and major depressive disorder (mood disorder causing a persistent feeling of sadness). A review of Patient A's, "History and Physical," (H&P) dated August 18, 2015, indicated the patient, "does NOT have the capacity to understand and make decisions." Patient B was interviewed on February 19, 2016. Patient B was asked about the staff response to call lights. Patient B stated the three to eleven shift was, "the worst." He stated he was blind and that he had to wait for assistance. He further stated that he had soiled himself waiting. Patient B said he had to sit in his soil (urine or bowel movement) until someone came. He stated that made him, "feel bad." Patient B's record was reviewed. Patient B, age 44, was admitted to the facility on July 9, 2013, with diagnoses that included benign neoplasm of cerebral meninges (a non-cancerous brain tumor), and hypertension (high blood pressure). A review of Patient B's, "H&P," dated July 25, 2015, indicated the patient, "has capacity to understand and make decisions." The Director of Staff Development (DSD) was interviewed on February 19, 2016. The DSD was asked about the facility policy for making rounds and checking on patients. The DSD stated patients should be checked every two hours. The DSD was informed of the observation of Patient A and the condition in which she was observed. The DSD stated that that was, "wrong and should not have happened." The Director of Nursing (DON) was interviewed on February 19, 2016. The DON was asked for the facility policy on making rounds and checking on patients. The DON stated the patients should be checked every two hours. With regards to Patient A, the DON stated they were aware, "it was a dignity issue," and had dealt with the situation. Requests were made for facility policy and procedures for the rounding or monitoring of patients. The DON stated there were no policies that addressed the timely monitoring of patients. Therefore, it was determined the facility failed to ensure Patients A and B were provided with care that maintained dignity and respect when Patient A was observed with a dried brown matter in her hair, across her forehead, on her clothing, bedding, and privacy curtain, and Patient B was made to wait an extended period of time in soiled briefs before assistance was provided which resulted in the patient sitting in his own waste until a facility staff member came to change him. The violation of the above regulation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 250000072 |
PALM TERRACE CARE CENTER |
250012713 |
B |
8-Nov-16 |
94WQ11 |
7625 |
Class B Citation Name of the Facility: Palm Terrace Health Care Complaint number: CA00436375 483.65(a) The facility must establish an infection Control Program under which it- (1) Investigates, controls, and prevents infection 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. The facility failed to implement an infection control program after Patient 1 was diagnosed with Legionella Pneumophila on July 22, 2014, one day after the patient's discharge from the facility. This failed practice increased the potential to transmit Legionnaire's Disease to all patients, from September 15, 2014, through March 25, 2015, and the actual transmission of the legionella bacteria to 10 patients, (Patients 4-13), and the actual transmission and subsequent death of one patient, Patient 4, where a contributing factor to her death was Legionnaire's Disease. Also three patients, (Patients 1-3) tested positive for the Legionella Pneumophila Antigen. On September 15, 2014, the facility reported to the California Department of Public Health (CDPH) that one patient, Patient 1 had tested positive for Legionella Pneumophila Antigen. The facility stated they received this information from the Riverside County Public Health Department. CDPH documentation indicated the facility was contacted multiple times by the Department from September 15, 2014, and January 29, 2015, with requests for copies of the facility's investigation, monitoring, testing, surveillance, and education related to the September 14, 2014, report of Legionnaire's Disease. The facility failed to provide the requested documentation and informed the Department they were following the Center for Disease Control (CDC) guidelines for Legionnaire's Disease. On March 25, 2015, at 9:30 a.m., an unannounced visit was made to the facility to investigate one complaint of two additional cases of Legionnaire's Disease (now a total of three) which were reported and linked to the patients while residing at the facility. On March 25, 2015, a record review was conducted for Patient 1. The patient had multiple admissions to the facility with the last admission dates of July 3, 2014, through July 19, 2014. During that last admission the patient complained of chest congestion and had a productive cough. A chest x-ray was ordered on July 14, 2014, (five days prior to discharge). Antibiotics were ordered by the physician. Patient 1 requested to be sent to the hospital, but the physician discharged the patient home with instructions to go to the hospital from there if there was no improvement. On July 20, 2014, one day after the patient's discharge, she was admitted to the general acute care hospital and diagnosed with Legionnaire's Disease. Beginning on March 26, 2015, all current facility patients were tested for Legionnaire's Disease. As a result, the urine of 12 current patients tested positive for the Legionnaire's antigen (any substance, including bacteria, foreign to the body that triggers an immune response), or a total of 13 infected patients. On March 27, 2015, the contracted water testing agency collected and sent for analytic testing 26 water samples from multiple areas throughout the facility including patient care areas, water heaters, and staff areas. On April 3, 2015, the results indicated five of the 26 samples showed detectable levels of legionella bacteria. On March 26, 2015, at 11:30 a.m., a review of the most current undated facility Policy and Procedure (P&P) titled, "Infection Control Program," indicated: * "The facility shall establish an infection control program designed to provide a safe, sanitary, and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection. * "Health Component"- Residents will be provided with screening for infectious diseases, physical exams, infection monitoring, and treatment for infectious diseases. * "Educational Component" - The staff development program will include orientation, training, and in-service programs and the Quality Improvement Program will include infection reports, demographic data, and regular review of the infection control program. * "Surveillance Component"- Surveillance of resident will include reporting individual incidents of infection and auditing medical records." A concurrent review of the most current, undated facility document titled, "Infection Control Plan," indicated, "The facility shall establish an Infection Control Committee which will oversee and implement the plan of the Infection Control Program.... Committee members will detect and record nosocomial (facility acquired) infections...provide a safe environment within the facility for the protection of residents...provide helpful data on the incidence of nosocomial infection in the facility...The Infection Control Committee shall meet at least monthly." During an interview conducted with the ADM and Director of Nursing (DON) on April 6, 2015, at 11:30 a.m., they were unable to produce monthly Infection Control Meeting Minutes. The ADM stated infection control issues were normally included in the quarterly Utilization Review (UR) meetings. He stated in the two meetings held since the September 2014 initial case of Legionnaire's Disease, the attendants had not discussed Legionnaires Disease. During an interview conducted with the ADM, DON, and Director of Staff Development on April 6, 2015, at 11:30 a.m., the following was noted: * After the first Legionnaire's case discovered September 15, 2014, the facility had not conducted any in-service training to staff relating to Legionnaire's Disease, early identification, signs, symptoms and treatments. * After the first Legionnaire's case discovered September 15, 2014, the facility had not completed any environmental tests, or received e-mail communications from an environmental testing company or invoices from an environmental testing company relating to testing the facility for Legionnaire's Disease. * There was no documentation supporting patient or facility surveillance conducted after the first Legionnaire's case discovered September 15, 2014. The facility failed to implement an effective infection control program to investigate, control, monitor, document, and provide evidence of process and outcome surveillance after Patient tested positive for Legionella Pneumophila Antigen on July 22, 2014. The facility failed to contract the local health department after learning about the Legionnaire's Disease diagnosis for Patient 1. The facility failed to conduct a thorough epidemiological (finding the root source) investigation and begin an intensive preventative and surveillance program for additional positive Legionella Pneumophila antigen cases per CDC and local county public health guidelines. The facility failed to investigate if evidence of continuing transmission of Legionnaire's Disease existed within the facility. The facility failed to conduct environmental testing to determine the source of legionella by collecting water samples from potential sources of aerosolized water after patient 1 was diagnosed with Legionnaire's Disease or Legionnaire's bacteria on July 22, 2014. The facility failed to ensure Patients 2 through 13 did not become Legionella positive while at the facility between January 20, 2015, through March 27, 2015. The above violations either jointly, separately, or in any combination had a direct or immediate relation to patient health, safety, or security. |
| 250000087 |
PROVIDENCE MT. RUBIDOUX |
250012948 |
B |
9-Feb-17 |
4MGS11 |
8913 |
Title 22 72311 (a) (3) (B) Nursing Service- General
(a) Nursing service shall include, but not be limited to, the following:
(3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly:
(B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.
During a complaint investigation initiated on November 5, 2015, it was determined that the facility failed to immediately notify Resident 1's physician regarding multiple episodes of hyperglycemia (high blood sugar) and failed to provide prompt interventions when Resident 1 experienced the episodes of hyperglycemia.
As a result of these failures, Resident 1 developed diabetic ketoacidosis (DKA - a serious condition which can lead to diabetic coma or even death) that required admission to the acute care hospital's intensive care unit for seven days
on an intravenous (IV - in the vein) insulin drip (fast acting insulin added to an intravenous solution and given at a rate to provide a specific amount of insulin per hour) to control Resident 1's hyperglycemia.
Resident 1's record was reviewed. Resident 1, a 58 year old female, was admitted to the facility on XXXXXXX 2015, with diagnoses which included diabetes mellitus type 2 (a chronic disease characterized by high levels of sugar in the blood).
According to American Diabetes Association, normal blood sugar ranges from 70- 140 mg/dL (milligram per deciliter- unit of measurement for blood sugar level).
Resident 1's history and physical completed during her first acute hospital admission, dated October 16, 2015, was reviewed and indicated, "Impression...Hyperglycemia. The patient had diabetes with uncontrolled hyperglycemia. The patient needs aggressive insulin therapy along with fluid hydration and close monitoring to prevent her from going into DKA..."
A document located in Resident 1's facility record titled, "Physician Order," dated October 18, 2015, indicated, "Continue all meds (medications) Stop Novolog (a fast acting insulin) Accucheck (a finger stick blood sugar test) T.I.D. (three times a day) per alternating custom schedule. Call MD (medical doctor) if BS (blood sugar) > (greater than) 250."
A document in Resident 1's facility record titled, "Blood Glucose Testing Record," using the alternating custom schedule, dated October 19 to 23, 2015, indicated the following:
1. October 19, 2015, Frequency: "before breakfast BS (blood sugar) - 120, after breakfast BS- HI (high), before lunch BS- HI; and
2. October 20, 2015, Frequency: "after breakfast BS- 294, before lunch BS- 363, after lunch BS 159".
The blood sugar results were obtained using a glucometer. The glucometer (a device that measures blood sugar from a drop of blood obtained from a finger stick) instruction manual provided by the Director of Nursing (DON) was reviewed. The manual titled, "Assure Platinum Blood Glucose Monitoring System," indicated if the glucometer reading was HI, it meant the blood glucose (blood sugar) was above 600 mg/dL (milligram/deciliter- concentration solution of blood sugar).
The October 19 and 20, 2015, nursing notes were reviewed. As written above in the "Blood Glucose Testing Record," the blood sugar levels obtained on October 19, 2015, after breakfast (HI) and before lunch (HI) were reported at 11:30 a.m. and at 5 p.m. respectively. Resident 1's high blood sugar levels were reported to the physician two to five and one- half hours late on October 19, 2015.
Resident 1's Medication Administration Record (MAR) dated October 19, 2015, indicated interventions for elevated blood sugar levels taken after breakfast and before lunch were provided at 12 N and 8 p.m. (three to eight and one-half hours late) on October 19, 2015.
There was no documented evidence Resident 1's high blood sugar of 294 after breakfast and 363 before lunch were reported as ordered by the physician on October 20, 2015.There was no documented evidence an intervention was provided when blood sugar levels were elevated to 294 after breakfast and 363 before lunch on October 20, 2015.
During an interview at 1:18 p.m. on November 10, 2015, Registered Nurse (RN) 1 stated the alternating schedule for the accucheck (blood sugar check) was being used by the facility medical director. RN 1 stated the accucheck schedule if ordered before breakfast should be done at 6:30 a.m., if after breakfast should be done at 9 a.m., before lunch at 11:30 a.m., after lunch at 2 p.m., before dinner at 4:30 p.m., after dinner at 7 p.m. and at bedtime at 9 p.m. RN 1 stated the medical doctor should be notified immediately if the blood sugar was high according to the doctor's order.
During an interview at 1:45 p.m. on November 10, 2015, the Director of Nurses (DON) stated elevated blood sugar was considered a change of condition. She stated any change of condition should be reported to MD and should be documented in the resident's medical record, including the new order given by the MD. The DON stated, she could not answer for the nurses regarding the time frame the change of condition was reported. She further stated she could not find any documentation if the elevated blood sugar levels on October 20, 2015, were reported to MD.
On October 24, 2015, the nurses' notes indicated Resident 1 started vomiting at 12:45 a.m., with an elevated blood sugar level of "HI." At 1 a.m., Resident 1 vomited two times with an elevated blood sugar level of "HI". At 1:25 a.m., Resident 1 had vomited again two times and the blood sugar level read high. Resident 1 requested to be sent to the hospital to further evaluate her projectile vomiting (vomit that exits the mouth with such force in that it is propelled over a short but significant distance).
When Resident 1 arrived at the hospital's Emergency Room (ER), her first blood pressure was recorded as 89/47 (as defined in the 22nd Edition of Taber's Cyclopedic Medical Dictionary, normal blood pressure is between 100 and 120 systolic (top number) and 80 or below diastolic (bottom number) at 2:40 a.m. Resident 1 had other laboratory studies completed with a critical blood sugar reading of 1,430 mg/dL (normal 70 to 140 mg/dL).
Resident 1 was admitted to the hospital's intensive care unit (department of a hospital that is designed and equipped for the monitoring, care, and treatment of seriously ill or injured patients) on an insulin drip (fast acting insulin added to an intravenous solution and given at a rate to provide a specific amount of insulin per hour).
Resident 1's history and physical for the second admission, dated XXXXXXX 2015 (six days after Resident 1's first discharge from the acute care hospital), indicated, "... She (Resident 1) has uncontrolled diabetes last time as well. She comes in now with encephalopathy (disease of the brain that alters brain function or structure), hypothermia (body core temperature dropped below normal which can be fatal), hyponatremia (condition that occurs when the level of sodium in the blood is abnormally low), and diabetic ketoacidosis; it is unclear how this could have happened at the nursing facility..."
According to American Diabetes Association, last edited March 18, 2015, "Diabetic Ketoacidosis (DKA) is a serious condition that can lead to diabetic coma or even death... DKA usually develops slowly. But when vomiting occurs, life-threatening condition can develop in a few hours...What causes DKA...Not enough insulin. Maybe you did not inject enough insulin. Or your body could need more insulin than usual because of illness..."
The facility policies and procedures were reviewed. The policy and procedure titled," Change in a Resident's Condition or Status,: dated April 2011, indicated,"...The Nurse Supervisor/charge nurse will notify the resident's Attending Physician or On-call Physician when there has been:...d. A significant change in the resident's physical/emotional/mental condition...i. Instructions to notify the physician of changes in the resident's condition..."
The policy and procedures titled, "Administering Medications," dated April 2010, indicated," Policy... Medications must be administered in accordance with the orders, including any required time frame..."
Therefore, the facility failed to immediately notify the physician of Resident 1's multiple episodes of hyperglycemia, and the facility failed to provide prompt interventions when Resident 1 experienced the multiple episodes of hyperglycemia resulting in Resident 1 developing DKA (placing Resident 1 at risk for diabetic coma or death) which required admission to the acute care hospital's intensive care unit for seven days on an insulin drip to control the resident's hyperglycemia.
The violation of this regulation presented a direct relationship to the health, safety, or security of the resident. |
| 250000087 |
PROVIDENCE MT. RUBIDOUX |
250013007 |
B |
7-Mar-17 |
D5VF11 |
3191 |
HSC 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
HSC 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation.
_________________________________________
The facility failed to implement their policy and procedure for the facility reporting all alleged incidents of abuse and neglect to the California Department of Public Health.
The facility had 18 incidents of alleged physical abuse, five incidents of alleged verbal abuse, one incident of unspecified abuse, and one incident of neglect (unsupervised resident who eloped from the facility) between October 17, 2016, and January 11, 2017.
On January 10, 2017, at 3:38 p.m., an interview was conducted with the Quality Assurance Nurse (QAN). A copy of the accident/incident log for October through December 2016 was requested. The QAN stated he was unable to print out the requested information.
On January 11, 2017, at 3 p.m., an interview was conducted with the Administrator and the Director of Nursing (DON). The Accident and Incidents logs for October thru December 2016, were requested.
On January 11, 2017 at 3:20 p.m., copies of the accident/incidents logs from October 17, 2016, thru January 11, 2017, were received.
(a) The facility Accident and Incident log included 26 incidents of alleged abuse and neglect noted between October 17, 2016, thru January 11, 2017.
There was no documentation to reflect the 26 incidents were reported to the Department.
In an interview conducted with the Administrator on January 11, 2017, at 3:45 p.m., he stated he was unsure if any of the resident-to-resident abuses or the elopement were reported to the Department. The Administrator stated he was not aware the alleged incidents of abuse and neglect needed to be reported to the Department of Public Health Licensing and Certification.
In a concurrent interview with the Director of Nursing (DON) she stated she did not report alleged incidents of resident-to-resident conflict because the facility handled them in-house. The DON stated several of the incidents included physical altercations and minor injuries.
A review of the facility policy and procedure titled, "Incident/Accident Management," with a revision date of December 2015, indicated:
"POLICY
It is the policy of this center to investigate incidents and report them as required by law.
FUNDAMENTAL INFORMATION
Purpose
...To meet the requirements of both state and federal law that incidents are investigated, documented and reported as mandated.
...PROCEDURES:
...10. The Administrator/designee will notify the appropriate state agency of incident(s) in accordance with state and federal law... "
The facility failed to implement their policy and procedure for reporting all alleged incidents of abuse and neglect to the California Department of Public Health. This failure increased the potential for re-occurrence of abuse and neglect and placed all residents in the facility at increased risk for abuse and neglect, up to and including physical and emotional harm. |
| 250000091 |
PROVIDENCE ORANGE TREE |
250013296 |
B |
21-Jun-17 |
X0JR11 |
10868 |
42 CFR 483.21 (b) (3) (i) Services Provided Meet Professional Standards
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
During a complaint investigation initiated on March 27, 2017, it was determined that the facility failed to ensure services met the professional standards of quality when a medication was consistently documented as administered for six months for one resident (Resident A) in spite of the medication being unavailable at the facility.
Resident A, a 59 year old female, was admitted to the facility on XXXXXXX 2016, with diagnoses which included type 2 diabetes mellitus (life-long disease in which there is a high level of sugar in the blood), hypertension (high blood pressure) with heart failure, and chronic hepatitis C (viral disease that leads to swelling/inflammation of the liver).
A physician order, dated October 12, 2016, for Resident A indicated an order for Harvoni (specific medication for chronic hepatitis C) tablets to be given once a day.
Resident A's Medication Administration Record (MAR) dated October 1 through 31, 2016, was reviewed and indicated:
a. October 13, 17, 22, 24, 25, 28, and 31, 2016, - documented as (9);
b. October 18, 19, and 20, 2016, - documented as (5); and
c. October 14-16, 21, 23, 26, 27, 29, and 30, 2016, - documented with a check mark.
According to the MAR codes, the codes 9 meant ?other/ see nurse notes?, 5 meant ?hold/see nurse notes?, and check mark meant ?administered?.
Resident A?s MAR in October 2016, had documentation of Harvoni being administered nine times out of 19 days.
The medication administration notes dated October 13 through 31, 2016, were reviewed and indicated Resident A's Harvoni medication was being held due to pending authorization from the insurance and was unavailable.
Resident A's MAR dated November 1 through 30, 2016, indicated:
a. November 1, 7, 8, 13, 14, 16-19, 21, 27-30, 2016, -were documented as given; and
b. November 2-6, 9-12, 15, 20, 22, 24, 26, 2016- were documented (9).
Resident A?s MAR in November 2016, had documentation of Harvoni being administered 14 times out of 30 days.
The medication administration notes dated November 1 through 30, 2016, were reviewed and indicated the Harvoni medication was pending insurance authorization (1 month after it was initially ordered).
Resident A's December 1 through 31, 2016, (2 months after the Harvoni was initially ordered) MAR indicated:
a. December 1, 2, 4, 6-9, 14, 17-20, 25, 26, 29, and 31, 2016- was documented with a check mark;
b. December 3, 5, 10-13, 15, 16, 21, 22, 24, 27-28, 2016- were documented as (9); and
c. December 23, 2016, -was documented as (5).
Resident A?s MAR in December 2016, had documentation of Harvoni being administered 16 times out of 31 days.
The medication administration notes dated December 1 through 31, 2016, were reviewed and indicated Resident A's Harvoni was unavailable, awaiting MD (medical doctor) clarification, awaiting liver biopsy (medical removal of tissue from a living subject to determine the presence or extent of a disease).
Resident A's MAR dated January 1 through 31, 2017, (3 months after the Harvoni was initially ordered by the physician) indicated:
a. January 1, 2, 4, 5, 10-13, 16, and 28, 2017, was documented as (9);
b. January 3, 6-9, 14, 15, 20, 21, 26, 27, and 31, 2017, were documented with a check mark; and
c. January 17-19, 22-24, 29-30, 2017, were documented as (5).
Resident A?s MAR in January 2017, had documentation of Harvoni being administered 12 days in 31 days.
The medication administration notes indicated the Harvoni medication was held pending liver biopsy and awaiting authorization.
Resident A's Medication Administration Record (MAR) dated February 1 through 28, 2017, (4 months after the medication was ordered by the physician), indicated:
a. February 1 to 3, 5-8, 11, 13-14, 19-20, 25-26, 2017, - were documented with a check mark;
b. February 4, 9, 12, 15-18, 21-24, 27-28, 2017, - were documented as (9); and
c. February 10, 2017, - was documented as (5).
Resident A?s MAR in February 2017, had documentation of Harvoni medication being administered 14 days in 28 days.
The medication administration notes dated February 1 through 28, 2017 were reviewed and indicated Harvoni medication was held due to unavailability, and pending authorization.
Resident A's MAR dated March 1 through 27, 2017, was reviewed and indicated the following:
a. March 1-2, 5-8, 11-13, 17, 19, 24, 27, 2017, were coded 9;
b. March 3-4, 9-10,14-16, 20-23, 25-26, 2017, was coded with a check mark.
Resident A?s MAR in March 2017, had documentation of Harvoni being administered 13 times in 27 days.
Resident A's progress notes dated March 1 through 26, 2017, were reviewed and indicated, "awaiting appt (appointment with ID (infectious disease) doc (doctor) for authorization "and "not available from pharmacy".
The above documentation from October 2016 through March 2017 indicated Resident A's Harvoni was being held due to unavailability and was pending authorization from insurance since October 2016.
On March 27, 2017, at 10:25 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated Resident A's Harvoni was unavailable and was on hold pending pharmacy to deliver.
Resident A?s MAR dated March 1 to 27, 2017, indicated LVN 1 had the medication Harvoni as administered multiple times (March 19, 20, 21, 25, and 26, 2017).
On March 27, 2017, at 12 p.m., the Director of Nursing (DON) stated the information he gathered was since October 2016, Resident A?s Harvoni had been unavailable.
On April 20, 2017, at 10:15 a.m., LVN 2 was interviewed. He stated if a medication was unavailable the nurses were expected to call the pharmacy to follow-up on delivery. LVN 2 stated the nurse was supposed to call the doctor to make them aware of unavailability of the medication.
On April 25, 2017, at 10:31 a.m., LVN 3 was interviewed. She stated she had never received Resident A?s Harvoni from the facility pharmacy. LVN 3 stated the appropriate way of administering medication should be for the nurse to check orders, check medication in accordance with the physician order, administer the medication and document what was administered. She stated if she knew the medication was unavailable she should have not documented it as given. LVN 3 stated the appropriate code should have been (9) and documentation should have been noted in the nurse?s note as not given.
Resident A?s MAR dated October 13 to 31, 2016, indicated LVN 3 had documented the medication Harvoni as administered for three consecutive days (October 14, 15, and 16, 2016).
On May 2, 2017, at 7:59 a.m., LVN 4 stated she follows the rule in medication administration of pour, pass then document. She agreed if there was no medication which was passed then there should not be documentation of medication being administered.
On May 2, 2017, at 2:40 p.m., Resident A's MAR was reviewed with LVN 4. She acknowledged documenting Resident A receiving Harvoni multiple times from October 2016 to January 2017. LVN 4 stated she could have overlooked documenting that it (Harvoni) was given when the medication was unavailable to be administered to Resident A. She stated she should have corrected the administered entries when she knew the Harvoni medication was not provided to Resident A due to unavailability.
Resident A?s MAR dated October 13 through 31, 2016, indicated LVN 4 had documented the medication Harvoni as administered multiple times (3 of 3 times she had taken care of Resident A) on October 21, 26, and 27, 2016.
Resident A?s MAR dated November 1 through 30, 2016, indicated LVN 4 had documented the medication Harvoni as administered multiple times (5 of 7 times she had taken care of Resident A) on November 1, 7, 8, 14, and 19, 2016.
Resident A?s MAR dated December 1 through 31, 2016, indicated LVN 4 had documented the medication Harvoni as administered multiple times (10 of 11 times she had taken care of Resident A) on December 1, 2, 7, 8, 14, 19, 20, 25, 26, and 31, 2016.
Resident A?s MAR dated January 1 through 31, 2017, indicated LVN 4 had documented the medication Harvoni as administered multiple times ( 8 of 8 times she had taken of Resident A) on January 3, 8, 9, 14, 20, 21, 26, and 27, 2017.
Resident A?s MAR dated February 1 through 28, 2017, indicated LVN 4 had documented the medication Harvoni as administered multiple times (10 of 10 times she had taken of Resident A) on February 1, 2, 7, 8, 13, 14, 19, 20, 25, and 26, 2017.
Resident A?s MAR dated March 1 through 27, 2017, indicated LVN 4 had documented the medication Harvoni as administered multiple times (6 of 6 times she had taken care of Resident A) on March 3, 4, 9, 10, 15, and 16, 2017.
On May 2, 2017, at 3:15 p.m., the facility pharmacy consultant stated Harvoni was costly and was only available at special outside pharmacy which did not include the current pharmacy being used by the facility.
There was no documented evidence Resident A?s Harvoni was ordered from an outside pharmacy from October to March 2017.
On May 3, 2017, at 9:58 a.m., the DON stated a medication which was unavailable and not administered should be documented as not given.
The facility policy and procedure was reviewed. The policy titled, " Administering Medications," revised December 2012, indicated, "...Medications shall be administered in a safe and timely manner, and as prescribed...Medications must be administered in accordance with the orders, including any required time frame...if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose..."
According to "Lippincott Nursing Center 8 rights of medication administration,"... 1. Right patient...2. Right medication...Check the order 3. Right dose...4. Right route... 5. Right time...6. Right documentation...* Document administration AFTER giving the ordered medication. * Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. 7. Right reason...8. Right response... "
Therefore, the facility failed to ensure the professional standards of quality were met when a licensed nurse consistently (6 months) documented a medication as administered despite the medication Harvoni being unavailable at the facility.
The above facts indicate that there was a willful material omission/falsification in the medical record for the patient. |
| 250000092 |
PALM SPRINGS HEALTHCARE & REHABILITATION CENTER |
250013436 |
B |
29-Aug-17 |
JRGJ11 |
8690 |
Fiduciary Abuse
F224
483.12(b)(1)-(3) PROHIBIT MISTREATMENT/NEGLECT/MISAPPROPRIATION
?483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms.
483.12(b) The facility must develop and implement written policies and procedures that:
(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(b)(2) Establish policies and procedures to investigate any such allegations, and
(b)(3) Include training as required at paragraph?483.95.
On May 22, 2017, a visit was made to the facility to investigate two linked complaints regarding the mishandling of funds for one resident (Resident 1).
During the investigation it was determined the facility failed to deposit Resident 1's funds into an interest bearing account and failed to monitor the total amount of funds in Resident 1's account. This failure caused Resident 1 to lose potential interest on the funds and also to become ineligible for Medi-Cal payment for medical care.
On May 22, 2017, the medical record for Resident 1 was reviewed. Resident 1 was admitted to the facility on February 28, 2014 with diagnoses including dementia (confusion, memory loss) and Chronic Obstructive Pulmonary Disease (disease causing shortness of breath).
On May 22, 2017, at 10:50 am, an interview was conducted with Administrator 1 (ADM 1). ADM 1 stated $13,000 of Resident 1's funds was found in a corporate account. ADM 1 stated the money was placed in the corporate account before ADM 1 took over as administrator at the facility. ADM 1 stated she had no idea why corporate was getting the funds, when it started, or how the funds were maintained for the resident. ADM 1 stated a check for the funds had been given to the new facility where Resident 1 now lived.
On May 22, 2017, at 11:15 am, an interview was conducted with Social Worker 1 (SW 1). SW 1 stated Resident 1 had a trust fund at the facility with a little under $1000. SW 1 stated the funds were used to buy toiletries, clothes, or any other personal items the resident wanted. SW 1 stated she did not know anything about Resident 1 having any additional funds.
On May 22, 2017, at 11:45 am, a phone interview was conducted with the Director of Patient Care Advocacy (DPCA). The DPCA stated he had received a call from Social Worker 2 (SW 2) (at the facility where Resident 1 had been transferred), regarding money being held for Resident 1. The DPCA stated he found $13,000 was held in a corporate account for Resident 1. The DPCA stated the corporate office was the payee for Resident 1's Social Security payments. The DPCA stated he called the corporate compliance office and asked for a check to be issued to Resident 1 and sent to her new residence. The DPCA stated he was not familiar with the corporate policy for handling resident funds.
On May 30, 2017, at 8:45 am, a phone interview was conducted with the supervisor at the Central Business Office (CBOS) for the corporation. The CBOS stated a resident's Social Security income should be received by the facility to pay their share of cost for their care and any remainder would be placed in a trust fund for the resident. The CBOS stated Resident 1's Social Security payments were sent to the facility, but automatically placed in a corporate account. The CBOS stated the funds were always under Resident 1's name in the corporate account. The CBOS initially stated this practice began in January 2015, but later amended the start date to October 2014. The CBOS stated the funds were mailed to Resident 1's new facility on May 18, 2017. The CBOS stated it would be the administrator at the facility who would be responsible to review the account's details and ask for any changes or corrections.
On May 30, 2017, documentation of Resident 1's corporate account was reviewed. The documentation indicated funds for Resident 1 were deposited into a corporate account every month beginning in October 2014. The share of cost deduction for medical care did not begin until January 2016.
On May 31, 2016 at 9:05 am, a phone interview was conducted with the Medical Records Supervisor (MRS). The MRS stated she tracks each of the resident's trust funds. The MRS stated a resident's Social Security would come to the facility, but would be automatically transferred to the Central Business Office. The MRS stated the only funds placed in the trust fund at the facility for each resident was $35 each month. Those funds were used to buy personal items or food not prepared at the facility that the resident wanted. The MRS stated the social worker had a petty cash fund from which she would give a resident the amount of money needed for a purchase. At the end of the month, money from the resident's account would repay the amount taken from the petty cash fund. The MRS stated she did not receive the corporate spreadsheets for the resident accounts and would not know how to read the corporate account spreadsheets. The MRS stated she thought Resident 1 received $686 in Social Security payment every month. The MRS stated she would only see the $35 deposited into Resident 1's trust fund for incidental purchases.
On May 31, 2017, at 9:35 am, a phone interview was conducted with The CBOS. The CBOS was asked to explain the notations made on Resident 1's spreadsheet of her corporate account. The CBOS stated "cash receipt" or "cash receipt-RFMS" would indicate Social Security payments to Resident 1. The CBOS stated the funds are posted to any month, there are no rules. As an example, The CBOS stated funds that came in March 2016 could be posted to January 2015. The notation, "Room Charge" was the notation used to indicate a share of cost. The CBOS stated funds held for a resident in the corporate account would not receive any interest. The CBOS stated Resident 1 did not receive any interest on the $13,000 held in the corporate account. The CBOS stated the Administrator at the facility would receive a monthly statement of the funds in the resident's corporate account.
On May 31, 2017, at 10:35 am, a phone interview was conducted with ADM 1. ADM 1 stated as administrator she does receive monthly statements for each resident's funds held in a corporate account. ADM 1 stated she was not aware of any resident receiving interest on their funds. ADM 1 stated, "That's the way is has always been done."
On June 20, 2017, at 11:35 am, an interview was attempted with Resident 1 with the assistance of another Health Facilities Evaluator Nurse (HFEN 1) as Spanish interpreter. Resident 1 was able to state her name, time of day, and the name of the facility where she is currently living. Resident 1 stated she remembered the previous facility. Resident 1 stated she had problems with her money at the previous facility every month. Resident 1 stated she did not want to talk about the money or anything else.
On June 20, 2017, at 11:45 am, an interview was conducted with Administrator 2 (ADM 2) of the facility where Resident 1 currently resides. ADM 2 stated Resident 1 would lose her Medi-Cal funding for health care as a result of the funds that were being placed in her trust fund at the current facility. ADM 2 stated this may result in Resident 1 needing to pay privately for her care.
On June 22, 2017, the facility policy and procedure (P&P) where the resident previously resided, dated November 15, 2001, and titled, "Resident Trust Accounts" was reviewed. The P&P indicated, "The resident trust fund is managed by the facility and is kept in an interest bearing account..." The P&P also indicated, "1. When the Resident's account approaches the state limit (a balance within $200 under the limit), the facility's Social Services Department or designee must notify the resident and/or responsible party. 2. In the case of excess resources, appropriate actions must be taken as necessary according to specific state regulations."
Therefore, the facility failed to deposit one resident's (Resident 1) funds into an interest bearing account and failed to monitor the total amount of funds in Resident 1's account. This failure caused Resident 1 to lose potential interest on the funds and also to become ineligible for Medi-Cal payment for medical care.
The above violations jointly, separately, or in any combination, had a direct or immediate relation to the health, safety, and security of patients. |
| 910000068 |
PALOS VERDES HEALTH CARE CENTER |
910007237 |
A |
03-Oct-13 |
HFIB11 |
11963 |
F 223 483.13(b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The Department received an entity reported incident on November 2, 2009, after a resident (Resident 1) alleged that LVN 1 sexually abused her on three separate occasions while providing care. First kissing her, then grabbing her breast, and most recently touching her private area.On November 17, 2009, an unannounced visit to the facility to investigate the incident was conducted.Based on interview and record review, the facility failed to ensure: 1. Resident 1 was free from sexual abuse. 2. Resident 1 felt safe, after the sexual abuse allegation. 3. Resident 1 had no direct contact with the perpetrator after the allegation, and after she expressed she was fearful. These failures resulted in Resident 1 having a reduction in mental capacity as exhibited by the resident?s feeling unsafe, depressed, agitated, and requiring more anti-anxiety medications because LVN 1 continued to work at the facility providing care to her. Resident 1 was transferred to a general acute care hospital (GACH) for a psychiatric evaluation and stayed for six days due to her agitation. According to the psychiatrist assessment, the resident was fairly stable prior to the incident.On November 17, 2009, a review of Resident 1's clinical record indicated she was a 55 year-old female admitted to the facility on June 5, 2009, with diagnoses that included hypothyroidism (thyroid gland does not produce a sufficient amount of the thyroid hormones), bipolar disorder (alternating moods of mania with episodes of depression), and insulin dependent diabetes mellitus (requiring insulin to control blood sugar levels). A review of an annual Minimum Data Set (MDS), a standardized assessment and care screening tool, dated September 2, 2009, indicated the resident?s long and short-term memory was intact. The resident's cognitive skill for daily decision-making was moderately impaired (with some difficulty in new situations). The resident had the ability to make herself understood and understand others. The resident required limited assistance (one-person assist) with transferring, personal hygiene, and toilet use, and extensive assistance with dressing and bathing.A review of a Resident Abuse Report Form, dated November 2, 2009, indicated the incident occurred on October 30, 2009, between the hours of 6-6:30 a.m., on the night shift (11 p.m.-7 a.m.) in Resident 1?s room. The report, which was written by the director of nursing (DON), indicated the resident had no behaviors such as sexual misconduct, making similar allegations, and/or any verbal or physical behaviors. A review of a typed social service interview with a certified nursing assistant (CNA 1), dated October 31, 2009, indicated the social worker called the facility to speak to CNA 1 after Resident 1 informed the facility of the sexual abuse allegation. According to the written interview, CNA 1 stated she heard a call light buzzing and found the resident mad, furious, and crying, indicating LVN 1 touched her private area. CNA 1 told the social worker the resident demonstrated to her how LVN 1 touched her. CNA 1 informed the social worker she had called LVN 1 into the resident?s room and he walked out of the room mad and upset. The social worker documented she had asked CNA 1 what was LVN 1?s facial expression while in the resident?s room, and CNA 1 stated, ?He looked guilty and his body language said it more.?According to the director of nursing?s (DON) written interview with the resident?s family member, dated November 2, 2009, and timed at 9:30 a.m., the family member stated the resident has never complained of any sexual abuse before and indicated she thought it would be unusual for the resident to complain of sexual abuse if it had not occurred. During an interview, on November 17, 2009, at 3:15 p.m., the DON stated the investigation of LVN 1 touching Resident 1 was still in progress, which was 18 days after the allegation. According to the DON, she interviewed the resident on several occasions and the resident related the occurrence of the incident the same each time. On November 17, 2009, at 3:30 p.m., during an interview, Resident 1 stated that in the early morning of October 30, 2009, LVN 1 came into her room to administer her insulin (used to remove excess glucose from the blood, which otherwise would be toxic) and put his hand down her stomach and touched ?her crotch? (her private part). The resident stated she yelled out and a certified nursing assistant (CNA 1) came into the room and she told CNA 1 what had occurred. The resident stated CNA 1 brought LVN 1 back into her room and he was very angry and called her a liar in front of CNA 1. Resident 1 stated LVN 1 had kissed and fondled her breast on two other occasions while he was providing care to her. Resident 1 stated CNA 1 told her to call the police the next time LVN 1did something to her. According to the resident, and as indicated in the social service progress note, dated October 30, 2009, and timed at 8:30 a.m., it was the resident who reported the sexual abuse and not LVN 1 or CNA 1. A review of a psychiatric evaluation, handwritten by the psychologist, dated November 5, 2009, and timed at 1-2 p.m., indicated he explored the resident?s feelings regarding the inappropriate touching by a male employee. The note indicated the resident stated that over the past month (October 2009) LVN 1 had sexually harassed her on three separate occasions. The resident expressed she was quite upset about it. The physician documented the resident informed him that something like sexual abuse had never happened to her before.A review of a letterhead typed psychiatric re-evaluation, dated November 9, 2009, without a time, indicated the resident was seen secondary to being agitated. Under the Mental Status Exam, the report indicated the resident had no hallucinations, delusions, suicidal or homicidal ideations, and with fair memory and cognitive capacity.On November 17, 2009, at 5 p.m., the administrator stated LVN 1 was not suspended, but should have been until the investigation was completed. The administrator stated, ?I have to weigh things, because I have known the LVN since the year 2000.? A review of a social service note, dated November 25, 2009, without a time, indicated the social worker met with Resident 1 and the resident expressed her frustrations about LVN 1 remaining to work at the facility. According to the note, the resident had more anxiety and depression after the incident. The social worker encouraged the resident to cry and talk more about her feelings. The social worker documented she informed the resident that the investigation was still ongoing (almost 30 days later). On December 7, 2009, while at the facility, an unidentified staff member placed a small piece of paper in the surveyor?s hand. The note read: Please investigate and do something to that "----- " (LVN 1's name) he did it to? ------ ---- ?(Resident 1's name).At 9:05 a.m., during an interview, on December 7, 2009, LVN 1 stated he went into Resident 1's room around 6 a.m., on October 30, 2009, to give her insulin. LVN 1 stated after giving the insulin injection to the resident he went back to the nursing station. LVN 1 stated CNA 1 called him into Resident 1's room because the resident had complained that he held her private part. When asked if there were other allegations against him, LVN 1 stated, ?I know about two from Resident 1. I heard from another staff that the resident stated I had kissed her before while taking her blood sugar.? On December 10, 2009, at 9 a.m., during a telephone interview, CNA 1 stated on October 30, 2009, around 6 a.m., she heard Resident 1 screaming her name. CNA 1 stated she went into Resident 1?s room and had to calm her down. CNA 1 stated Resident 1 showed her how LVN 1 grabbed her crotch. CNA 1 stated she went to LVN 1 and brought him to the resident's room. CNA 1 stated LVN 1 was irate and told the resident she was a liar and both the resident and LVN 1 were yelling at each other. The resident demonstrated again what LVN 1 had done to her. CNA 1 stated Resident 1 does not lie and had told her of a previous incident of LVN 1 kissing her. CNA 1 stated after the incident on October 30, 2009, LVN 1 would call her to accompany him into Resident 1?s, because if he went by himself, the resident would scream. CNA 1 stated Resident 1 would become upset every time LVN 1 was around her and would scream. CNA 1 stated the resident informed her on the morning of the incident she did not tell LVN 1 to give her the insulin in her stomach, but wanted it given in her arm.CNA 1 stated after the incident on October 30, 2009, LVN 1 tried to convince her that Resident 1 was confused and told her, ?We have to stick together.? CNA 1 stated LVN 1 was very nervous telling her, ?I cannot lose my job, I have a sick wife.?A review of a nurse?s note dated December 2, 2009, and timed at 7:30 a.m., indicated Resident 1 was exhibiting screaming and yelling outbursts. According to the note, the resident was crying and agitated while refusing care. Another nurse?s note, dated the same day, but timed at 4:30 p.m., indicated the resident?s family was at the bedside. The resident?s physician was called and gave an order to transfer the resident via ambulance to the GACH for a psychological evaluation. A review of Medication Administration Records (MARs) for October 2009 and November 2009, indicated the resident had a physician?s order to receive Klonopin 0.5 mg (used in treatment for anxiety and panic attacks) every four hours whenever necessary (PRN) for anxiety. According to the MARs, the resident received one Klonopin for anxiety in the month of October. However, after the sexual abuse allegation in October 2009, the resident received eight Klonopin (0.5 mg) in the month of November 2009. A review of the GACH?s Emergency Room nurse?s note, dated December 2, 2009, and timed at 5:09 p.m., indicated the resident was transferred to the hospital after being assaulted by a staff member three times and being angry that he was still working in the facility. The nurse?s note indicated the resident stated, ?I reported the assault to the facility, but nothing was done and I?m angry he still works there.? The note further indicated the Sheriff?s Department was called and a deputy arrived and took a report. A review of an electronic ?Admission Psychiatric Evaluation? dictated on December 3, 2009, at 12:09 p.m., indicated under history of present illness, the resident who had been fairly stable until a few weeks ago ( incident occurred a few weeks prior), has become increasingly labile (unstable/fluctuating mood) and agitated. The physician dictated there were reports that the resident had reported being touched in her private area by one of the staff. Reportedly, the physician dictated the resident had become agitated and fearful. The psychiatrist dictated under Weaknesses and Strengths, the resident?s strengths included her history of cooperation with treatment. Resident 1 received psychiatric treatment for six days with medication changes while in the GACH and was discharged on December 8, 2009.A review of a ?Victim Notification Hearing? dated, July 23, 2010, and timed at 8 a.m., indicated Resident 1 was scheduled to appear in the case against LVN 1 after he was charged with a crime (unprofessional conduct- excessive force, mistreatment or abuse).The facility failed to ensure: 1. Resident 1 was free from sexual abuse. 2. Resident 1 felt safe, after the sexual abuse allegation. 3. Resident 1 had no direct contact with the perpetrator after the allegation, and after she expressed she was fearful.The above violations jointly, separately, or in any combination presented a substantial probability that death or serious physical or mental harm would result. |
| 910000068 |
PALOS VERDES HEALTH CARE CENTER |
910007238 |
B |
03-Oct-13 |
HFIB11 |
9034 |
F 225 Abuse 483.13(c) (2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 483.13(c)(3) The facility must have evidence that all alleged violations are thoroughly Investigated, and must prevent further potential abuse while the Investigation is in progress. 483.13 (c)(4) The results of all investigation must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. F226 483.13(c) Staff Treatment of Residents The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The Department received an entity reported incident (CA00206906) on November 2, 2009, and two complaints, received in December 2009 (CA00209940 and CA00210360) after a resident (Resident 1) alleged that a licensed vocational nurse (LVN 1) sexually abused her on three separate occasions while providing care. First kissing her, then grabbing her breast, and most recently touching her private area.On November 17, 2009, an unannounced visit to the facility to investigate the complaint was conducted.Based on interview and record review, the facility failed to protect Resident 1 and implement its abuse policy and procedure by failing to:1. Report the allegation of sexual abuse to the oncoming shift, since the allegation occurred at 6 a.m. 2. Notify the Department of Public Health and/or Ombudsman of the abuse allegation timely.3. Immediately remove LVN 1, during the investigation to keep the resident safe, as indicated in its policy. These failures resulted in Resident 1 feeling depressed, anxious, and unsafe. On November 17, 2009, a review of Resident 1's clinical record indicated she was a 55 year-old female admitted to the facility on June 5, 2009, with diagnoses that included hypothyroidism (thyroid gland does not produce a sufficient amount of the thyroid hormones), bipolar disorder (alternating moods of mania with episodes of depression), and insulin dependent diabetes mellitus (requiring insulin to control blood sugar levels). A review of an annual Minimum Data Set (MDS), a standardized assessment and care screening tool, dated September 2, 2009, indicated the resident?s long and short-term memory was intact. The resident's cognitive skill for daily decision-making was moderately impaired (with some difficulty in new situations). She had the ability to make herself understood and understand others. The resident required limited assistance (one-person assist) with transferring, personal hygiene, and toilet use, and extensive assistance with dressing and bathing.A review of a Resident Abuse Report Form, dated November 2, 2009, indicated the incident occurred on October 30, 2009, between the hours of 6-6:30 a.m., on the 11 p.m.-7 a.m. shift in Resident 1?s room. The report, which was written by the director of nursing (DON), indicated the resident had no behaviors such as sexual misconduct, making similar allegations, and/or any verbal or physical behaviors. The form indicated the department was not notified of the abuse allegation until November 2, 2009. On November 17, 2009, a review of the facility?s investigation indicated the allegation was not thoroughly investigated. The interviews only consisted of interviews with the resident, the resident?s family member, the alleged perpetrator (LVN 1), and a certified nursing assistant (CNA 1). There was no indication the facility had interviewed any other residents that LVN 1 provided care to or any other night-shift staff LVN 1 supervised as indicated in the facility?s abuse policy.During an interview, on November 17, 2009, at 3:15 p.m., the DON stated the investigation of LVN 1 touching Resident 1 was still in progress, which was 18 days after the allegation. According to the schedule LVN 1 was working during the facility?s investigation. On November 17, 2009, at 3:30 p.m., during an interview, Resident 1 stated that in the early morning of October 30, 2009, LVN 1 came into her room to administer her insulin (used to remove excess glucose from the blood, which otherwise would be toxic) and put his hand down her stomach and touched ?her crotch? (her private part). The resident stated she yelled out and CNA 1 came into the room and she told CNA 1 what had occurred. The resident stated CNA 1 brought LVN 1 back into her room and he was very angry and called her a liar in front of CNA 1. Resident 1 stated LVN 1 had kissed and fondled her breast on two other occasions while he was providing care to her. Resident 1 stated CNA 1 told her to call the police the next time the LVN did something to her. According to the resident, and as indicated in the social service progress note, dated October 30, 2009, and timed at 8:30 a.m., it was the resident who reported the sexual abuse and not LVN 1 or CNA 1. On November 17, 2009, at 5 p.m., the administrator stated LVN 1 was not suspended,but should have been until the investigation was completed. The administrator stated, ?I have to weigh things, because I have known the LVN since the year 2000.? On December 7, 2009, at 9:05 a.m., during an interview,LVN 1 stated he went into Resident 1's room on October 30, 2009, at around 6 a.m.,to give her insulin. LVN 1 stated after giving the insulin injection to the resident he went back to the nursing station. He stated CNA 1 called him into Resident 1's room because the resident had complained that he held her private part. LVN 1 stated he made documentation in the resident's chart regarding the incident, but did not call the administrator, DON, and/or report the incident to the oncoming shift. LVN 1 stated he was too tired to call and tell anyone when his shift was over. He stated he wrote a narrative report on November 2, 2009, to give to the administrator regarding the incident. LVN 1 stated he was not suspended until November 18, 2009, which was a day after the allegation was investigated by the Department, and 19 days after the alleged sexual abuse.LVN 1 stated the policy of the facility for an abuse allegation was to report the allegation to the administrator, the DON, and to the police as soon as possible, but stated he did not do so. He also stated the investigation should start immediately and the alleged perpetrator should be suspended.A review of the facility?s policy titled, ?Abuse Investigation Protocol? dated June 2000, the following was included under investigation: 1. Upon receipt of any allegation, the administrator or designee will thoroughly investigate the situation. 2. The individual in charge of the abuse investigation will notify the ombudsman. 3. Employees accused of resident abuse will be suspended from duty while investigation is pending. 4. Interview other residents to whom the accused employee provides care or services. 5. Interview staff members who have had contact with the resident during the 48-hour period prior to the time of the incident. On December 10, 2009, at 9 a.m., during a telephone interview, CNA 1 stated on October 30, 2009, around 6 a.m., she heard Resident 1 screaming her name. CNA 1 stated she went into Resident 1?s room and had to calm her down. CNA 1 stated Resident 1 showed her how LVN 1 grabbed her crotch. CNA 1 stated she went to LVN 1 and brought him to the resident's room. CNA 1 stated LVN 1 was irate and told the resident she was a liar. The resident demonstrated again what he did. CNA 1 stated Resident 1 does not lie, and had told her of a previous incident of LVN 1 kissing her. CNA 1 was asked what she did with the information of the LVN kissing the resident. CNA 1 stated she was not on duty during the time of the kissing occurred, but stated the resident informed her she had reported the incident to the social worker. CNA 1 stated, ?After the incident on October 30, 2009, LVN 1 would call me to go into Resident 1?s room with him, because if he went by himself, the resident would scream. CNA 1 stated Resident 1 would become upset every time LVN 1 was around her.The facility failed to protect Resident 1 and implement its abuse policy and procedure by failing to:1. Report the allegation of sexual abuse to the oncoming shift, since the allegation occurred at 6 a.m. 2. Notify the Department of Public Health and/or Ombudsman of the abuse allegation timely.3. Immediately remove LVN 1, during the investigation to keep the resident safe, as indicated in its policy. The above violation had a direct relationship to the health, safety, or security of Resident 1. |
| 910000068 |
PALOS VERDES HEALTH CARE CENTER |
910009808 |
B |
29-Mar-13 |
0NT911 |
4147 |
72315(b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. On May 24, 2010, the Department of Public Health received an anonymous complaint that Patient 1 was verbally abused by a charge nurse (Employee A). An unannounced visit was made to the facility on May 24, 2010, to investigate the complaint.Based on interview and record review, the facility failed to ensure Patient 1 was not verbally abused by Employee A.Employee A yelled at Patient 1, and threw a book on the floor next to her. According to the admission record Patient 1 was admitted January 11, 2010, with diagnoses that included osteoporosis (disease of the bones) and depression. The Minimum Data Set (MDS) assessment dated January 25, 2010, indicated the patient?s cognitive skills for daily decision making were independent. The patient was able to make herself understood with clear speech and understood others. She required extensive assistance from the nursing staff with her activities of daily living. The MDS also indicated the patient complained of moderate hip pain daily. There was a physician?s order dated February 3, 2010, for Baclofen 10 mg, twice a day (treats muscle spasm). On February 8, 2010, the physician ordered Vicodin 5/500 one tablet as necessary every four hours for pain, orally, and on March 11, 2010, Lidoderm Patch 5 percent to be applied to the patient?s left upper arm for pain daily at 9 a.m. and off at 9 p.m. The Licensed Personnel Weekly Progress Note, dated March 14, 2010, at 4:45 p.m., indicated Patient 1 was asking for her 5 p.m. medications. The note indicated that the patient was told that her medications were not due until 5 p.m. The note indicated Patient 1 did not listen and followed the charge nurse (Employee A) around insisting to get her medication and arguing with the charge nurse.On March 16, 2010, at 9 a.m., a note from the social service designee indicated Patient 1 reported an incident that occurred March 14, 2010, between her and the Employee A. A review of the Resident Grievance/Complaint Form, dated March 16, 2010, indicated Patient 1 stated on March 14, 2010, the charge nurse (Employee A) got mad, yelled and threw a book on the floor close to her. The grievance report indicated that it happened twice that day when she asked for her pain medication, Employee A did not treat her good. When she asked Employee A why the other charge nurses gave her all her pain medications together, Employee A got mad and yelled at her.The Grievance/Complaint Form dated March 16, 2010, documented an interview with Employee B who witnessed Patient 1 crying and upset. Employee B stated that it happened twice because she saw Patient 1 crying and upset with Employee A earlier. Then the second time when Employee A was passing the medication, Employee B said that she was in the room close to Patient 1?s room and she overheard Employee A?s voice mad and loud. Employee B stated that she got nervous because Employee A was arguing with Patient 1.During an interview on May 24, 2010, at 10 a.m., with Patient 1 regarding the March 14, 2010, incident she stated she asked Employee A about her medications for her muscle spasms and her Vicodin for pain. Employee A screamed and yelled at her and threw a big book near her onto the floor. On May 26, 2010 at 11 a.m. during a telephone conversation with Employee B, she stated she informed the 3 p.m. to 11 p.m. shift registered nurse (RN 1) what she heard on March 14, 2010. Employee B stated she was feeding another patient in the room next to Patient 1?s room and heard Employee A screaming at Patient 1 about the patient?s medications. Employee B stated she peeked into Patient 1?s room and saw and heard Employee A screaming at the patient, but did not see Employee A throw a big book. The facility failed to ensure Patient 1 was not verbally abused by Employee A.Employee A yelled at Patient 1, and threw a book on the floor next to her. The above violation had a direct or immediate relationship to the health, safety, and security of Patient 1, and all other patients of the facility. |
| 910000068 |
PALOS VERDES HEALTH CARE CENTER |
910009809 |
B |
29-Mar-13 |
0NT911 |
3475 |
Health and Safety Code ? 1418.91. Reports of incidents of alleged abuse or suspected abuse of residents (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.On May 24, 2010, the Department of Public Health received an anonymous complaint that a resident (Patient 1) was verbally abused by a charge nurse. An unannounced visit was made to the facility on May 24, 2010, to investigate the complaint.Based on interview and record review, the facility failed to: 1. Report an incident of alleged abuse made by Patient 1 against an employee of the facility to the Department of Public Health Services immediately or within 24 hours of the alleged abuse. This violation placed Patient 1 and other residents in the facility at risk for physical and emotional harm and was a violation of Patient 1's personal rights and safety.According to the admission record Patient 1 was admitted January 11, 2010, with diagnoses that included osteoporosis and depression. The Minimum Data Set (MDS) assessment dated January 25, 2010, indicated the patient?s cognitive skills for daily decision making were independent. The patient was able to make herself understood with clear speech and understood others. She required extensive assistance from the nursing staff with her activities of daily living. The MDS also indicated the patient complained of moderate hip pain daily. A review of the Resident Grievance/Complaint Form, dated March 16, 2010, indicated Patient 1 stated on March 14, 2010, the charge nurse (Employee A) got mad, yelled and threw a book on the floor close to her. The grievance report further indicated that it happened twice that day when she asked for her pain medication, Employee A did not treat her good. When she asked Employee A why the other charge nurses gave her all her pain medications together, Employee A got mad and yelled at her. There was also an interview with Employee B who witnessed Patient 1 crying and upset. Employee B stated that the incidenthappened twice because she saw Patient 1 crying and upset with Employee A earlier. Then the second time when Employee A was passing medications, Employee B said that she was in the room close to Patient 1?s room and she overheard Employee A?s voice mad and loud. Employee B stated that she got nervous because Employee A was arguing with Patient 1.The Grievance/Complaint Form dated March 16, 2010, indicated the administrator was informed of the incident on the same date. However, there was no documented evidence that the Department received an entity reported incident from the administratorby phone or by letter. During an interview with Employee C on May 24, 2010 at 12 p.m., he stated the incident should have been reported but was unable to explain why he did not report the incident to the Department.Based on interview and record review, the facility failed to: 1. Report an incident of alleged abuse made by Patient 1 against an employee of the facility to the Department of Public Health Services immediately or within 24 hours of the alleged abuse. This violation placed Patient 1 and other residents in the facility at risk for physical and emotional harm and was a violation of Patient 1's personal rights and safety.The above violation had a direct or immediate relationship to the health, safety, and security of Patient 1, and all other patients in the facility. |
| 910000022 |
Primrose Post-Acute |
910011657 |
B |
04-Nov-15 |
TQJY11 |
12392 |
F201 42 CFR 483.12 (a)(2) Transfer and Discharge Requirements The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless: (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health had improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare of 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(vi) The facility ceases to operate On October 19, 2014, at 10 a.m., an unannounced visit was made to the facility to investigate a complaint alleging a resident was denied readmission to the facility.Based on interview and record review, the facility's administrative staff failed to follow their transfer and discharge policy by failing to: Readmit Resident 12, on two separate occasions; September 30, 2014, and October 3, 2014, when an attempt was made to have her readmitted to the facility. This deficient practice resulted in Resident 12 being transferred from general acute care hospital (GACH) 1 to GACH 2 unnecessarily, placing the resident in a community where access to the resident was inconvenient for the resident?s responsible party and had the potential to cause isolation, depression, confusion and anxiety. On September 30, 2014, Resident 12 was transferred to GACH 1 for evaluation of back pain, uncontrolled behaviors and chronic obstructive pulmonary disease (COPD, a progressive disease that makes it hard to breathe) with exacerbation. That same day, September 30, 2014, the resident was cleared, by the GACH, to return to the skilled nursing facility (SNF) but the administrator refused to readmit her.A review of Resident 12's Admission Records indicated she was readmitted to the SNF on September 29, 2014. On September 30, 2014, she was transferred to GACH 1 for evaluation of back pain, uncontrolled behaviors and chronic obstructive pulmonary disease with exacerbation.Licensed Personnel Progress Notes, dated September 30, 2014 at 12:20 p.m., indicated Resident 12 complained of back pain. She was offered Tylenol, oxygen and repositioning all of which the resident refused. The resident's physician was called and an order was given to transfer her to GACH 2 for evaluation and treatment.There was a Physician's Order, dated September 30, 2014 at 12:20 p.m., to transfer Resident 12 to GACH 2 for evaluation and treatment of severe back pain, COPD exacerbation and uncontrolled behavior.A review of the Licensed Personnel Progress Notes, dated September 30, 2014, at 1:30 p.m., indicated Resident 12 was transferred. A review of GACH 1?s Admission Records indicated Resident 12 was admitted on September 30, 2014, at 2:17 p.m. A review GACH 1?s Physician Notes, dated September 30, 2014, at 6:58 p.m., indicated Resident 12 was medically screened and stable for disposition from the unit. A review of GACH 1?s time line of events, dated September 30, 2014, indicated the following: 8:20 p.m. - spoke with the SNF staff who informed GACH 1's registered nurse (RN) that Resident 12 was not accepted back. When asked why, there was no response. 8:38 p.m. - GACH 1's social worker call the SNF and spoke with RN 3 to inform him the SNF must hold Resident 12's bed for seven days. RN 3 indicated the SNF's administrator would call her back. 8:48 p.m. - RN 3 from the SNF called GACH 1's social worker to inform her Resident 12 was transferred to GACH 1 for behavioral issues and needed a psych evaluation. GACH 1's social worker informed RN 3 the resident was seen by a clinician at 3:57 p.m., and an evaluation was unnecessary. RN 3 informed GACH 1's social worker the resident could not return to the SNF without a psych evaluation and there was nothing he could do. 9:17 p.m. - GACH 1's social worker discussed the situation with a director of the GACH 1?s unit. It was decided to transfer Resident 12 back to the SNF since she had been medically and psychologically cleared. 9:30 p.m. - GACH 1's RN called the SNF and gave a report to RN 3. 10:29 p.m. - GACH 1's transportation was at Resident 12's bedside. Resident 12 was discharged in stable condition. On October 20, 2014 at 10:56 a.m., during a telephone interview, the Complainant stated she was told by the facility that Resident 12 was being transferred to GACH 2 because she was having pain in her back. She subsequently found out the resident had been transferred to GACH 1. Later that evening GACH 1 called her to report the resident had been treated and was being transferred back to the SNF. It was late in the evening (after 10 p.m.) so she decided to go the facility to see about the resident the following morning. When the Complainant arrived at the facility the morning of October 1, 2014, the SNF staff told her the resident was not at the facility, she had not been readmitted the prior evening and they did not know where she was. On October 20, 2014, at 11:55 a.m., during an interview, the Administrator stated GACH 1 called to readmit Resident 12 back to the facility but she never arrived. On October 20, 2014, at 3:02 p.m., during an interview, RN 1 stated he was as the front desk when Resident 12's responsible party came in asking where the resident was. RN 1 stated he told the resident's responsible party the resident was not there, she had been discharged from the facility the previous day and had not returned.On December 9, 2014, at 4:06 p.m., during a telephone interview, RN 3 stated GACH 1 called to report Resident 12 was ready to be transferred back to the facility. RN 3 inquired with the administrator who told him the resident should have been transferred to GACH 2 but was sent to GACH 1 by mistake. The administrator did not want to readmit the resident and wanted a psychiatric evaluation completed before the resident could return. GACH 1 called the facility to report the resident had been treated and they were going to send her back and proceeded to give him a report. RN 3, who worked the 3 p.m., - 11 p.m., shift stated Resident 12 arrived at the facility (not sure of the time) and was brought inside by the ambulance attendants on a gurney. The resident was never taken to her room but was transferred from one gurney to another gurney and a different transportation service transported the resident to GACH 2. RN 3 stated the administrator was present when the resident arrived and thought he had arranged for the ambulance to be waiting when the resident arrived at the facility. RN 3 stated there was no paper work generated when Resident 12 arrived at the facility because she was sent out immediately. On October 20, 2014, at 10:56 a.m., during a telephone interview, the Complainant stated she was upset when she arrived at the facility and no one, including the administrator, knew where Resident 12 was. The police were called. The complainant stated they finally located the resident who was at GACH 2. The complainant stated no one could explain how the resident went from GACH 1 to GACH 2. The facility staff insisted Resident 12 never arrived at the SNF.A review of the Emergency Provider Record, from GACH 2, indicated Resident 12 was admitted on September 30, 2014, at 11:45 p.m. A review of the Initial Assessment/Discharge Planning Record, by GACH 2?s discharge coordinator, dated October 3, 2014 at 4:30 p.m., indicated Resident 12 was admitted from the SNF but was not accepted back. A further review of this document indicated the discharge coordinator spoke with the SNF?s administrator to make him aware (after he refused readmission) Resident 12?s responsible party was refusing to send the resident to another facility. According to this document SNF?s administrator called GACH 2?s discharge coordinator to report the resident would be transferred to another SNF for a short time only. GACH 2's discharge coordinator called the resident's responsible party who confirmed the resident could be sent to another SNF for a few days only. According to the Admission Face Sheet, indicated Resident 12 was discharged from GACH 2 on October 3, 2014. On October 20, 2014, at 11:56 a.m., during a telephone interview, the Complainant stated GACH 2 called her to report Resident 12 was ready to be transferred back to the SNF but the SNF?s administrator refused to take her back. The Complainant called the SNF and the administrator told her they did not have a bed available because of some type of infection they had in the building. The Administrator asked the Complainant if she would agree to send Resident 12 to another facility for a few days until the infection cleared up then they would readmit the resident. The Complainant stated she agreed to transfer the resident to another SNF because she felt as though she had no choice. She was concerned the SNF wanted to get rid of the resident and they would not honor their agreement to readmit the resident. She stated she was right and as of (October 20, 2014, 17 days after the resident was discharged from GACH 2) the administrator had not called to have the resident readmitted to the facility. She stated she also cares for a disabled family member and it has been difficult getting to the new facility to visit Resident 12 because of the distance and her other responsibilities. She stated she lives approximately 5 minutes from the SNF the resident originally resided at.A review of the facility?s census, dated October 3, 2014, indicated the facility capacity was 68 and they had a total of 63 residents in house with no bed holds. A further review of the facility census report indicated Resident 12 was still listed as part of the in-house residents; the resident?s bed had not been given away and was still available. On October 23, 2014, at 1:12 p.m., during a telephone interview, GACH 2's discharge coordinator stated she spoke to the administrator of the SNF on October 3, 2014, he stated they were not accepting Resident 12 back. She asked him why and he responded they did not want her back and you can send her somewhere else. The discharge coordinator stated she called the resident's responsible party, who initially refused to send the resident to another SNF. However, eventually the responsible party agreed to transfer her to another SNF because the administrator told her the resident would only be there for 2-3 days. A facility policy on Transfers and Discharges, not dated, indicated the only reasons the facility can transfer you to another facility or discharge you against your wishes are: 1. It is required to protect your well-being, because your needs cannot be met in our facility; 2. It is appropriate because your health has improved enough that you no longer need the services of our facility; 3. Your presence in our facility endangers the health and safety of other individuals; 4. You have not paid for your stay in our facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5. Our facility ceases to operate; 6. Material or fraudulent misrepresentation of your finances to us. If you are discharged against your wishes, we will provide transfer and discharge planning as required by law. The facility's administrative staff failed to follow their transfer and discharge policy by failing to: Readmit Resident 12, on two separate occasions; September 30, 2014, and October 3, 2014, when an attempt was made to have her readmitted to the facility. This deficient practice resulted in Resident 12 being transferred from GACH 1 to GACH 2 unnecessarily, placing the resident in a community where access to the resident was inconvenient for the resident?s responsible party and had the potential to cause isolation, depression, confusion and anxiety. These violations had a direct relationship to the health, safety or security of residents |
| 910000068 |
PALOS VERDES HEALTH CARE CENTER |
910011665 |
B |
31-Aug-15 |
DFLE11 |
8113 |
42 CFR 483.13(b) - Abuse F 223 The facility must ensure that each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. ?Verbal abuse? is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. ?Physical Abuse? includes hitting, slapping, pinching and kicking. On July 15 2011, an onsite visit was made to the facility to investigate an allegation of verbal and physical abuse. Based on interview and record review, the facility failed to ensure Resident 2 was not subjected to verbal and physical abuse from another resident, Resident 1 by failing to: 1. Ensure resident(s) with behavior symptoms are monitored continuously to prevent abuse. 2. Intervene to separate resident(s) before an incident of abuse occurs. Ensure resident(s) with behavioral symptoms have a physician order for the use of a cane as an assistive device and the resident was monitored to prevent abuse to Resident 2, who sustained a right ear laceration. According to the facility?s report, a certified nursing attendant (CNA 2) saw Resident 2 being hit on his right ear with a cane by Resident 1. Resident 2 sustained a one centimeter laceration to the right ear. Resident 1 was reported to the local enforcement agency and taken to the GACH for further evaluation. According to the facility report, dated May 31, 2011, around 7:35 a.m., Resident 2 was coughing continuously and unable to stop or hold the cough. Resident 1 became irritated and went to Resident 2?s room doorway approached and told Resident 2 to stop coughing because it was bothering him. Resident 1 standing in front of Resident 2?s room doorway with his cane hit Resident 2 on his right ear. A review of the Enforcement Agency?s report dated July 8, 2011, indicated Resident 2 stated he has been a resident at the facility for the past five years and during breakfast Resident 1, who stays in the room across the hall from him came to his door and told Resident 2 to ?Shut his mouth or I will beat you?re a--?. Resident 2 stated he coughs uncontrollably due to his medical condition and it upsets Resident 1. Resident 2 asked Resident 1 what he was going to do to him because he cannot stop coughing. Resident 1 then stepped into Resident 2?s doorway and swung his wooden cane with his right hand at Resident 2, striking Resident 2 on his right ear. Resident 2 grabbed the cane with both hands and began to struggle with Resident 1.According to the Enforcement Agency?s report, a wooden cane approximately 36 inches long and beige in color was described as the weapon.During an interview on July 15, 2011 at 1 p.m., with CNA 1, she stated, while waiting for the breakfast trays she heard Resident 2 say loudly to Resident 1 what do you want and leave me alone he would call the charge nurse. Then CNA 1 saw Resident 2 and called the charge nurse and saw Resident 2 bleeding from his right earlobe. CNA 1 stated she did not see Resident 2 hit Resident 1 with his cane. In an interview on July 15, 2011 at 1:15 p.m., licensed vocational nurse (LVN 3) stated she was the charge nurse the day the incident occurred, but did not see anything. LVN 3 stated CNA 1 and CNA 2 saw the incident and called LVN 3 to come to the area. LVN 3 stated that CNA 1 and CNA 2 stood between the residents. LVN 3 stated Resident 1 has a history of yelling at other residents. LVN 3 stated she has previously heard Resident 2 tell Resident 1, before this incident he will deform and change the formation of Resident 1?s face.During an interview on July 15, 2011 at 2:30 p.m., CNA 2 stated she was passing out breakfast trays and was between the two residents? rooms when due to Resident 2?s continuous coughing, Resident 1 without his cane walked over to Resident?s 2?s room door and in the corridor told Resident 2 to shut the ?F? up?. Resident 1 walked back to his room and Resident 2 started coughing again. Then Resident 1 with his cane walked back to Resident 2?s room door and shook his cane in Resident 2?s face and told Resident 2 to shut the ?F...up. Resident 2 grabbed onto the cane and both residents now in the corridor started roughly tussling and struggling with the cane. CNA 2 stated she witnessed Resident 1 hit Resident 2 with the cane. CNA 2 stated she stopped the tussling/struggling with the cane.During an interview on July 15, 2011 at 3 p.m., the director of nursing (DON) stated Resident 1 does not have a physician?s order to use the cane used to hit Resident 2. The DON stated Resident 1 used the cane to walk around the facility. When the DON was asked should Resident 1 have a physician?s order for the cane, the DON stated yes.During a telephone conversation on July 21, 2011 at 10 a.m., with the physical therapy director, he stated Resident 1 used his own personal cane for ambulating around the facility and there is no physician order for the cane. According to the admission record, Resident 2 was admitted to the facility on November 16, 2009, with diagnoses that included diabetes mellitus, depression (persistent low mood accompanied by low self-esteem and a loss of interest or pleasure in normally enjoyable activities) psychosis (loss contact with reality) and encephalitis (acute infection and inflammation of the brain).Review of the History and Physical dated January 8, 2011, indicated Resident 2 has the capacity to understand and make decisions. The Minimum Data Set (MDS) an assessment and screening tool, dated November 18, 2010, indicated Resident 2 ?s cognitive skills are intact for daily decision making. The resident has the ability to make self-understood and understands others. The resident?s physical and verbal behavior towards others has not been exhibited. The resident requires supervision with walking in his room and corridor and the adjacent corridor. Resident 2 does not require a mobility device, such as a front wheel walker or cane. Review of the physician?s order dated May 29, 2011, indicated to treat Resident 2??s right ear laceration by cleansing with normal saline, pat dry, apply bacitracin ointment and cover with dry dressing and secure with tape every day for 14 days, then reassess. Review of the plan of care, dated April 8, 2011, indicated Resident 2 has a behavioral mannerism of coughing when around people. The nursing interventions are to monitor the resident when coughing, and encourage the resident to relax when his mannerism bothers him. According to the facility?s admission record, Resident 1was admitted to the facility on June 16, 2010, with diagnoses including hypertension and status post pacemaker, chronic leukemia (a slowly developing form of cancer that causes the production of abnormal blood cells). A review of the Initial History and Physical, dated January 6, 2011, indicated Resident 1 has the capacity to understand others and make decisions.Resident 1?s clinical record did not include a physician?s order for an assistive device to ambulate with a cane.According to the facility?s undated policy titled, Resident Abuse, it is the facility?s policy to provide a safe environment for residents. The facility?s failure to: 1. Ensure resident(s) with behavior symptoms are monitored continuously to prevent abuse. 2. Intervene to separate resident(s) before an incident of abuse occurs. 3. Ensure resident(s) with behavioral symptoms had a physician order for the use of a cane as an assistive device and the resident was monitored to prevent abuse to Resident 2, who sustained a laceration to the right ear.The above violation had a direct relationship to the heath safety or security of Resident 2. |
| 910000022 |
Primrose Post-Acute |
910011828 |
B |
04-Nov-15 |
CV2J11 |
12118 |
F 205 42 CFR 483.12 (b) Notice of Bed Hold - Hold Policy and Readmission 42 CFR 483.12(b)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies (i) The duration of the bed-hold policy under the State Plan, if any, during which the resident is permitted to return and resume residence in the nursing facility, and (ii) The nursing facility?s policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return. 483.12 (b)(2) Bed hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section. F 206 42 CFR 483.12(b)(3) Permitting Resident to Return to Facility A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility to the facility immediately upon discharge the first availability of a bed in a semi-private room if the resident ? (i) Requires the services provided by the facility; and (ii) Is eligible for Medicaid nursing facility services. Based on interview and record review the facility failed to: 1. Provide a written bed hold notice to the resident's responsible party when Resident 1 was transferred to the general acute care hospital (GACH).2. Readmit the resident to the first available male bed in a semi-private room appropriate for his needs, determined by the GACH, and a physician order dated April 7, 2014 which indicated that the resident was cleared by psych.On March 26, 2014 at 2:58 p.m., the Department of Public Health Licensing and Certification received a written complaint from Resident 1?s responsible party that indicated Resident 1 was transferred from a Skilled Nursing Facility (SNF) on a 5150 (a person, as a result of a mental health disorder, is a danger to others or to himself), to a GACH for an evaluation. The resident was seen in the Emergency Room at the GACH then discharged back to the SNF. The SNF refused to readmit the resident and returned the resident via ambulance to the GACH. On March 27, 2014 at 3 p.m., an unannounced complaint visit was made to the SNF to investigate an allegation that the SNF refused Resident 1?s re-admission and returned the resident to the GACH. According to the facility?s admission record, Resident 1 was readmitted to the facility on September 25, 2013, with diagnoses that included schizophrenia (a mental disorder characterized by abnormal social behavior and failure to recognize what is real), psychosis (disorder in which thoughts and emotions are so impaired that contact is lost with external reality) and delusional (false or unrealistic beliefs or opinions.The Minimum Data Set (MDS) an assessment and screening tool, dated October 7, 2013, described Resident 1 as been able to make himself understood and understood others. The resident?s cognitive skills for daily decision making were severely impaired. The resident?s behavioral pattern indicated no hallucinations (perceptual experiences in the absence of real external sensory stimuli) and no delusions. According to the Psychological Consultation, dated March 10, 2014, Resident 1 clearly met the criteria for a psychotic disorder per history and per the reports of staff observations and was diagnosed with a Psychotic Disorder, The consultation report further indicated that Resident 1 may benefit from psychotherapy to decrease mental health symptoms and assist with adjustments to medical/functions issues and skilled nursing placement. Prognosis was guarded due to cognitive deficits and medical conditions. A review of the Licensed Personnel Progress Notes, dated March 25, 2014, indicated Resident 1 was in bed and wet from head to toe. The resident's assigned certified nursing attendant attempted to provide care. The resident became aggressive, combative, agitated and hitting the staff and refusing care. The charge nurse approached the resident to encourage the resident to allow staff to provide care. The resident became more combative. The director of nursing and the administrator encouraged the resident to cooperate, to provide care. The resident hit the administrator. The Medical Psychiatric Services was called and arrived at the facility to transfer and evaluate the resident for his violent behavior. The resident's attending physician was made aware that Resident 1 was on a 5l50 (a person, as a result of a mental health disorder, is a danger to others or to himself). Review of the facility?s physician's order, dated March 25, 2014, indicated to transfer the resident to the GACH for psychiatric evaluation due to aggressive and violent behavior towards staff. Review of the GACH Inpatient Admission Order and Certification Form, dated March 26, 2014 at 12 a.m., indicated the Resident 1?s diagnoses included aggressive behavior, combativeness and schizophrenia and was admitted for twenty-three hours on an observation hold. During an interview on March 27, 2014 at 3:15 p.m., with registered nurse (RN 1) he stated Resident 1 returned to the facility on March 25, 2014, via ambulance with emergency personnel. RN 1 stated the emergency ambulance personnel parked the resident on the gurney in front of the nursing station. RN 1 stated the facility did not receive a telephone call from the GACH that the resident was returning. RN 1 stated the resident just showed up and the emergency ambulance personnel stated the resident was cleared by the GACH for discharge and returned Resident 1 to the SNF. RN 1 stated he called the director of nursing and was told not to accept the resident. RN 1 stated he did not telephone the GACH to find out if the resident was medically cleared. RN 1 stated he was not sure the resident would manifest his aggressive behavior and told the ambulance emergency personnel to return Resident 1 to the GACH. On March 27, 2014 at 4:25 p.m., during an interview with the facility?s director of nursing (DON), she stated on March 25, 2014, the facility was not notified by the GACH t Resident 1was returning to the facility. The resident?s re-admission had to be approved by the physician and the resident?s readmission was refused. The DON stated that the resident?s 7 day bed hold notice should be in the resident's chart to hold the first available bed for the resident. The director of nursing stated she was unable to find the copy of the 7 day bed hold notice in the resident's clinical record. In addition, the DON stated the clinical record failed to indicate that the facility provided the resident or the responsible party with the 7 day bed hold notice at the time of the resident's transfer to the GACH for an evaluation. Review of the GACH?s physician order dated April 7, 2014, indicated to discharge Resident 1 to the SNF and was cleared by psych. Review of the GACH?s e Social Worker/Psychosocial Note dated April 10, 2014, indicated Resident 1 was ready for SNF placement and the SNF did not want to accept Resident 1 back to the facility. The Social Worker/Psychosocial Note dated April 17, 2014, indicated the SNF administrator called the GACH social worker and stated a SNF nurse had to evaluate the patient first before the resident could return to the SNF. The Social Worker/Psychosocial Note dated April 17, 2014, indicated the GACH?s administrator to get the SNF?s update because the SNF continues to refuse Resident 1?s return to the facility. The GACH?s chief executive officer spoke to the Hearing Officer and the official decision was that the SNF has to take patient back at the SNF. The Social Worker/Psychosocial Note dated April 18, 2014, indicated the director of nursing (DON) from the SNF arrived at the GACH to evaluate the patient, today, but did not say whether or not Resident 1 would be accepted back to the facility.Review of Resident 1?sclinical record on September 10, 2015 at 2 p.m., with the DON indicated there was no documented indication the previous director of nursing, who evaluated Resident 1 at the GACH on April 18, 2014, documented an evaluation or recommendation to re-admit the resident to the facility. Also there was no documentation in the clinical record the SNF social worker or the administrator called the GACH or spoke to the social worker at the GACH.Review of the daily SNF Residents Census dated March 25, 2014, March 26, 2014 and March 27, 2014, indicated Resident 1 was discharged. There was no indication on the daily Residents Census the resident was placed on a 7 day bed hold after discharged from the facility. According to the GACH?s record the Resident was admitted to the GACH on March 26, 2014. Review of the SNF Residents Census for April 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 2014, indicated there were available male beds in a semi-private room.In a telephone interview on September 11, 2015 at 10 a.m., with the SNF?s Business Office Manager, she stated Resident 1?s name was not indicated as being on a bed hold on the March 2014 Residents Census, because in a stand-up meeting, the administrator stated the resident would not be returning to the facility and did not place the resident?s name on bed hold. During a telephone interview on September 11, 2014, at11 a.m., Resident 1?s responsible party/ complainant stated she requested the GACH to return the resident to the SNF. The responsible party/complainant stated this was the first facility the resident resided in and wanted the resident to return to that SNF. According to the facility?s policy titled Bed Hold Notification, dated January 1, 2004, the facility shall inform the resident or the resident?s representative, in writing of the right to exercise the bed hold provision under the State Plan (7 days for California), at the time of admission, and at the time of transfer for hospitalization or therapeutic leave. If the resident?s attending physician notifies the facility in writing that a Medicaid resident?s stay in the general acute care hospital is expected to exceed seven (7) days, the facility shall not be required to maintain the bed hold. The facility shall readmit a Medicaid resident requiring SNF services, immediately upon the first availability of a bed in a semi private room when his/her hospitalization or therapeutic leave exceeds the bed hold period. According to the State of California Department of Health Care Services Office of Administrative Hearings and Appeals hearing officer?s Decision and Order: ?Resident was appropriate for acute psychiatric hospital (APH) level of care at the time of these proceedings, April 2, 2014, the appeal is GRANTED. Goldstar Health Care Center is required to offer Resident readmission to the first available male bed in a semi-private room that is appropriate for his needs once a determination is made by the GACH or an APH that Resident is both medically and psychiatrically cleared and requires the services provided by Facility. This is the FINAL DECISION AND ORDER of the Department and no further administrative remedies are available. The facility failed to: 1. Provide the resident or responsible party with a written 7-day bed hold notice, transferred to the GACH on March 25, 2014. 2. The daily SNF Residents Census failed to indicate 7 day bed hold days for the resident 3. Readmit the resident to the first available male bed in a semi-private room appropriate for his needs, determined by the GACH, and a physician order dated April 7, 2014 which indicated that the resident was cleared by psych. The violation had a direct relationship to the health, safety or security of the resident. |
| 910000068 |
PALOS VERDES HEALTH CARE CENTER |
910012564 |
B |
12-Sep-16 |
DY7S11 |
10029 |
F-223 CFR 483.13 (b) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. On 7/19/16, during a Recertification survey, an investigation was conducted regarding an incident of alleged resident abuse. Based on interview and record review, the facility failed to implement its own abuse policy and procedure by failing to: 1. Ensure Resident 2, who had a history of aggressive physical behavior, did not physically abuse Resident 1 by scratching her face and arms. 2. Respond in a timely manner when Resident 1screamed for help, as Resident 2 scratched her face and arms. 3. Provide adequate supervision during and after the physical altercation between Resident 1, and Resident 2, to ensure Resident 1 was safe. During an initial tour on July 19, 2016 at 2 p.m., Employee 4 stated Resident 2 was transferred from the facility because she got in to a fight with her roommate Resident 1. According to the admission record Resident 1 was a 74-year-old female who was admitted to the facility on October 11, 2004 with diagnoses that included peripheral neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), pressure sore (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and muscle weakness. The Minimum Data Set (MDS - a standardized resident assessment and care screening tool) dated April 7, 2016, indicated Resident 1 had no impairments in her daily-decision making, required supervision (oversight and encouragement) for activity of daily living and was totally dependent on staff for ambulation. According to the admission face sheet Resident 2 was a 65-year-old female who was admitted to the facility on June 12, 2015 with diagnoses that included dementia with behavior disturbances (a group of thinking and social symptoms that interferes with daily functioning), schizophrenia (a mental disorder characterized by abnormal social behavior and failure to understand what is real), psychosis (a mental disorder characterized by a disconnection from reality), depression (a brain disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Resident 2 required a gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach), and had dysphagia (a language disorder that affects a person's ability to communicate). A review of Resident 2?s MDS assessment dated July 20, 2016 indicated the resident was confused, and needed supervision from staff for transfer, and ambulation. The care plan (undated) indicated Resident 2 was alert, confused, and combative with staff during the care. A review of Resident 2's psychiatric re-evaluation dated May 17, 2016, indicated Resident 2 was irritable, labile (rapid shifts in outward emotional expressions) and combative (ready or eager to fight). According to a progress note dated July 16, 2016, Resident 2 was very alert and educated, but was resistant to being assisted with care. A review of the physician's order for Resident 2 dated May 31, 2016 included administering Thorazine (an antipsychotic medication for treating mental illness, and behavioral disorders) 25 milligram (mg) three times a day for psychosis manifested by combativeness (ready or eager to fight). During an interview with Resident 1 on July 15, 2016, at 8:30 a.m., she stated her roommate (Resident 2) would get upset when she called staff to assist whenever she (Resident 2) became agitated, or looked like she was going to get out of bed. Resident 1 stated on July 1, 2016, around 10:30 p.m., during the 3 to 11 p.m., shift, she noticed Resident 2 trying to climb out of her bed, so she placed the call light on. Resident 2 then grabbed the edge of her bed and used her bedside table to get to her. At which time, Resident 1 stated she took her backscratcher and banged on the bedrails, at the same time screaming for help, but no one came. Resident 2 was able to reach her and scratched her face and arms. After the attack, Employee 6 finally came in and asked what happened to her face. Employee 6 left the room to get help. Resident 1 stated she was scared and pleaded with Employee 6 not to leave her alone with Resident 2, but CNA 6 left her alone in the room. Resident 1 stated she was afraid that Resident 2 would knock her set (Television) over to the floor. Resident 1 stated she believed Resident 2's feeding tube prevented her from getting to her television. Resident 1 further stated it took 4 employees (Employee 5, Employee 6, Employee 7, and Employee 8) to tie Resident 2 with a sheet while she was fighting them. Resident 1 stated Employee 7 knew the resident was aggressive, but still left her in the room all night with Resident 2. Resident 1 stated even the CNA's have said that Resident 2 was strong. On July 15, 2016 at 8:30 a.m., Resident 1 further stated after Resident 2 attacked her, she asked the staff for a phone so the police could be called. The resident stated ?No one brought her a phone.? Resident 1 stated Resident 2 was so aggressive that at times the staff would tie her and her hands with a sheet to hold her down. "Resident 1 stated she was fearful and a thin (sheet) was not going to hold and keep Resident 2 away from her. Resident 1 further stated during the attack incident she asked the facility to call the police. A review of the clinical records lacked documentation the facility ever contacted the police department. During an interview with Employee 4 on July 26, 2016, at 11:20 a.m., she stated Resident 1 had fresh scratches on her face and arms, so she reported the incident between Resident 1 and 2 to the Registered Nurse (RN 2). Employee 4 was asked if she considered the incident as abuse, she stated "I'm not sure because it was resident to resident, as far as she knew resident to resident was not considered abuse." A review of the licensed personnel weekly progress notes dated July 1, 2016 a 10:15 p.m., indicated Resident 1 claimed Resident 2 scratched her. The notes indicated Resident 1 sustained scratches to the left side of her face, and the left forearm. The administrator investigative report dated July 2, 2016 at 10:15 p.m., indicated Resident 1 was heard calling for help, and was found with scratches on her face and left upper and lower arm. The resident told the staff she was scratched by her roommate (Resident 2). The notes indicated Resident 2 had diagnoses of schizophrenia, psychosis, depression, anxiety, and was on multiple medications for psychosis manifested by combativeness, screaming and hitting staff. The notes indicated even though Resident 2 was on multiple psychotropic medication, she was still manifesting all those behaviors. The notes concluded after investigation abuse was not suspected. During an interview with the DON on July 26, 2016 at 11:40 a.m., she stated the incident between Resident 1 and Resident 2 was not considered abuse. The DON stated because Resident 2 was schizophrenic and Resident 1 had psychosis (refers to an abnormal condition of the mind described as involving a loss of contact with reality). The DON stated the facility's interdisciplinary team (IDT), which included the Dietary, Social Service Director (SSD), and Activity director; all agreed it was not abuse. The DON stated Employee 6 reported Resident 1 had scratches, and on July 1, 2016, Employee 5 reported the resident was claiming she was scratched by her roommate. During an interview with the Employee 9 on July 26, 2016, at 12:15 p.m., she stated it was reported to her that Resident 1 tried to "shoo" away Resident 2 with her back scratcher, but could not remember who told her. The DSD stated the CNA's found Resident 2 at the foot of Resident 1's bed. The incident between Resident 1 and Resident 2 "was considered abuse." During an interview with Employee 8 on July 26, 2016, at 4:45 p.m., she stated on the day of the incident she heard Employee 6 screaming for help, but did not really remember that night, because she was in a rush trying to get back to her station (station 2). Employee 8 further stated Employee 5 knew what happened. Employee 8 stated Resident 1 showed her the scratch mark on her face, and saw Resident 2 on the floor. During an interview with Employee 6 on July 26, 2016 at 4:45 p.m., he stated on the day of the incident he heard Resident 1 screaming, and found the resident with scratches on her face. Employee 6 was asked why he left Resident 1 alone with Resident 2, and he stated because he went to get help, besides the resident could have hurt him too. Employee 6 stated he never thought Resident 2 would get up and attack Resident 1. Employee 6 stated Employee 8 and Employee 7 helped put Resident 2 back to bed, using a restraint but was not sure. A review of the facility?s undated abuse policy indicated to provide a safe environment for residents. It also indicates each resident has the right to be free from verbal, sexual, physical, mental and financial abuse, neglect or mistreatment, corporal punishment and involuntary seclusion. Based on interview and record review, the facility failed to implement its own abuse policy and procedure by failing to: 1. Ensure Resident 2, who had a history of aggressive physical behavior, did not physically abuse Resident 1 by scratching her face and arms. 2. Respond in a timely manner when Resident 1screamed for help, as Resident 2 scratched her face and arms. 3. Provide adequate supervision during and after the physical altercation between Resident 1, and Resident 2, to ensure Resident 1 was safe. The above violations had a direct relationship to the health, safety, or security of Resident 1. 1 |
| 920000056 |
Panorama Meadows Nursing Center, LP |
920009668 |
B |
11-Dec-12 |
CCI511 |
5608 |
Title 22, Division 5, Chapter 3, Article 6 - 72601((a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter 1, Division 17, Part 6, Title 24, California Administrative Code and requirements of the State Fire Marshal. On October 18, 2012, at 2 p.m. an unannounced visit was made to the facility to investigate a referral from the Office of Statewide Health Planning and Development (OSHPD), regarding alterations to the facility without permits and/or approval. Based on observation, and record review, the facility failed to comply with the requirements of OSHPD, the authority having jurisdiction for alteration and construction work in healthcare facilities by: 1. Made alterations to the fire alarm system without required permits, plan approval, inspection, testing or approvals.2. Altered the electrical connection from the building structure to the signage at the front of the building without OSHPD review or approvals.3. Replaced several water heaters that had already been placed in service without required permits, plan approval, inspection, testing or approvals.4. Installed several Heating, Ventilation, and Air Conditioning (HVAC) units and ductwork without required permits, plan approval, inspection, testing or approvals from OSHPD.5. Replaced laundry equipment without required permits, plan approval, inspection, testing or approvals from OSHPD. 6. Installed a metal cover and support beams for the back entrance walkway and sitting benches without fire sprinklers and required review, permits or approvals from OSHPD. 7. Installed fire sprinkler piping in the shed enclosure for the water heaters without minimum clearances to protect the piping from damage.During observation and interview on October 18, 2012, the administrator stated these alterations were done in past and he was working on gathering information and documentation for these projects. He had also stated that several vendors had been contacted to work on obtaining permits and approval from OSHPD for the above projects. A review of the OSHPD Fire Marshal Field Visit Report dated 10/19/2011, indicated: 1. 10/17/12-Noted installation, upgrade and/or alteration of the fire alarm system without required permits, plan approval, inspection, testing or approvals.- Example of non-compliant installation of fire alarm cabling; the cable is not supported, lying on the ceiling joists and not fire-stopped where it penetrates the smoke barrier wall. 2.10/17/12-Noted apparent trenching from the building structure to the signage at the front of the building that appears to indicate electrical alterations or additions without OSHPD review or approvals.3. 10/17/12-Noted the installation of several replacement water heaters that have already been placed in service without required permits, plan approval, inspection, testing or approvals. The two water heaters installed at the rear of the building have been located in a shed enclosure that does not appear to have been permitted, as well.4. 10/17/12-Noted the installation of several new and/or replacement HVAC systems without required permits, plan approval, inspection, testing or approvals from OSHPD. Also, noted excessive lengths of factory-made flexible ducting in the attic space, as well.- Examples of replacement HVAC equipment installed without permits or approvals; the equipment is larger than the equipment pads and does not appear to be properly secured. Broken flex with exposed conductors. Disconnect installed on the vent louvers of the housing. Ducting replaced with excessive lengths of factory-made ducting. 5. 10/17/12-Noted the original laundry room equipment appear to have been replaced without required permits, plan approval, inspection, testing or approvals from OSHPD. 6. 10/17/12-Noted the installation of a covered entrance at the rear of the building that is missing fire sprinklers and without required review, permits or approvals from OSHPD.7. 10/17/12-In addition to comment #3 above, noted the fire sprinkler piping installed in the shed enclosure for the water heaters has not been provided with minimum clearances to protect the piping from damage.The facility failed to comply with the requirements from the Office of Statewide Planning Health Planning and Development (OSHPD), the authority having jurisdiction for alteration and construction work in healthcare facilities by: 1. Altering the fire alarm system without required permits, plan approval, inspection, testing or approvals.2. Altering the electrical connection from the building structure to the signage at the front of the building without OSHPD review or approvals.3. Replacing several water heaters that had already been placed in service without required permits, plan approval, inspection, testing or approvals.4. Installing several HVAC units and ductwork without required permits, plan approval, inspection, testing or approvals from OSHPD.5. Replacing laundry equipment without required permits, plan approval, inspection, testing or approvals from OSHPD. 6. Installing a metal cover and support beams for the back entrance walkway and sitting benches without fire sprinklers and required review, permits or approvals from OSHPD. 7. Installing fire sprinkler piping in the shed enclosure for the water heaters without minimum clearances to protect the piping from damage.This violation had a direct relationship to the health, safety, and security of all patients of the facility. |
| 920000056 |
Panorama Meadows Nursing Center, LP |
920011102 |
B |
10-Nov-14 |
0V2811 |
4537 |
Code of Federal Regulations 483.70(h)F465 The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.The facility failed to provide a safe environment for the residents by failing to: 1. Protect the residents against inhaling dust and debris during construction inside of the facility by not providing masks for the residents. The facility staff was wearing masks at the time of the investigation. 2. Relocate the residents that were in the construction area. 3. Put up a temporary barrier to prevent the dust and debris from spreading throughout the facility.This created an unsafe living area and caused discomfort for all residents in the affected areas. On March 11, 2014, an unannounced visit was made to the facility to investigate a complaint regarding construction in the facility creating a large amount of dust that was affecting the residents. During a tour of the facility at 2:30 p.m., the following was observed: 1. Most of the staff members were wearing masks that covered their nose and mouth. The floor throughout the facility had been removed. The concrete underneath was exposed. 2. Resident 1 was heard coughing in her room. She said she was coughing because of the dust in the facility from the construction. She also said no one offered her a mask. 3. Employee 4 said that the dust was ?real bad? in the morning, but now it was better.4. Resident 5 said the dust in the facility was bad. The construction had been going on for about two weeks. 5. Resident 6 said that the dust was bad in the morning but had settled down a little.6. Employee 7 said that on Saturday March 8, 2014, three days ago, the facility was very dusty because they were scraping up the floor. Inside the physical therapy room the microwave table, a storage shelf, and an oxygen concentrator were covered with dust. 7. Resident 8 said the dust bothered her. She also said the housekeeping staff did not know how to clean. She cleaned her own bathroom every morning. 8. Resident 9 was in the physical therapy room sneezing. He said the dust was making him sneeze. 9. The top of the water container at the nurses? station was covered with dust. During an interview at 2:30 p.m., the Director of Nursing said they offered the residents masks to wear but they did not want them.On March 12, 2014, at 3:30 p.m. after receiving another complaint regarding the dust, it was observed the facility was very dusty and residents and staff were still complaining about the dust. During an interview at 4 p.m. the administrator said they were going to put up a plastic in the construction area and relocate the residents to another part of the facility during the day when construction is going on. The administrator was given a "Notice of Intent to Issue a Citation" and asked to submit an immediate written plan to explain how the facility was going to protect the residents from the dust and debris. On March 13, 2014, at 10 a.m., after receiving another complaint regarding the dust in the facility, it was observed that there was no plastic barrier in place. There was construction going on outside of Room 16 and there was a resident in the room in bed.During an interview at 10:20 a.m. the administrator was asked to submit a plan immediately how she would protect the residents from the dust and debris.The plan included: 1. Stop construction immediately and cover all work areas with plastic post barriers. 2. The Maintenance Supervisor will monitor the work during construction at all times to ensure that plastic post barrier is in place prior to and during ongoing construction. 3. Monitor that all residents are removed from the resident rooms adjacent to the work area in the corridor or in the rooms undergoing construction. 4. Provide and encourage residents to wear masks. 5. Encourage residents to stay clear of work areas. The facility failed to provide a safe environment for the residents by failing to: 1. Protect the residents against inhaling dust and debris during construction inside of the facility by not providing masks for the residents. The facility staff was wearing masks at the time of the investigation. 2. Relocate the residents that were in the construction area. 3. Put up a temporary barrier to prevent the dust and debris from spreading throughout the facility.The above violation had a direct or immediate relationship to the health, safety or security of residents, staff and the public. |
| 920000056 |
Panorama Meadows Nursing Center, LP |
920011103 |
B |
10-Nov-14 |
0V2811 |
2749 |
Code of Federal Regulations 483.35(i) F 371 The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions. The facility failed to take effective measures to eliminate cockroaches and to subsequently maintain the kitchen and equipment free from such infestations and in a clean and sanitary manner. As a result, the facility had an infestation of cockroaches. During an observation of the kitchen on March 11, 2014, at about 4 p.m., the following was noted: 1. Approximately 30 cockroaches were crawling under the dishwasher. Five cockroaches crawled from behind the base coving in the janitor closet and a baby cockroach was crawling above the two compartment sink. Four cockroaches were crawling under the two compartment sink and three more were crawling next to the opening of the walk-in refrigerator. 2. Cleaning cloths were in a bucket full of liquid that had the word "sanitizer" written on the bucket. The Dietary Service Supervisor (DSS) checked for the presence of sanitizer and there was none noted in the bucket when tested. She said the cloths were used for cleaning throughout the kitchen. 3. The area behind the knobs on the stove had an accumulation of dust and food debris. 4. The area between the stove and the warmer had a build-up of grease and food debris. 5. The floor had an accumulation of dirt and debris. 6. The plate covers, the base the plates sit on, and the dishwasher racks, had an accumulation of a black substance. During an interview, the DSS said the kitchen staff had a regular cleaning program, but could not explain why the kitchen had an accumulation of so much dirt and debris. The pest control company work order dated December 9, 2013, had documentation that recommended the DSS to remove the food and debris in the corners of the kitchen. It also indicated the drain was clogged/dirty, and should be cleared and steam cleaned or scrubbed to remove organic debris, and standing water provides moisture which supports pests. The work order dated January 13, 2014, indicated the pest control technician found dead and live German cockroaches. He also found food debris on the shelves and in the corners in the kitchen. The technician recommended removing the food debris and to clean and sanitize the shelves to prevent pests and contamination.Therefore, failure of the facility to take effective measures to eliminate cockroaches and to subsequently maintain the kitchen and equipment clean and free from such infestations and in a clean and sanitary manner, had a direct relationship to the health, safety and security of all residents and staff. |
| 920000056 |
Panorama Meadows Nursing Center, LP |
920012653 |
AA |
9-Jan-17 |
GNL611 |
19086 |
F309 CFR? 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. F279 ?483.20(d) A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessment to develop, review and revise the resident?s comprehensive plan of care. ?483.20(k) Comprehensive Care Plans (1) 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 following: (i) The services that are to be furnished to attain or maintain the resident?s highest practicable physical, mental, and psychosocial well-being as required under ?483.25; and (ii) 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). F281 483.20 (k) (3) (i) The services provided or arranged by the facility must meet professional standards of quality; and F282 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. On March 22, 2013, the Department received a complaint regarding a skilled nursing facility (SNF) that alleged on March 18, 2013 at 11:12 a.m. Resident 1 was observed bleeding from the right upper arm by the physical therapist who called the nurse supervisor. The resident was assisted back to bed while applying direct pressure to the arm. The paramedics were called, the resident?s oxygen saturation dropped. Oxygen therapy was initiated. At 11:24 a.m., Resident 1 stopped breathing, with no pulse. Cardiopulmonary Resuscitation (CPR) was immediately initiated and the paramedics transferred the resident to the general acute care hospital (GACH). The GACH discharge notes indicated Resident 1 passed away on XXXXXXX 2013 at 11:12 p.m. On March 28, 2013, an investigation of the above allegation was initiated. A review of Resident 1?s Certificate of Death indicated Resident 1 died on XXXXXXX 2013 at 11:12 p.m. from hemorrhagic shock (a condition associated with the sudden and rapid loss of significant amount of blood), caused by excessive bleeding from the arteriovenous (AV) fistula (a vascular access site for a hemodialysis treatment to remove wastes from the blood). The facility failed to provide necessary care and services to prevent Resident 1, who had a pattern of recurrent bleeding from his dialysis access site, from bleeding to death. These failures include but are not limited to: 1. Failure to provide immediate emergency care to Resident 1 to control profuse bleeding from an AV fistula site, to prevent the loss of excessive blood volume that caused hemorrhagic shock. 2. Failure to provide effective emergency nursing care measures, such as the use of a tourniquet, strong manual pressure, or a clamp, to control Resident 1?s profuse, uncontrolled bleeding from the AV fistula. 3. Failure to develop and implement care plan interventions to include methods for effectively controlling blood loss for Resident 1, who had a recent history of bleeding from the AV fistula site. 4. Failure to implement the undated facility policy and procedure titled ?Care of the Dialysis Resident? to include monitoring the access site, in order to determine early signs of complication of the site, such as bleeding. 5. Failure to monitor Resident 1 every shift for bleeding of the dialysis access site as indicated in the care plan. As a result, Resident 1 had uncontrolled, sustained bleeding, to such an extent that the resident developed excessive blood volume loss, followed by hemorrhagic shock, ultimately resulting in his death. A review of the admission record indicated Resident 1 was a 68 year-old male originally admitted to the skilled nursing facility (SNF) on XXXXXXX and was readmitted on XXXXXXX with diagnoses that included chronic kidney disease, blindness of the right eye, peptic ulcer (an ulcer in the stomach) disease, anemia (condition marked by a deficiency of red blood cells) and hypertension (high blood pressure). The Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated March 5, 2013, indicated Resident 1 had moderately impaired vision, had intact cognitive skills, required supervision in care, and required dialysis. (Resident 1 was received dialysis at a kidney dialysis center three times a week. Dialysis was done by way of a dialysis access site known as an AV fistula, or AV shunt, created by a vascular surgeon, by joining an artery and a vein together to be used as an access site). There was a plan of care initiated on April 6, 2011, for at ?risk for bleeding due to Heparin (an anticoagulant or blood thinner medication) therapy at dialysis.? The care plan goal indicated ?Will minimize risk for bleeding for three months?. The care plan did not include the use of necessary tools, devices or effective methods such as a tourniquet, strong manual pressure or a clamp commonly used to control bleeding in case of an emergency in health care facilities. The care plan also indicated Resident 1?s access site would be monitored for signs and symptoms of bleeding every shift. However, a review of the treatment record for March 2013, and the licensed personnel progress notes from March 16, 2013, to March 18, 2013, did not indicate the resident?s access site was monitored every shift for bleeding, in order to determine early signs of complication of the site. A review of the undated facility policy and procedure titled ?Care of the Dialysis Resident?, indicated to monitor the resident?s access site for bleeding, to prevent complications of hemorrhage. A review of the physician?s orders dated February 15, 2013, indicated Resident 1 had the following orders: 1. Dialysis every Tuesday, Thursday and Saturday. 2. Monitor right upper arm AV shunt for bruit (a sound caused by abnormal narrowing of an artery) and thrills (a vibratory sensation felt) every shift. 3. Aspirin 81 milligrams by mouth every day for clot prevention. (Aspirin can have side effects such as bleeding). A review of the Pre and Post-Dialysis Checklist (assessment) from March 2, 2013, to March 16, 2013, indicated Resident 1?s AV shunt access site on the right upper arm was checked for bruit and thrill and the dressing (bandage) over the AV shunt was dry and intact (in place). The Pre and Post-Dialysis Checklist did not contain monitoring or an assessment for bleeding. A review of the Treatment Sheet dated March 2013, also indicated Resident 1?s right upper extremity AV shunt was monitored each shift for Bruit and Thrill from March 1, 2013, to March 18, 2013. According the Emergency Department (ED) note and the History and Physical (H&P) examination records obtained from the GACH, Resident 1 had a pattern of recurrent bleeding from the dialysis access AV site as follows: 1. The H&P examination record dated January 1, 2013, indicated Resident 1 was brought to the GACH emergency department (ED), from the Dialysis Center. The H&P indicated information obtained from the rescue ambulance personnel as well as the resident who was able to provide a clear history on his own told the physician he had a small amount of bleeding from the dialysis shunt the day before, but this stopped and did not need to seek treatment for it. He went to his dialysis that day as per his usual schedule. Prior to accessing his dialysis access catheter, he began having bleeding from the right arm dialysis graft. He was pulsatile (had pulse) and required strong manual pressure applied by the dialysis center. Vital signs reviewed by the paramedics were noted to be normal and he was brought to the ED for further evaluation. The resident was treated and readmitted to the skilled nursing facility on XXXXXXX. 2. The H&P examination record dated January 29, 2013 at 2:31 p.m., indicated Resident 1 was admitted to the GACH, emergency department (ED) with chief complaint of active bleeding dialysis access site. The ED note indicated the resident was brought to the ED on referral from the dialysis center, when prior to access for dialysis, the resident was noticed with fairly significant bleeding from the right upper AV dialysis access site. A pressure dressing was applied to the wound which was able to control bleeding and then he was brought to the ED for further evaluation. The emergency room course indicated suturing (stiching) of the lesion (wound) was done and was able to control the bleeding. A review of the surgical report dated January 29, 2013, indicated the resident had a repair of the right upper extremity AV fistula, due to bleeding. A review of the Resident Transfer Form indicated Resident 1 was readmitted to the skilled nursing facility on XXXXXXX 3. The H&P examination record dated February 12, 2013, indicated Resident 1 was admitted to the GACH with chief complaint of ?Bleeding from the AV fistula.? At the GACH Resident 1 underwent vascular surgery to repair a bulging, weak area in the wall of an artery, with leakage of blood from an artery into the surrounding tissue, and removal of a blood clot. Resident 1 was readmitted to the skilled nursing facility on February 15, 2013. A review of the SNF Licensed Personnel Weekly Progress Notes indicated the SNF nurses were notified of Resident 1?s recent history of bleeding from the AV fistula site as follows: 1. December 31, 2012 at 4 p.m., indicated a kidney dialysis center staff informed the SNF that Resident 1 did not have dialysis due to ?uncontrolled bleeding? at the right AV shunt (fistula), and the resident was transferred to a GACH by the paramedics. 2. January 29, 2013, indicated the SNF received a call from a kidney center, that Resident 1 was transferred to a GACH due to severe bleeding on the right upper arm AV shunt. 3. February 12, 2013, indicated per the dialysis center, Resident 1 had a nonfunctioning shunt (?It burst?) and the resident was transferred to a GACH by 911 Emergency Medical Services (EMS). Resident 1?s care plan interventions dated April 6, 2011, for at risk for bleeding remained unchanged without interventions to address emergency measures required to stop bleeding, despite incidents of bleeding that required the resident to be transferred to the GACH from the kidney dialysis center on December 31, 2012, January 29, 2013, and February 12, 2013. There was a care plan dated January 31, 2013, titled ?Status post repair of the right upper arm AV fistula bleeding.? The care plan intervention indicated to monitor right upper arm AV fistula for bleeding and report if noted. The care plan did not include a method for controlling blood loss even though Resident 1, two days earlier, on January 29, 2013, was transferred to a GACH due to severe bleeding at the right upper arm AV shunt (fistula). The care plan did not include the necessary interventions, tools, and devices required, such as strong manual pressure, hemostat (clamps) and/or a tourniquet, commonly used to effectively control profuse bleeding in case of an emergency in health care facilities. A review of the licensed nurse?s note dated March 18, 2013 indicated at 11:12 a.m., Physical Therapist (PT 1) while passing by Resident 1?s room observed the resident bleeding and called the Registered Nurse Supervisor (RN 1). RN 1 went to Resident 1?s room and saw the resident standing near his bed pressing his right upper arm with a blood soaked towel, noted blood on the floor around the resident?s bed, and assisted the resident to bed. The AV shunt on the right upper arm was bleeding profusely with dressing intact on the shunt but noted with blood gushing out of the dressing and applied pressure using the tip of fingers and gauze. But the bleeding continued and Resident 1 became unresponsive with oxygen saturation of 80% (oxygen saturation is a measure of how much oxygen the blood is carrying, a range of 96% to 100% is generally considered normal), on 15 liters of oxygen by mask. At 11:18 a.m. the paramedics were called; the resident stopped breathing, with no pulse, and CPR was initiated and the resident was noted responding to the CPR with shallow breathing and neck pulse. Resident 1?s vital signs were: blood pressure 80/50 (reference range 120/80) pulse 40 beats per minutes (reference range 60 to 100) respiration 12 breaths per minute (reference range 12 to 16). At 11:25 a.m. the paramedics arrived and took over the care. Resident 1 was transferred to the GACH emergency room at an unspecified time. On October 21, 2015 at 10:30 a.m. in a telephone interview with PT 1, she stated that she recalled Resident 1 and the incident of bleeding at the SNF (on or around March 18, 2013). PT 1 stated, it likely happened in the morning, she was walking in the hallway, when she saw Resident 1 in his room, bleeding and there was a puddle of blood on the floor. PT 1 stated she did not see anyone else in Resident 1?s room. PT 1 stated she ran screaming in the hallway and told the Licensed Vocational Nurse (LVN) 1, as she knew ?it was very serious?. PT 1 stated LVN 1 went straight to Resident 1?s room. PT 1 stated she did not go into Resident 1?s room to stop Resident 1?s bleeding, but she had planned to do so. PT 1 stated by the time she returned to Resident 1?s room everyone, such as the supervisor and the certified nursing assistants (names were not known) were in Resident 1?s room. PT 1 stated she had been trained to stop bleeding, but she thought the nurses would take care of Resident 1. PT 1 stated she did not know what LVN 1 did once she went into Resident 1?s room, because the privacy curtain was drawn. On October 15, 2015 at 5 p.m. in an interview with LVN 2, he stated he was on duty as a treatment nurse the day that Resident 1 was found bleeding. LVN 2 stated he went to Resident 1?s room at an unknown time, because he heard PT 1 call out. LVN 2 stated the first he saw Resident 1, there was a lot of blood on the wall and curtains. LVN 2 stated RN 1, was in Resident 1?s room and RN 1 was trying to put pressure on Resident 1?s dialysis site, but he did not know specifically how RN 1 did so. LVN 2 stated RN 1 had the staff bring her towels to assist her. LVN 2 stated that whoever sees a resident bleeding should call for help, but stay in the resident?s room and place pressure on the dialysis site, until the bleeding stops or until the paramedics arrive. LVN 2 stated he thought Resident 1 bled so much because he was taking blood thinners and aspirin. LVN 2 stated he did not know the amount of time it might take to stop profuse bleeding, with strong continuous pressure applied. There was no documented evidence on the licensed nurse?s note dated March 18, 2013, that PT 1, who first saw Resident 1 bleeding, provided immediate emergency care to Resident 1 to control profuse bleeding from an AV fistula site, and to prevent the loss of excessive blood. There was no documented evidence on the licensed nurse?s note dated March 18, 2013, that indicated RN 1 used a hemostat (clamps) and/or a tourniquet or applied strong manual pressure to immediately stop Resident 1's bleeding. Instead, RN 1 ineffectively used her finger tips and a gauze to stop the bleeding, and Resident 1 became unresponsive. The Emergency Room Report dated March 18, 2013 at 11:59 a.m. indicated Resident 1 was brought to the emergency room by EMS, with a chief complaint of bleeding shunt, opening shunt. On presentation to the emergency department, Resident 1 was critically ill, non-responsive and combative. Resident 1 had a blood pressure in the 60?s systolic (the upper number showing the highest arterial blood pressure of a cardiac cycle, reference range (RR) of less than 120 millimeters of mercury (mmHg)), and a pulse oximetry (oxygen saturation), in the 70?s (RR of 96 percent (%) to 100%). The resident had evidence of normocytic anemia (a low number of red blood cells), with a low hemoglobin (a red protein responsible for transporting oxygen in the blood) of 10.8, (grams per deciliter- G/dL, Low (L) in a (RR) of 13.5 to 17.0 G/dL.) The resident was transfused O Negative blood (a blood type) due to hemorrhagic bleed. The diagnostic impression was hemorrhagic shock. The resident was admitted to the Intensive Care Unit at an unspecified time. The Acute Hospital Discharge Summary dated XXXXXXX, indicated Resident 1 expired at the GACH on XXXXXXX2013 at 11:12 p.m., the same date as his admission. The cause of death was hemorrhagic shock and bleeding AV graft (fistula). According to the Certificate of Death, dated XXXXXXX 2015, Resident 1?s immediate causes of death were: (A) Hemorrhagic shock (B) Bleeding Arteriovenous Fistula. The facility failed to provide necessary care and services to prevent Resident 1, who had a pattern of recurrent bleeding from his dialysis access site, from bleeding to death. These failures include but are not limited to: 1. Failure to provide immediate emergency care to Resident 1 to control profuse bleeding from an AV fistula site, to prevent the loss of excessive blood volume that caused hemorrhagic shock. 2. Failure to provide effective emergency nursing care measures, such as the use of a tourniquet, strong manual pressure, or a clamp, to control Resident 1?s profuse, uncontrolled bleeding from the AV fistula. 3. Failure to develop and implement care plan interventions to include methods for effectively controlling blood loss for Resident 1, who had a recent history of bleeding from the AV fistula site. 4. Failure to implement the undated facility policy and procedure titled ?Care of the Dialysis Resident? to include monitoring the access site, in order to determine early signs of complication of the site, such as bleeding. 5. Failure to monitor Resident 1 every shift for bleeding of the dialysis access site as indicated in the care plan. The facility?s failure to provide immediate emergency care and use necessary and effective measures to immediately control Resident 1?s profuse bleeding, resulted in uncontrolled, sustained bleeding, to such an extent the resident developed excessive blood volume loss, followed by hemorrhagic shock, and ultimately resulted in his death. The above violation presented imminent danger that death or serious harm would result, or a substantial probability that death or serious physical harm would result, and was a direct proximate cause of the death of Resident 1. |
| 920000056 |
Panorama Meadows Nursing Center, LP |
920012839 |
B |
22-Dec-16 |
GNL611 |
3754 |
CCR Title 22 Section 72511 (a) If a facility does not employ qualified personnel to render a specific service to be provided by the facility, there shall be arrangements through a written agreement with outside resources which shall meet the standards and requirements of these regulations. CCR Title 22 Section 72533(a) Each facility shall maintain current complete and accurate personnel records for all employees. CCR Title 22 Section 72533 (a) (2) Such records shall be retained for at least three years following termination of employment. Employee personnel records shall be maintained in a confidential manner, and shall be made available to authorized representatives of the Department upon request. The facility failed to ensure the personnel records were retained for one outside resource employee [Physical Therapist (PT) 1] and for three facility employees, [Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 1, and LVN 2], to meet the standards and requirements as indicated in these regulations by failing to: 1. Ensure the personnel record of PT 1 was retained and was available to authorized representatives of the Department; and 2. Ensure the personnel records of facility employees, RN 1, LVN 1 and LVN 2, were retained for at least three years following termination of employment. As a result, the employees? personnel training records and in-service records could not be determined in order to ensure the staff received training and in-services to meet the needs of a patient (Patient 1), who required dialysis. On October 15, 2015, while investigating an entity reported incident (CA00348202), at 4 pm, a review of the facility's Monthly Time Sheet for October 2015, indicated LVN 1 was a current facility employee; RN 1 and LVN 2 were not included on the current employee schedule. On October 15, 2015, at 4:15 pm, a review of the facility personnel files did not include employee records prior to April 15, 2013, for RN 1, LVN 1, or LVN 2. On October 15, 2015, at 4:20 pm, a review of the facility personnel files also did not include an employee record for PT 1. On October 15, 2015, at 4:30 pm, in an interview with the director of nurses, she stated the personnel file for PT 1 was not available for review because the previous rehabilitation therapy company kept PT 1's personnel files. On October 15, 2015, at 5:45 pm, in an interview with the administrator regarding the personnel files for RN 1, LVN 1 and LVN 2, and PT 1, he stated the employees' files were not available for review because the previous owner of the facility took the personnel files after a change of ownership. On August 15, 2016, at 1:32 pm, in an interview with the director of staff development, he stated the personnel files were taken from the facility by the prior owner on April 15, 2013. The facility failed to ensure the personnel records were retained for one outside resource employee (PT 1), and for three facility employees, (RN 1, LVN 1, and LVN 2), to meet the standards and requirements as indicated in these regulations by failing to: 1. Ensure the personnel record of PT 1 was retained and was available to authorized representatives of the Department; and 2. Ensure the personnel records of facility employees, RN 1, LVN 1 and LVN 2, were retained for at least three years following termination of employment. As a result, the employees? personnel training records and in-service records could not be determined in order to ensure the staff received training and in-services to meet the needs of a patient (Patient 1), who required dialysis. The above violation had a direct relationship to the health, safety, or security of all patients, including Patient 1. |
| 920000056 |
Panorama Meadows Nursing Center, LP |
920013221 |
A |
7-Jun-17 |
C6KO11 |
14657 |
?483.25
(b) Skin Integrity -
(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual?s clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
On April 29, 2017, at 8 a.m., during an unannounced recertification survey, Resident 1 skin condition was investigated
Based on observation, interview, and record review, the facility failed to ensure a resident who was admitted to the facility without a pressure ulcer (an injury to the skin and underlying tissue from prolonged skin pressure) and was identify at risk to develop pressure ulcer receives necessary care, consistent with professional standards of practice, to prevent development of left ischium (back of the lower portion of the hip bone [sit bone]) pressure ulcer, and a resident with pressure ulcer receives necessary treatment and services, to promote healing, and prevent infection, including:
1. Failure to implement pressure ulcer prevention interventions as indicated on the plan of care, such as turning and repositioning for a resident who required extensive assistance with one person assisting for bed mobility (moving to and from lying positions, turning side to side, and positioning body while in bed).
2. Failure to accurately identify the resident actual location of the pressure ulcer in order to ensure consistency in assessment, treatment, and monitoring.
3. Failure to ensure weekly pressure ulcer assessments was done in order to determine the healing status of the pressure ulcer in accordance with the National Pressure Ulcer Advisory Panel.
4. Failure to provide immediate nutritional measures to promote healing of the pressure ulcer as indicated in the undated facility policy for "Care and Prevention of Pressure Sore."
5. Failure to notify the physician when the resident's pressure ulcer worsened as indicated in the plan of care, in order to obtain additional interventions necessary to promote healing of the pressure ulcer.
These deficient practices resulted in Resident 1 developing Stage I (an area of persistent redness), pressure ulcer that progressed to unstageable pressure ulcer (pressure ulcer that is covered with dead tissue and unable to determine how deep the wound is) to the left ischium while in the facility, and had a potential to result in delayed healing of the pressure ulcer.
A review of the admission record Resident 1 was initially admitted to the facility on XXXXXXX 2016, and readmitted on February 4, 2017, with diagnoses that included pneumonia (lung inflammation caused by bacterial or viral infection), generalized muscle weakness, acute embolism and thrombosis of deep veins (blood clot), and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe).
A review of the Minimum Data Set (MDS - a comprehensive assessment and care-screening tool), dated March 22, 2017, indicated Resident 1's cognitive skills (the act or process of knowing, perceiving) were moderately impaired and required extensive assistance with one person assisting for bed mobility (moving to and from lying positions, turning side to side, and positioning body while in bed), transfer (moving to or from: bed, chair, wheelchair, standing position), dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 had no pressure ulcer, wounds and skin problems.
A review of the Braden Scale for Predicting Pressure Sore Risk form dated February 4, 2017, indicated Resident 1 had a total score of 15. A total score of 15 to 18 indicates at risk to develop pressure ulcer.
A review of the Resident Admission Form, an initial data collection nursing assessment, dated February 4, 2017, indicated Resident 1 had no pressure ulcer on admission from a general acute care hospital (GACH).
A review of Resident 1?s care plan dated February 4, 2017, for at risk for developing pressure ulcer, bruising, and other types of skin breakdown related to reduced mobility, fragile skin, use of psychotropic and analgesic medications, incontinence of bowel and bladder, history of skin alteration, anemia, COPD, and aging process. The interventions included turning and repositioning as needed when in bed or wheelchair, weekly body checks, treatments as ordered, pressure relieving devices as needed, and notify the physician of any changes.
On April 28, 2017 at 4:30 p.m., Resident 1 was observed in bed lying on her back. During an interview at the time of the observation, Resident 1 stated "I have a bad sore on my buttocks." Resident 1 also stated she cannot turn to reposition herself in bed because she has numbness in her legs so the nursing staff has to do it for her.
During an observation of skin treatment on April 29, 2017 at 10:15 a.m., Resident 1 had an unstageable pressure ulcer located on the left ischial area. During an interview with Licensed Vocational Nurse 1 (LVN 1) at the time of the observation, LVN 1 stated Resident 1 developed the pressure ulcer located in the left ischial area at the facility. LVN 1 stated the pressure ulcer began as a Stage 1 and progressed to an unstageable pressure ulcer. LVN 1 stated the pressure was unstageable because the depth cannot be determined because of the presence of eschar (dead tissue found in full thickness wound).
A review of the Resident Progress Notes dated April 4, 2017, indicated Resident 1 was noted with four (4) centimeter by 2.5 centimeter non-blanchable redness on right buttock. The skin was intact and did not have a discharge. The physician was made aware and new orders were received.
A review of the Treatment Flowsheet dated April 4, 2017, to April 19, 2017, indicated Resident 1 was receiving treatment to the right inner buttock. The order indicated to cleanse the right inner buttock with normal saline, pat dry, apply Venelex (ointment to help wound heal), cover with dry dressing daily for 14 days.
A review of the physician's order dated April 20, 2017, indicated a treatment for left ischial pressure sore. The treatment indicated to cleanse the area with normal saline, pat dry, apply Venelex ointment, and cover with dry dressing daily for 30 days.
On April 29, 2017 at 11:10 a.m., during an interview and concurrent review of Resident 1's progress notes and Skin Progress Report dated April 4, 2017 to April 29, 2017, Licensed Vocational Nurse 2 (LVN 2) stated Resident 1 developed a Stage 1 on the left ischial area at the facility but the site of the pressure ulcer that was documented and reported to the physician was on the right buttock. LVN 2 stated a clarification was done on April 20, 2017, (16 days after the initial identification of the pressure ulcer) indicating the pressure ulcer was on the left ischial area and not on the right buttock. LVN 2 also confirmed the weekly assessment of the pressure ulcer was not done on April 18, 2017, a week after the pressure ulcer on the left ischial area worsened to Stage 2.
A review of the Skin Progress Report indicated treatment was provided to the right buttock, (while actually treatment was provided to the left ischial area per staff) as follows:
1. On April 4, 2017, initial assessment of a Stage 1 pressure ulcer measuring 3.5 centimeters (cm) in length by 4 cm in width and indicated presence of epithelial tissue on the wound bed.
2. On April 11, 2017, Stage 2 pressure sore measuring 3.5 cm in length by 4 cm in width and indicated presence of epithelial tissue on the wound bed. The report did not indicate the pressure ulcer's response to the current treatment nor was there a description of the pressure ulcer's surrounding tissue character.
3. On April 18, 2017, the report did not indicate an assessment was done of the pressure ulcer in order to determine the status of the pressure ulcer such as if it was healing, or worsening, to include stage, size and depth, wound bed description, drainage, response to treatment, wound bed characteristic, and surrounding tissue character.
4. On April 25, 2017, unstageable pressure ulcer to the left ischial measuring 3.5 cm in length and 4 cm in width and indicated presence of epithelial tissue, granulation tissue, slough (dead tissue, usually cream or yellow in color) light drainage. The report did not indicate response to treatment, wound bed characteristic and surrounding tissue characteristic.
A review of Resident 1's Trunk Wound Assessment indicated an initial consultation was done on April 27, 2017, by a wound care specialist. According to the assessment Resident 1 had an unstageable pressure ulcer to the left ischium measuring 4.0 cm in length and 5.1 cm in width with presence of odor, scant drainage, and necrotic tissue/devitalized tissue.
A review of the Certified Nursing Assistant Daily Charting Form for Resident 1 for the month of April 2017 indicated the following:
1. On April 1, 2017 - April 30, 2017, during the night shift (11:00 p.m. - 7:00 a.m. shift, Resident 1 was not positioned every two hours and as needed.
2. On April 8, 2017 - April 30, 2017, during the day shift (7:00 a.m. - 3:00 p.m. shift, Resident 1 was not positioned every two hours and as needed.
On April 28, 2017 at 9:22 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was able to reposition herself but needs two people to pull her up in bed. CNA 1 was aware Resident 1 has a pressure ulcer but was not able to identify the correct location of the pressure sore.
On April 29, 2017 at 11:10 a.m., during an interview, LVN 2 stated there should have been updated care plan and an interdisciplinary (IDT) meeting to identify possible causes of how the pressure ulcer developed and identify interventions to manage and treat the pressure sore. LVN 2 was unable to provide documented evidence the resident's physician was notified of Resident 1's change of condition on April 11, 2017, when the pressure ulcer on the left ischial area worsened from Stage 1 to Stage 2, and on April 25, 2017, when the pressure ulcer on the left ischial area worsened from Stage 2 to unstageable pressure ulcer, in order to obtain additional interventions necessary to promote healing of the pressure ulcer.
On April 29, 2017 at 11:10 a.m., during an interview and concurrent review of Dietary Progress Notes for Resident 1, LVN 2 stated the RD's latest progress notes entry was dated March 24, 2017, and indicated Resident 1 did not have a pressure ulcer at the time of the review. LVN 2 stated the RD was not notified when Resident 1 developed pressure ulcer in the left ischium.
Nutritional measures from the RD meant to prevent further deterioration of the skin, were not provided immediately as indicated in the facility policy for "Care and Prevention of Pressure Sore". For example, on April 11, 2017, Resident 1's pressure sore on the left ischial area worsened from Stage 1 to Stage 2, but nutritional measures from the RD were not provided immediately. On April 25, 2017, the resident's pressure sore on the left ischial area worsened from Stage 2 to unstageable pressure sore, but nutritional measures from the RD were not provided immediately.
A review of the facility's undated policy titled "Care and Prevention of Pressure Sore," indicated "all available measures shall be taken to prevent skin breakdown and pressure sores. If these conditions occur, treatment is to be initiated immediately and preventive measures taken to prevent further deterioration of the skin."
According to the National Pressure Ulcer Advisory Panel (NPUAP), a comprehensive assessment of the individual and his or her pressure ulcer (sore) informs development of the most appropriate management plan and ongoing monitoring of wound healing; that includes a focused physical examination, nutrition, pain related to pressure ulcers, employment of pressure relieving and redistributing maneuvers, risk for developing additional pressure ulcers, ability to adhere to a prevention and management plan. Assessment of the pressure ulcer includes reassessing it at least weekly and document results of all wound assessments. Wound assessment includes location, category/stage, size, tissue type, color, periwound condition, wound edges, exudates, odor. (National Pressure Advisory Panel. (2014). npuap.org).
The facility failed to ensure a resident who was admitted to the facility without a pressure ulcer (an injury to the skin and underlying tissue from prolonged skin pressure) and was identify at risk to develop pressure ulcer receives necessary care, consistent with professional standards of practice, to prevent development of left ischium pressure ulcer, and a resident with pressure ulcer receives necessary treatment and services, to promote healing, and prevent infection, including:
1. Failure to implement pressure ulcer prevention interventions as indicated on the plan of care, such as turning and repositioning for a resident who required extensive assistance with one person assisting for bed mobility.
2. Failure to accurately identify the resident actual location of the pressure ulcer in order to ensure consistency in assessment, treatment, and monitoring.
3. Failure to ensure weekly pressure ulcer assessments was done in order to determine the healing status of the pressure ulcer in accordance with the NPUAP.
4. Failure to provide immediate nutritional measures to promote healing of the pressure ulcer as indicated in the undated facility policy for "Care and Prevention of Pressure Sore."
5. Failure to notify the physician when the resident's pressure ulcer worsened as indicated in the plan of care, in order to obtain additional interventions necessary to promote healing of the pressure ulcer.
These deficient practices resulted in Resident 1 developing Stage I, pressure ulcer that progressed to unstageable pressure ulcer to the left ischium while in the facility, and had a potential to result in delayed healing of the pressure ulcer.
The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 1. |
| 920000054 |
PANORAMA GARDENS |
920013357 |
A |
24-Jul-17 |
CPDH11 |
10017 |
CFR 483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
483.25 (h) Accident Hazards/Supervision/Devices
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
On 6/28/16, at 8:30 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1?s quality of care.
Based on interview and record review, the facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and failed to ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent falls and injuries, including:
1. Failure to ensure the plan of care for Resident 1?s risk for falls included in the interventions the frequency and level of supervision required for the resident?s safety.
2. Failure to re-evaluate the plan of care when Resident 1?s restlessness increased to ensure effectiveness of interventions to prevent falls and minimize injuries.
3. Failure to implement the facility?s policy and procedures on Fall Risk Assessment by not including supervision in Resident 1?s fall prevention protocol.
4. Failure to implement the facility's policy and procedure on Pain Management by not using pharmacologic interventions to manage Resident 1?s pain after the fall.
As a result, on 6/13/16 Resident 1 sustained a fall resulting in a right hip fracture that required transfer to a general acute care hospital (GACH) where on XXXXXXX 16, underwent surgery to repair the fracture.
A review of the clinical record indicated Resident 1 was admitted to the facility, on XXXXXXX15, with diagnoses including osteoporosis (bones become weak and brittle), dementia (decrease in the ability to think, great enough to affect a person's daily functioning), anxiety (feeling of worry, nervousness, or unease, typically about an event or something with an uncertain outcome), and osteoarthritis (joint disease) to the elbow.
The Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 6/10/16, indicated Resident 1 was totally dependent for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing with one person physical assistance. The resident used a wheelchair for locomotion and a walker for walking assisted by staff.
The Care Area Assessment (CAA), dated 6/11/16, indicated Resident 1 had difficulty maintaining sitting balance and had impaired balance during transitions.
A review of the Fall Risk Assessment dated 6/4/16, indicated Resident 1 was disoriented, had a high risk for falls due to fall history, poor vision, decreased muscular coordination, change in walking pattern, balancing problem while standing/walking, and required the use of an assistive device (a walker) to walk.
A physician?s order dated 6/3/16, indicated to give Resident 1 Ativan (antianxiety medication to treat nervousness) 0.5 milligrams (mg) daily as needed for restlessness.
A physician?s order dated 6/3/16, indicated Resident 1 was to receive Norco [a combination medicine of hydrocodone (narcotic) and acetaminophen (analgesic) to treat moderate to severe pain] 5-325 milligram (mg) tablet as needed every six hours for moderate to severe pain.
Another physician?s order dated 6/4/16, indicated to apply a pad alarm (a device use to alert staff when the resident is attempting stand up) in bed and in wheelchair to prevent unassisted transfers.
A plan of care dated 6/4/16, indicated Resident 1 had acute / chronic pain related to arthritis and osteoporosis and the interventions included following the pain scale to medicate as ordered.
A plan of care dated 6/4/16, developed for Resident 1?s fall risk was updated on 6/9/16 to indicate an increased fall risk due to Resident 1?s increased restlessness. The approaches did not include monitoring/supervising the resident and how frequent the supervision was needed.
According to Licensed Vocational Nurse 2 (LVN 2) nursing progress note dated 6/9/16, timed at 9:25 a.m., Resident 1 continued with episodes of unassisted transfers and Ativan was given. At 1:54 p.m., LVN 2 documented Resident 1 continued with episodes of unassisted transfers, pad alarm was in place and safety precautions were observed.
According to Registered Nurse 1 (RN 1) nursing progress notes dated 6/13/16, timed at 12:25 p.m., Resident 1 was up in a wheelchair, attempted to get up without assistance, and appeared anxious and restless. The resident was confused, unable to make needs known, and Ativan was given.
According to LVN 1?s nursing progress note dated 6/13/16, timed at 7:12 p.m., Resident 1 was found lying on the floor complaining of discomfort to the right lower extremity when the area was touched. The physician was notified and ordered to transfer Resident 1 to a GACH.
A review of the medication record (MAR) dated 6/13/16 indicated Resident 1 had 8/10 pain; however, there was no documented evidence, Norco was given to the resident for pain as ordered before transferring the resident to the GACH.
A review of the ambulance Run Sheet dated 6/13/16 indicated Resident 1 left the facility at 8:20 p.m., without any pain medication administered. Upon leaving the facility and during transport, Resident 1 was experiencing pain rated 9/10.
A review of the GACH computerized tomography (CT ? a radiological test) scan, dated 6/14/16, indicated Resident 1 had a comminuted (broken in multiple pieces) displaced right intertrochanteric femoral neck fracture (fracture to the upper part of the thigh bone, the hip) with adjacent soft tissue swelling.
The x-ray report of Resident 1?s right hip dated 6/15/16 indicated Resident 1 had an intertrochanteric fracture of the right hip.
Resident 1 underwent surgery on 6/16/16 to repair the broken hip. The operating room (OR) notes dated 6/16/16 indicated Resident 1 underwent open reduction and internal fixation (ORIF - first the broken bone is reduced or put back into place, next an internal fixation device is placed on the bone).
On 6/28/16, at 10:10 a.m., during an interview, the Director of Nursing (DON) stated Resident 1 was in the hallway at Station 3. LVN 1 was with the resident initially, and then left to see another resident. The DON stated Resident 1 the fall was unwitnessed and after the fall, the resident grimaced whenever his right hip was touched.
On 7/7/16, at 7:41 a.m., during an interview, Registered Nurse 1 (RN 1) stated on the day of the fall, Resident 1 was restless and was trying to get out of the wheelchair. The physician was notified and increased the order of Ativan to routine every eight hours. RN 1 stated Resident 1 should have been supervised due to repeated attempts of unassisted transfers.
On 7/7/16, at 8:30 a.m., during an interview, the assistant DON (ADON) stated Resident 1 stated supervision should have been added to the care plan.
On 7/7/16, at 8:45 a.m., during a telephone interview, LVN 1 stated on the day of the fall, Resident 1 was more anxious than usual and, in the morning, was given Ativan due to increased episodes of attempting to get up unassisted. The resident was sitting up in a wheelchair at the nursing station with a pad alarm. LVN 1 stated she went to pass medication to another resident and left Resident 1 in the hallway unsupervised. When she came out of the room, she found the resident lying on the ground.
The facility's policy and procedure titled, "Pain Management," dated 5/2007, indicated the facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning. The facility was to develop and implement a plan, using pharmacologic and/or non -pharmacologic interventions to manage pain and/or try to prevent the pain consistent with the resident's goals.
The facility's policy and procedure titled, "Fall Risk Assessment," dated 5/2007 indicated any resident identified as high risk for falls would have a prevention protocol initiated and documented on the care plan. Prevention protocol included supervision.
The facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and failed to ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent falls and injuries, including:
1. Failure to ensure the plan of care for Resident 1?s risk for falls included in the interventions the frequency and level of supervision required for the resident?s safety.
2. Failure to re-evaluate the plan of care when Resident 1?s restlessness increased to ensure effectiveness of interventions to prevent falls and minimize injuries.
3. Failure to implement the facility?s policy and procedures on Fall Risk Assessment by not including supervision in Resident 1?s fall prevention protocol.
4. Failure to implement the facility's policy and procedure on Pain Management by not using pharmacologic interventions to manage Resident 1?s pain after the fall.
As a result, on 6/13/16 Resident 1 sustained a fall resulting in a right hip fracture that required transfer to a GACH where on XXXXXXX 16, underwent surgery to repair the fracture.
The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 1. |
| 930000773 |
PROVIDENCE LITTLE COMPANY OF MARY TRANSITIONAL CARE CENTER |
930008536 |
B |
05-Jan-12 |
S9I211 |
6198 |
Patients? Rights T22 Div Ch3 ART 5 72527 (a) (11) (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:(11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs.On August 11, 2011, an unannounced investigation was conducted to investigate a facility reported incident regarding an allegation of abuse.Based on record review and interview, the facility failed to ensure that Patient 1 was treated with dignity and respect by Staff A, who told the patient that if he could not perform the therapy, then Staff A would discontinue the therapy and his medical insurance would be terminated.Patient 1 felt threatened, by the remarks made by Staff A and was upset. Findings: On August 11, 2011, a review of the facility's Investigation Incident Report Form dated August 10, 2011 at 12:30 p.m., disclosed Patient 1 stated that Staff A (Occupational Therapist) told him that if he cannot do the therapy, then his medical insurance would "kick him out of here (facility)." According to Patient 1, he felt threatened and was scared of Staff A.On August 11, 2011, the evaluator conducted a review of Patient 1's medical record. The Face Sheet indicated Patient 1 was admitted to the skilled nursing facility on August 9, 2011, with diagnoses that included acute renal failure, dehydration, and urinary tract infection.The "View Assessment" section of Patient 1's electronic record dated August 9, 2011, at 10:15 a.m., indicated an initial occupational therapy evaluation was completed for Patient 1. According to the initial evaluation, the patient's additional past medical history included bladder cancer and generalized weakness. Patient 1 was oriented to person, place, time and situation. Patient 1 needed assistance in dressing and toileting was able to eat by himself, and his rehabilitation potential was assessed to be fair. The plan was to provide occupational therapy 5 times a week for one week. (Occupational Therapy is treatment that helps individuals achieve independence and improve one's ability to perform daily activities). The View Assessment dated August 9, 2011 at 3:54 p.m., indicated an initial physical therapy evaluation was also completed for Patient 1. The View Assessment dated August 10, 2011, completed by Staff C, indicated the occupational therapy was started at 9:19 a.m., and the patient was agreeable to the treatment session. The patient was going to the radiation treatment in early afternoon and wanted to rest at this time. The View Assessment dated August 10, 2011, completed by Staff A, indicated Patient 1 had declined occupational therapy treatment after being encouraged to do so multiple encouragement. Staff A explained to the patient the importance of getting up for meals and light hygiene tasks and Patient 1 declined. Patient 1 will be discharged from occupational therapy and the physician was notified. On August 11, 2011, at 11:02 a.m., the evaluator conducted an interview with Patient 1. He stated, "I am still upset because of her comments. Staff A told me if I don't cooperate the facility will have to terminate my insurance. I told her this is crazy and that I did not want to do the treatment. Staff A told me that she will discontinue my treatment and tell my doctor. "The evaluator asked Patient 1 how he felt about what Staff A told him. Patient 1 raised his left hand and gestured "this small"! Patient 1 stated, "I was trying to rest because I was scheduled for a radiation treatment. I sensed urgency on her part. It is a lousy way to do business and I could not figure out what I did to her? She thinks that she can abuse old people. " On August 11, 2011, an interview was conducted with Staff B, who was present in Patient 1's room at the time of the incident. Staff B stated, "Patient 1 was very upset and Staff A told him that if he did not get up, I (Staff A) will have to call your doctor and your insurance will be cut off. Patient 1 told her that he had the right to say "no" and that he did not want to exercise."On August 11, 2011, at 11:15 a.m., an interview was held with Staff A and she stated that she was trying to encourage Patient 1 to exercise and cooperate. Patient 1 said that he did not want to exercise and was getting upset. Staff A stated Patient 1 "I told him that I will discontinue the treatment, his insurance would get canceled, and I would tell the doctor."When the evaluator asked, "did you ask Patient 1 why he did not want to cooperate and exercise?"Staff A said, "no. " A review of the Employee Chronological Record dated August 11, 2011; completed by Staff C (Rehab Manager) disclosed "the patient was anxious and upset at the time of incident. Staff A should have taken a step back from the situation and let the patient calm down. Staff A should have stayed away from the terminology "discharge" when Patient 1 was already upset and anxious." Staff C discussed with Staff A the need to assess the patient closely and to recognize the anxiety or stress that may affect the patient's participation in the therapy.A review of the facility's policy and procedure entitled, Resident Rights dated April 2011, stipulated the patients had the right to be treated with consideration, respect and full recognition of dignity and individuality. The facility shall ensure the rights of the patients are protected and promoted and not violated. The facility failed to ensure that Patient 1 was treated with dignity and respect by Staff A causing Patient 1 to be upset, feel threatened and scared. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Patient 1. |
| 930000611 |
PACIFICA HOSPITAL OF THE VALLEY D/P SNF |
930011378 |
A |
19-Jun-15 |
FNO511 |
13955 |
CFR 483.25(l) DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. CRF 483.60 (c) DRUG GEGIMEN REVIEW, REPORT IRREGULAR, ACT ON The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. The pharmacist must report any irregularities to the attending physician, and the director of nursing, and these reports must be acted upon. On October 18, 2014, an unannounced visit was made to the facility to conduct a re-certification survey. The survey was completed on November 3, 2014. Based on interview and record review, the facility failed to: 1. Ensure that Resident 8 who had not used antipsychotic medications (Seroquel and Lithium) were not given these drugs unless antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in Resident 8's clinical record. Resident 8 continued to receive Seroquel and Lithium from August 2013 through October 2014 with clinically significant risk, existing adverse consequences, and drug interactions. 2. Act on the documented drug irregularities identified by the facility's consultant pharmacist. The deficient practice resulted in Resident 8 was receiving: (a) Seroquel and Lithium from August 2013 through October 2014 without a clear indication for use to treat a specific condition as diagnosed and documented in Resident 8's clinical records; (b) duplicate drug therapy with Reglan and Dexilant (to treat heartburn/gastric reflex disease); (c) multiple drug interactions between Seroquel, Reglan, Lithium, and Lisinopril (blood pressure medication); (d) Colace (stool softener) in higher than recommended dose from June 2014 through October 2014.The above violations resulted in Resident 8 exhibited the symptoms of medication adverse reactions, and Resident 8 was treated with Lacri-lube for dry eyes, Constulose and Docusate Sodium for constipation, Reglan for stomach discomfort, Baclofen for involuntary muscle movement and Ativan for anxiety.Findings: According to the facility's patient registration form, Resident 8 was a 58 year-old male who was admitted on August 20, 2013, with diagnoses that included respiratory failure, tracheostomy (an opening surgically created that allows air passage to help in breathing), and spinal cord contusion (injuries as a result of high-impact motor vehicle accidents). Review of Resident 8's history and physical dated August 21, 2013 at 6:07 p.m., indicated, "(Resident 8) was a victim of an accident ...He was traveling in his bicycle and hit a parked car ... Multiple trauma including facial trauma ... "Review of Resident 8's physician orders, dated August 2013, included the following medications: Lithium 150 mg every day for mood stability manifested by episodes of depression or mania manifested by sadness or excessive demands, such as using call light frequently, Seroquel 25 mg at bedtime for psychosis with agitative features manifested by non-compliance and resistive to care.According to Resident 8's psychiatric consultation dated September 6, 2013, at 11:44 a.m., medical physician (MD 2) indicated, "(Resident 8) with no prior psychiatric history. He was hit by a car when he was traveling on his bicycle. He suffered multiple injuries ...While going through hospitalization and so forth, he became irritated, out of control and agitated, and I believe as a result he was placed on Lithium (150 mg every morning) and Seroquel (25 mg at bedtime). As per the staff the patient still exhibits agitation ...not able to accept the fact that how much physically disabled he is. Patient himself realizes this and tells me that he just loses control when he thinks about the admission (after his bicycle accident) and what it has done to him. (Resident 8) otherwise is not psychotic. Mood seems to be stable. Never been hospitalized in a psychiatric hospital. I will increase Seroquel to 25 mg three times a day and lithium to 300 mg every day ...No evidence of psychosis or mania. "Resident 8's plans of care for Seroquel and lithium dated, August 20, 2013, September 3, 2013, March 4, 2014, indicated, monitor drug levels, notify MD (physician) if abnormal noted. Evaluate need for continued use of psychotropic medications at least weekly in summary and monthly in team conference. Ensure lowest effective dose is given. Discontinue medication if not needed. Monitor resident for changes in condition.A review of Resident 8's physician orders, dated October 2014, included: Seroquel 50 mg three times a day (150 mg daily), Lithium 300 mg every morning, Reglan 10 mg three times a day for (GERD - gastroesophageal reflux or acid reflux), Dexilant 60 mg 30 minutes before breakfast for (GERD), Lisinopril 2.5 mg via G-tube every morning - hold for systolic blood pressure less than 95, Colace (docusate sodium) 250 mg three times a day for constipation, baclofen 20 mg three times a day for muscle spasms (involuntary muscle movement), zinc sulfate 220 mg every day for wound healing, vitamin C 500 mg after dinner for wound healing, Ativan 1 mg via G-tube every 12 hours as needed for anxiety manifested by hyperventilation (is rapid or deep breathing that can occur with anxiety or panic) or shortness of breath.On October 22, 2014 at 10:30 a.m., during an interview, the director of nursing (DON 1), stated, "MD 1 did not clarify on Medication Administration Record (MAR) or in his physician order what side effects to monitor for Resident 8 ... Non-compliance is not a psychotic event. The hashmarks on the MAR indicate non-compliance." During an interview on October 22, 2014, at 11 a.m., the registered nurse (RN 2) stated, "Resisting care is not psychosis. The type of behavior the resident is having supposed to be added to the MAR. We do not have specific behaviors to be monitored from the physician. Seroquel is not an antidepressant it is an antipsychotic." According to Food and Drug Administration (FDA) label information (package inserts) for Seroquel indicated, adverse reactions include but not limited to; constipation, dry mouth, blurred vision, Tardive Dyskinesia (potentially irreversible, involuntary muscle movement), sedation, difficulty breathing, anxiety, agitation, stomach discomfort, and weight gain. http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020639s061lbl.pdf Review of physician orders for Resident 8 indicated the following medications were prescribed to treat dryness, constipation, involuntary muscle movement, anxiety and hyperventilation (difficulty breathing): a. September 2, 2013 Lacri-Lube ophthalmic ointment for dry eyes b. September 8, 2013 Constulose daily for constipation c. October 2, 2013 Reglan for GERD. However, manufacturer cautions against the use of Reglan while taking Seroquel due to increased risk of involuntary muscle movement. d. January 1, 2014 Baclofen 20 mg three times a day for involuntary muscle movement e. March 12, 2014 Seroquel was increased to 75 mg via G-tube three times a day (225 mg total daily dose). Review of a Physician note dated March 21, 2014, indicated Resident 8 complained of sedation. f. June 11, 2014 Docusate Sodium 250 mg three times a day (total daily dose of 750 mg above the suggested maximum recommended of 300 mg a day) to treat constipation in addition to Constulose for the treatment of constipation. g. August 31, 2014 Ativan 1 mg every 12 hours as needed for anxiety manifested by hyperventilation or shortness of breath.On October 22, 2014 at 11:10 a.m., DON 1 in the presence of DON 2, reviewed Resident 8's clinical records and stated, "He did not see Lithium labs (laboratory values used to check if medication is in therapeutic range to be effective) or an order for labs. MD 1 and MD 2 did not write any orders for lithium labs. A patient on lithium for over a year should have lithium labs." According to DailyMed, the official provider of Food and Drug Administration (FDA) label information (package inserts), indicated, "Dosage must be individualized according to serum levels and clinical response. Regular monitoring of the patient's clinical state and of serum lithium levels is necessary." http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/017812s028,018421s027lbl.pdfDuring an interview with the Risk Manager, on October 22, 2014 at 3:30 p.m., she reviewed the Psychiatric Consultation dated September 6, 2013, timed at 11:44 a.m., and stated, "Clearly there was no psychosis or justification for resident to be on Seroquel or Lithium. I didn't even know there was an interaction between Seroquel and Reglan."On October 23, 2014 at 12:50 p.m., Resident 8 was observed in his room lying in bed talking with his nurse. When asked about the medications Resident 8 stated, "I take Norco for pain and Seroquel is for my anxiety."During an interview with the Consultant Pharmacist, on October 23, 2014 at 2:30 p.m. she stated, "Reglan is not recommend be given long term due to increased risk of involuntary muscle movement while on antipsychotic (Seroquel). Based on (Resident 8's) clinical record could not see the need for Seroquel. I wanted the physician to provide a better diagnosis. Seroquel is to be used for a well-documented, well established psychiatric issue. Physician and licensed nurses should actually define the problem and use non pharmacological interventions. Not appropriate for patient (Resident 8) to be on Seroquel." On October 23, 2014 at 3:35 p.m., during an interview, MD 2 stated, Gradual Dose Reduction should be done to get patient off of antipsychotic and patient should be monitored monthly for adverse reaction. A review of Pharmacist's Consultation Reports, dated August 2013, October 2013, and July 2014 requesting clinical justification for the use of Seroquel, an antipsychotic medication and for Resident 8, with no prior history of psychosis. "(Seroquel) cannot be used for non-compliance or resistive to care. Please consider reducing the dose with the eventual goal of discontinuation ...please indicate the specific diagnosis/indication requiring treatment ...Evaluate for causes of behavior ...and assessment of alternative intervention." A review of Pharmacist's Consultation Reports, dated August 2013 and October 2013, indicated, "After reviewing Resident 8's chart, there appears to be no diagnosis and/or documentation in the resident record which supports continued use of the following medication ...Lithium. " The Pharmacist's Consultation Report, dated, April 2014 request to discontinue Reglan (metoclopramide) because of its many undesirable side effects (such as drowsiness, tremor, and restlessness) and monitor Resident 8 for involuntary movements now and at least every three months. September 2014 consultant pharmacist recommended discontinuation of Resident 8's zinc sulfate which may cause GI (stomach) upset. Zinc Sulfate was not recommended to use beyond 90 days and may delay wound healing.On September 9, 2014, the consultant report by the pharmacist indicated Resident 8 was receiving Seroquel for an unclear diagnosis. The report indicated if the therapy is to continue at the current dose, to provide rationale describing a dose reduction as clinically contraindicated. Resident 8's clinical record included a recommendation letter addressed to MD 1 signed by the facility's registered dietitian indicated: "Recommend providing Vitamin C for wound healing. Recommend D/C (discontinue) zinc sulfate, patient has been on it since 9/13 (September 2013)." October 2014 consultant pharmacist recommended Resident 8's Colace (docusate sodium, a stool softener) to be reduced from 750 milligram (mg) a day to the maximum suggested dose of Colace 300 mg once daily. A review of the facility's policy titled, "Psychotropic Medication Management" dated 7/13, indicated under Sub-Acute Unit Specific:12. The Sub-acute unit will ensure that residents who have not used anti-psychotic drugs are not given drugs unless anti-psychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record.13. Residents on the Sub-acute Unit who use anti-psychotic drugs will receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.14. All Residents who are on anti-psychotic medication will have their behaviors manifested clearly and specifically identified and documented in the Interdisciplinary care plan, in order to ensure objective and appropriate monitoring. Failure of the facility to ensure that Resident 8 who had not used antipsychotic medications (Seroquel and Lithium) were not given these medications unless antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the resident's clinical record, and to act on the documented drug irregularities identified by the facility's consultant pharmacist, presented either an imminent danger that serious harm would result or a substantial probability that serious physical harm would and did result. |
| 930000611 |
PACIFICA HOSPITAL OF THE VALLEY D/P SNF |
930012259 |
B |
18-May-16 |
SJB511 |
8392 |
CFR 483.65 Infection Control 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.Based on observation and record review, the facility failed to follow infection control practices to prevent spread of infection from one patient to another by failing to: 1. Ensure Patient 12, who tested negative for Methicillin Resistant Staphylococcus Aureus (MRSA is a micro-organism that is more difficult to treat than most strains of staphylococcus aureus, can infect surgical wounds, the bloodstream, the lungs or the urinary tract, and can be life-threatening), would not share the same room with Patient 20, who tested positive for MRSA of the nares, resulting in Patient 12 being tested positive for MRSA of the nares after six days of sharing the same room.2. Ensure Patient 11 would be screened for MRSA following admission to the facility in accordance with the facility's policy and procedure.3. Ensure Patient 11, who tested positive for Vancomycin-Resistant Enterococci bacteria (VRE - bacteria live in our intestines and skin that can cause serious infections, especially in people who are ill or weak), would not share the same room with Patient 12, who was tested positive for MRSA of the nares. This deficient practice placed Patient 11 at risk for MRSA infection and Patient 12 at risk for VRE infection.During the initial tour of the Neuro 2 unit, accompanied by the registered nurse 24 (RN 24), on February 2, 2016, at 11 a.m., there was a sign "Contact Isolation and Droplet Isolation" posted outside of Patient 11?s and 12?s room. A review of the room assignment indicated Patient 11 and 12 were sharing the same room from January 9, 2016 to February 3, 2016. According to Patient 12?s admission record, the patient was admitted to the facility on December 10, 2015, with diagnoses of chronic respiratory failure and intracranial hemorrhage (bleeding in the brain). Patient 12 had tracheostomy (a surgical opening into the trachea or breathing passage, for purposes of breathing and removal of lung secretions), gastrostomy tube [(GT) a tube that is surgically inserted into the stomach for purposes of nutrition delivery and medication administration) and pressure ulcers (injury to skin) on the sacral area and the right lateral foot.A review of the facility's room assignment record indicated Patient 12 shared the same room with Patient 20 from January 1, 2016, through January 8, 2016. According to the laboratory report, dated December 11, 2015, Patient 12 was tested negative for MRSA and per laboratory report dated October 15, 2015, Patient 20 was tested positive for MRSA of the nares.According to the laboratory reports dated January 6, and January 15, 2016, Patient 12 was tested positive for MRSA of the sputum. According to admission screening report dated December 10, 2015, Patient 12 tested negative for MRSA before sharing the room with Patient 20.A review of Patient 11's admission record indicated the patient was admitted to the facility on April 24, 2010, with diagnosis of respiratory failure. Patient 11 was ventilator (breathing machine) dependent and had a GT.According to the laboratory results, dated January 1, 2016, Patient 11 tested positive for VRE in sputum and was placed on droplet isolation. According to the laboratory report dated January 20, 2016, Patient 11 tested positive for VRE in urine, and was placed on contact isolation in a room with Patient 12, who was free of VRE, however had MRSA of the sputum and was on contact isolation for MRSA.A review of Resident 11?s clinical record indicated there was no documented evidence the resident was screened for MRSA upon admission to the facility.As stipulated in the facility?s policy number II.M.2 titled ?MRSA Screening? the testing criteria for MRSA were patients discharged from an acute care hospital within 30 days prior to the admission to the facility: patients who were admitted to the critical care unit, all dialysis patients, patients transferred from skilled nursing facility and patients scheduled for inpatient surgery who had documented medical conditions which cause susceptibility to the infection. The above mentioned patients had to be screened for MRSA within four hours of admission to the facility.On February 3, 2016, at 2:15 p.m., during an interview with the registered nurse (RN 22) stated the unit lacked adequate space for patients who required isolation. When asked how many isolation rooms were available, RN 22 replied there were a total of five isolation rooms.On February 3, 2016 at 2:25 p.m., an interview was conducted with the RN 23, who was the director of infection control. RN 23 was questioned how he determined which patients, who required isolation, could be cohorted together. RN 23 stated he checks patients? information daily, such as: whether a patient was diagnosed with a contagious infection, their vital signs, and laboratory results. RN 23 stated it was difficult to re-locate a patient on the subacute unit who did not have a tracheostomy, or other potential sites that could become infected. RN 23 further stated many of the patients on the subacute unit were immuno-compromised (a state in which someone's immune system's ability to fight infectious disease is compromised or entirely absent).According to the facility?s policy and procedure titled ?Isolation Precautions? revised October 2014, a patient on contact isolation precaution had to be placed in a private room; when private room is unavailable, placed the patient in a room with a patient(s) who had active infection with the same microorganism, but with no other infection (cohorting). When a private room is not available, and cohorting is not achievable, the epidemiology of the microorganism and the patient population had to be considered when determining patient placement.Based on observation and record review, the facility failed to ensure infection control practices to prevent spread of infection from one patient to another were followed by failing to: 1. Ensure Patient 12, who tested negative for Methicillin Resistant Staphylococcus Aureus (MRSA is a micro-organism that is more difficult to treat than most strains of staphylococcus aureus, can infect surgical wounds, the bloodstream, the lungs or the urinary tract, and can be life-threatening), would not share the same room with Patient 20, who was tested positive for MRSA of the nares, resulting in Patient 12 being tested positive for MRSA of the nares after six days of sharing the same room.2. Ensure Patient 11 would be screened for MRSA following admission to the facility in accordance with the facility's policy and procedure.3. Ensure Patient 11, who was tested positive for Vancomycin-Resistant Enterococci bacteria (VRE - bacteria live in our intestines and skin that can cause serious infections, especially in people who are ill or weak), would not share the same room with Patient 12, who tested positive for MRSA of nares. This deficient practice placed Patient 11 at risk for MRSA infection and Patient 12 at risk for VRE infection.The above violation had a direct relationship to the health, safety, or security of patients. |
| 940000089 |
PACIFIC CARE NURSING CENTER |
940008078 |
B |
20-Jan-12 |
IQ9K11 |
41050 |
The citation narrative for this penalty will not fully display due to narrative length limitations. Please send a request toÿÿCHCQdata@cdph.ca.govÿto obtain a full copy of this citation narrative.ÿ
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.
? Linens
Personnel must handle, store, process and transport linens so as to prevent the spread of infection.
The Department received a complaint allegation on February 11, 2011, that indicated 35 percent of the residents had rashes due to dirty beds.
An unannounced complaint investigation was conducted on February 25, 2011.
Based on observation, interview, and record review, the facility failed to follow their policy and procedure on infection control by not:
1. Ensuring Resident 1, who had a rash for over two months, and was treated, with Elimite (a scabicide used to treat scabies) was seen by a dermatologist.
2. Prophylactically treating Resident 1?s roommates (Residents 2 and 3) at the same time Resident 1 was treated for scabies.
3. Implementing isolation precautions, during the Elimite treatment, as per the facility?s policy and California Public Health Department (CPHD) recommendations, to prevent transmission of scabies.
4. Following the physician?s order in obtaining three stool specimens for Resident 4, who had many episodes of diarrhea (liquid stool) to rule out Clostridium Difficile (C Diff.)
5. Isolating Resident 4 when C Diff. was suspected as indicated in the facility?s policy and the California Public Health Department (CDPH) recommendations for preventing the spread of C. Diff.
6. Isolating Resident 4, who had a rash and was treated with Elimite (a scabicide used to treat scabies) as per the facility?s policy and CDPH recommendations.
7. Treating Resident 4?s roommate (Resident 5) prophylactically when Resident 4 was treated for scabies.
8. Reporting to the Public Health Department and Licensing and Certification when a scabies outbreak occurred for 10 of 10 randomly selected residents (Residents 6, 8, 9, 10, 13, 16, 17, 18, 19 and 22) who had a rash and received Elimite (an anti parasitic medication used to treat scabies).
9. Prophylactically treat the 10 residents? roommates (Residents 7, 11, 12, 14, 15, and 23), staff and visitors as per the facility?s policy and California Department of Public Health (CDPH) guide lines.
10. Tracking rashes, isolating residents treated for scabies, and providing prophylaxis treatment to resident's roommates, staff, and visitors as per the facility's policy and procedures.
11. Following the CDPH guidelines for the use of Elimite that could be toxic. The facility used the scabicide inappropriately when they applied it on all residents admitted and re admitted to the facility with or without a rash.
12. Maintain hot water temperatures at 160 F or above to safely wash linens.
These system failures resulted in the spread of disease and infection, and residents not being evaluated and accurately diagnosed, which caused a delay in adequate treatment to Resident 1.
On February 28, 2011, records were reviewed and indicated the following:
a. Resident 1 was admitted to the facility on December 13, 2001 and readmitted on November 5, 2009 with diagnoses that included Alzheimer's disease, dementia (both of which are brain disorders that cause progressive loss of intellectual and social skills), and insulin dependent diabetes mellitus.
A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated February 17, 2010, indicated the resident was non ambulatory and had unclear speech as evidenced by slurred or mumbled words. The resident rarely or never was able to make herself understood and rarely or never had the ability to understand others. The resident's cognitive skills were severely impaired. According to the MDS, the resident was totally dependent on staff for all activities of daily living (ADL) which included bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Her range of motion was impaired on both sides of her upper extremities (shoulder, elbow, wrist, hand).
A review of the Non Pressure Sore Skin Problem Report dated December 5, 2010, indicated the resident had a scattered rash on the back and breasts. According to the skin report on December 26, 2010, the resident's rash was ongoing.
A review of the nurse's notes dated January 1, 2011, indicated the resident had multiple scratch marks on her left forearm. The nurse's note on January 4, 2011, indicated the resident still had the rash with multiple scratch marks to the left forearm. The nurse's note on January 15, 2011 indicated the resident had a whole body rash.
A review a physician's telephone order dated January 27, 2011, indicated to apply Elimite cream (a scabicide used to treat scabies) from the head to toe and leave on for 12 hours, shower in the morning and then repeat in seven days. There was no order to place the resident in isolation.
A review of the Medication Administration Record (MAR), dated January 27, 2010, indicated the resident was treated with Elimite cream for the body rash. There was no documented evidence the resident was placed in isolation, the room and clothes were decontaminated, and the resident's roommates (Resident 2 and 3) received treatment prophylactically per the facility?s policy and CPHD recommendations for the treatment of scabies.
A review of the Non Pressure Sore Skin Problem Report dated January 30, 2011, indicated the resident's rash remained scattered over the body. The report dated February 6, 2011 and February 21, 2011 indicated the scattered rash was ongoing all over the body and abdomen area.
A review of a dermatologist (a doctor who specializes in treating conditions that affect the skin, hair, and nails) progress note dated February 25, 2011 indicated he saw the resident and order new treatment for the rash. The physician ordered Ivermectin 9 mg (oral anti parasitic) to be given via G tube one time, Elimite cream to be applied from head to toe for 12 hours then repeated in seven days.
A review of the MAR for the month of February 2011 indicated the resident was given 16 doses of Atarax (an ant histamine used for itching).
On February 28, 2011, at 4:35 p.m., during an observation, Resident 1's rash was scattered, bright red and prickly spots all over the body. The rash was mostly on her back and right breast area and there was also some mite tracking observed.
B. Resident 2, Resident 1's roommate, face sheet indicated the resident was admitted to the facility on November 1, 2001 and readmitted on November 5, 2008, with diagnoses that included paranoid schizophrenia (a chronic mental illness in which a person loses touch with reality (psychosis) and cerebral infarction (ischemic kind of stroke due to a disturbance in the blood vessels supplying blood to the brain).
A review of a care plan dated November 11, 2010, indicated the resident had a rash between the toes (inter digits) on both feet.
A review of a nurse's note dated November 26, 2010, indicated Resident 2 had a rash on both feet. The nurse's note on December 14, 2010 indicated the resident developed a rash on the right hand and left arm.
A review of the MDS dated December 28, 2010, indicated the resident had unclear speech, and a limited ability at making concrete requests. According to the MDS, the resident was totally dependent on the staff for all ADLs, including bed mobility, transfers, walking, dressing, toileting, and personal hygiene.
A nurse's note dated January 6, 2011, indicated the resident had scratches on the left arm and on the back of the left shoulder. Another nurse's note dated January 9, 2011, indicated the resident had a rash on the abdomen and a nurse's note dated January 12, 2011, indicated the resident's rash was ongoing with multiple scratch marks on the left knee.
According to the record the resident was not treated with Elimite for the rash or prophylactically when Resident 1 was treated as indicated in the facility's policy and procedure for scabies.
C. Resident 3, a roommate to Residents 1 and 2, face sheet indicated the resident was admitted to the facility on January 8, 2008, and readmitted on May 29, 2008. The resident had diagnoses that included acute respiratory failure with a tracheostomy, aneurysm (a ballooning at a weak spot in an artery wall) seizure disorder and hypertension (a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated).
A review of the MDS dated January 18, 2011, indicated the resident had limited ability in making concrete requests. The MDS indicated the resident was totally dependent on staff for bed mobility, transfers, dressing, toileting and personal hygiene.
According to the record, Resident 3 did not have a rash and was not treated prophylactically when Resident 1 was treated for scabies as indicated in the facility's policy and procedure to prevent scabies.
D. A review of Resident 4's record indicated the resident was admitted to the facility on October 7, 2008, and readmitted on February 9, 2011. The resident's diagnoses included congestive heart failure, hypertension, and depression.
A review of a "Short Term Problem" dated February 4, 2011, indicated the resident had a generalized body rash.
A review of an acute hospital physician's progress note dated February 8, 2011, indicated the resident had a skin rash while in the acute hospital.
A review of the Medication Administration Record (MAR) for the month of February 2011 indicated the resident was treated with Elimite cream on February 9, 2011 upon readmission to the facility.
A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated February 16, 2011, indicated the resident was alert and spoke clearly and was able to understand others. According to the MDS, the resident required limited assistance with activity of daily living (ADLs).
A review of the nurse's notes dated February 11, 2011, indicated the resident had several bowel movements resulting in loose stools.
The physician's order, dated February 11, 2011, indicated to collect three stool specimens to rule out C Diff (a species of Gram positive bacteria that causes diarrhea and other intestinal disease when competing bacteria in the gut flora are wiped out by antibiotics). However, on February 28, 2011 the facility failed to follow the physician's order in obtaining the stool specimens and/or placing the resident in isolation as indicated in their policy and procedure for C diff. infection.
On February 28, 2011 at 8:35 a.m., during an interview, the resident stated she had been very itchy as a result of the rash all over her body, especially at night. She stated the dermatologist had been to see her several times. The resident's rash was prickly red with many scratch marks on her arms and legs. Resident 4 also stated she was never placed in isolation nor were her clothes ever taken to be washed and/or room decontaminated. In addition, the resident stated she had diarrhea for three weeks and was just starting to feel better. The resident stated she had collected the stool samples and given them to the nurse.
During an interview on February 28, 2011, at 8:50 a.m., the assistant director of nurse (ADON) stated she was unable to locate Resident 4's stool specimen. She stated she called the laboratory and it was not done.
On February 28, 2011, at 9 a.m., during an interview, the DON stated if a resident was suspected to have C Diff. they should be placed in isolation and obtain stool specimens. When she was asked if Resident 4's stool specimens were collected she replied after reviewing the resident's record, ?It was not collected.?
e. Resident 5, Resident 4's roommate, record indicated the resident was admitted to the facility on February 15, 2011 with diagnoses that included pneumonia (an inflammatory condition of the lung) and Vancomycin Resistant Enterococcus (VRE) of the rectum (bacterial strains of the genus Enterococcus that are resistant to the antibiotic vancomycin).
A review of a physician's order dated February 15, 2011, indicated the resident was to be treated with Elimite cream upon admission to the facility for skin prophylaxis to start on February 16, 2011.
There was no documented evidence the facility isolated Resident 5 while Elimite was applied and/or the resident's room and clothes decontaminated as their policy stipulates.
F. According to the clinical record (face sheet), Resident 6 was admitted to the facility on August 4, 2009, with the most recent readmission on September 28, 2010. The resident diagnoses included cerebral vascular accident (CVA) with right side weakness, hypertension, congestive heart failure, and expressive aphasia (a condition in which the patient knows what he wishes to say but is unable to get the words out).
A Minimum Data Set (MDS), a standardized assessment and care screening tool, dated August 26, 2009, indicated the resident was totally dependent in dressing, eating, toilet use, personal hygiene, and bathing. According to the MDS, the resident was incontinent (no voluntary control) of bowel and bladder. The MDS indicated Resident 6 had rashes.
A September 24, 2010 entry on the Short Term Problems indicated ?RUE (right upper extremity) swollen with redness and rash.? A November 15, 2010 entry indicated ?right lower extremities rash.?
A review of a Short Term Care Plan, dated October 15, 2010, indicated the resident had a skin rash on the right foot.
A review of a Non Pressure Sore Skin Problem Report, dated November 15, 2010, indicated the treatment was initiated to the right lower extremity rash. Another entry dated February 11, 2011, indicated the resident had a scattered body rash.
On January 27, 2011 the physician's order indicated ?Elimite cream apply from neck to toes, leave on for 12 hours and give shower in the morning. Repeat in one week as prophylaxis. "
According to the Treatment Record, the resident received the second treatment of Elimite on February 3, 2011.
A February 25, 2011 dermatology consult, indicated the resident was seen for suspicion of scabies, after the facility was questioned about the increasing number of resident?s rash being treated with Elimite. The dermatologist documented to continue to monitor.
There was no documented evidence the resident was placed in isolation and the room and clothing decontaminated as per the facility's policy.
G. Resident 7, a roommate to Resident 6, was admitted to this facility on June 30, 2004, with the most recent readmission on May 15, 2007. The resident's diagnoses included depression, hypertension, esophageal reflux (caused by stomach acid coming up from the stomach into the esophagus), dysphagia (difficulty swallowing), seizure disorder (abnormal electrical activity in the brain), and macrocytic anemia (blood with an insufficient concentration of hemoglobin)
A MDS dated September 10, 2010, indicated Resident 7 required extensive assistance in dressing, toilet use, personal hygiene, and bathing. The resident was incontinent (no voluntary control) of bowel and bladder.
There was no documented evidence Resident 7 was treated with Elimite when the roommate, Resident 6, was treated as indicated by the facility's policy and procedure.
H. According to an Admission Record (face sheet) Resident 8 was admitted to the facility on July 23, 2010 and readmitted on January 7, 2011. The resident's diagnoses included acute respiratory failure with a tracheostomy (a surgical airway in the cervical trachea), hypertension, and morbid obesity.
According to the readmission orders dated January 7, 2011, the resident received Elimite treatment applied to the body for prophylaxis upon readmission to the facility.
A MDS, dated February 1, 2011, indicated the resident was non ambulatory and was totally dependent upon the staff for care.
According to a Treatment Record dated February 23, 2011 the resident was identified to have a rash on the right upper arm.
There was no documented evidence the resident was placed in isolation during the Elimite treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated.
i. Resident 9, a roommate to Resident 8, Admission Record (face sheet) indicated the resident was admitted to the facility on February 12, 2011.
The Comprehensive Resident Assessment, incorrectly dated February 11, 2011, indicated the resident had a generalized body rash. The admission orders dated February 11, 2011 indicated to apply Elimite cream on the resident's neck to the toes and leave on for 12 hours.
There was no documented evidence the resident was placed in isolation during the Elimite treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated. As a roommate, Resident 9 was not treated at the same time as Resident 8, per the facility?s policy.
J. According to an Admission Record (face sheet), Resident 10 was admitted to the facility on June 2, 2009, with the most recent readmission on October 10, 2010. The resident's diagnoses included insulin dependent diabetes mellitus, acute respiratory failure, and hypertension.
A physician's order dated November 11, 2010, indicated to apply Elimite cream from neck to toes, leave on for 12 hours, and wash off in the morning for prophylaxis.
A Non Pressure Sore Skin Problem Report dated November 11, 2010, indicated the resident was readmitted with a red raised rash with a treatment obtained.
On November 15, 2010, the facility received a new telephone order from the physician for the ongoing red raised body rash to discontinue Betamethasone and change to Triamcinolone cream (TMC) 0.1% ointment and triple antibiotic twice daily for 30 days and continue to monitor.
There was no documented evidence the resident was placed in isolation during the Elimite treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated.
K. Resident 11, a roommate to Resident 10, was admitted to facility on November 9, 2010 and readmitted on December 10, 2010. The resident's diagnoses included dementia and acute respiratory failure with a tracheostomy (an incision in the neck and opening a direct airway through an incision in the trachea), and ventilator dependent.
A physician's order dated December 14, 2010, indicated ?apply Elimite cream from neck to toes, leave on for 12 hours wash off in the morning for prophylaxis.?
There was no documented evidence the resident was placed in isolation during the Elimite treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated.
L. Resident 12, roommate to Residents 10 and 11, was admitted to the facility on May 5, 2010, with the most recent readmission on October 27, 2010, the resident's diagnoses included dependence on respirator, pneumonia, and insulin dependent diabetes mellitus.
A MDS dated May 18, 2010 and January 10, 2011, indicated the resident was totally dependent on staff for dressing, eating, toilet use, personal hygiene, and bathing. Resident 12 was ?incontinent of bowel.? Resident 12 had an indwelling catheter and used pads/briefs.
A physician's order dated December 13, 2010, indicated ?Apply Elimite cream from head to toes at night and leave on for 12 hours, then wash in the morning, for prophylaxis."
There was no documented evidence the resident was placed in isolation during the Elimite treatment and/or the resident?s room and clothes were decontaminated as the facility's policy stipulated.
M. Resident 13, according to an Admission Record (face sheet) was admitted to this facility on September 8, 2009, with the most recent readmission on February 14, 2011. The resident's diagnoses included congestive heart failure (the heart can't pump enough blood to meet the body's needs) and anemia (a condition in which blood lacks adequate healthy red blood cells).
A MDS dated January 11, 2010, indicated the resident required extensive assistance in dressing, supervision in eating, personal hygiene, and physical help in bathing. According to the MDS, the resident had rashes and was receiving application of ointments/medications.
A September 16, 2010 physician's order indicated, "Apply Elimite cream from the neck to the toes, and leave on for 12 hours, then wash in the morning and repeat in one week.?
Another physician's order dated February 15, 2011 indicated, "Apply Elimite cream from neck to toes and leave for 12 hours, give shower in the morning and repeat in seven days for prophylaxis.
There was no documented evidence the resident was placed in isolation during the Elimite treatment and/or the resident's room and clothes were decontaminated as the facility?s policy stipulated.
N. Resident 14, roommate to Resident 13, Admission Record (face sheet) indicated the resident was admitted to the facility on January 24, 2011. The resident's diagnoses included hypertension, pneumonia and anemia.
A MDS dated February 3, 2011 indicated Resident 14 required extensive assistance in dressing, totally dependent in eating, personal hygiene, and was totally dependent in bathing and toilet use. The resident was incontinent of bowel and bladder.
According to the record, Resident 14 did not have a rash. However, the resident was not treated with Elimite at the same time the roommate (Resident 13) was treated with Elimite as indicated by the facility's policy.
O. Resident 15, roommate to Residents 13 and 14, Admission Record (face sheet) indicated the resident was admitted to the facility on March 23, 2010 and readmitted on January 4, 2011. The resident's diagnoses included seizure disorder, insulin dependent diabetes mellitus, and congestive heart failure.
A physician's order dated December 23, 2010, indicated ?Apply Elimite cream from the neck to toes and leave on for 12 hours and shower in the morning for prophylaxis."
A review of a MDS dated December 30, 2010 indicated Resident 15 was totally dependent on staff for dressing, eating, toilet use, personal hygiene, and bathing.
A Non Pressure Sore Skin Problem Report entry dated January 4, 2011 indicated ?rash on the right and the left arms."
There was no documented evidence the resident was placed in isolation during the Elimite treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated.
P. Resident 16 was admitted to this facility on May 17, 2010, with the most recent readmission on October 11, 2010. The resident's diagnoses included dementia, intracerebral hemorrhage (profuse bleeding), hypertension, and ventilator dependent.
A December 6, 2010 entry on the Non Pressure Sore Skin Report indicated the resident had a generalized body rash.
A review of a MDS dated December 21, 2010 indicated the resident was totally dependent on the staff for dressing, eating, toilet use, personal hygiene, and bathing. Resident 16 was incontinent of bowel and bladder.
A February 3, 2011 entry on the Treatment Record indicated ?Elimite cream from neck to toes leave for 12 hours then shower in the morning for prophylaxis.?
There was no documented evidence the resident was placed in isolation during the Elimite treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated (specify something).
Q. Resident 17, a roommate to Resident 16, was admitted to this facility on January 5, 2010, with the most recent readmission on April 29, 2010. The resident's diagnoses included septic shock (an extreme immune system response to an infection that has spread throughout the blood and tissues), tracheostomy, and seizures (abnormal electrical activity in the brain).
A review of a MDS dated January 6, 2011 indicated the resident was totally dependent in dressing, eating, toilet use, personal hygiene, and bathing. According to the MDS, Resident 17 was incontinent of bowel and bladder. |
| 940000049 |
PARAMOUNT MEADOWS NURSING CENTER |
940009192 |
B |
27-Mar-12 |
J73H11 |
5306 |
Title 22 ? 72315. Nursing Service-Patient Care. (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. ? 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. On 10/19/11, at 2 p.m., an unannounced visit was made to the facility to investigate an entity reported incident of physical abuse to Patient 1 by Certified Nursing Assistant 1 (CNA 1) and witnessed by Patient 2. Based on interview and record review, the facility failed to ensure Patient 1 was treated as an individual with dignity and respect and had the right to be free from physical abuse by failing to: Ensure Patient 1 was not physically abused by CNA 1, who while in the patient?s room to take her blood pressure, grabbed her arm and when the patient resisted, CNA 1 hit the patient on the shoulder area. As a result, the patient became agitated, was crying uncontrollably and was fearful of CNA 1. On 10/19/11, a review of the clinical record revealed Patient 1 was a 47 years old female, admitted to the facility on 8/26/11, with diagnoses including acute respiratory failure, dependence on respirator, tracheostomy [a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs], dysphagia (difficulty swallowing) and muscle weakness.The Minimum Data Set (MDS ? a standardized assessment and care plan tool), dated 9/16/11, indicated Patient 1 had memory problems, was able to make herself understood and understand others and required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and bathing.On 10/19/11, at 2:10 p.m., the administrator and the Director of Nursing stated an investigation about the abuse allegation was started on 10/3/11, when Patient 1 alleged the physical abuse and Patient 2 (Patient 1?s roommate) confirmed the allegation.The facility?s investigation report indicated on 10/3/11, between 6:50 a.m. and 7 a.m., Licensed Vocational Nurse 1 (LVN 1) and Registered Nurse 1 (RN 1) heard Patient 1 crying loudly in her room and both went to the patient?s room. The patient was sitting in the wheelchair crying, trying to slide down and trying to hit CNA 1. Patient 1 stated she did not want CNA 1 in her room while LVN 1 and RN 1 assisted the patient to the floor. When CNA 1 left the room, Patient 1 stated CNA 1 hit her. At that time, Patient 2 stated when CNA 1 tried to take her roommate?s blood pressure, Patient 1 hit CNA 1 and then she heard a slapping sound and Patient 1 started crying uncontrollably.The facility?s investigation report indicated Patient 1 was hit on the left shoulder and there was no visible injury. It also included a written statement from CNA 1 denying she hit the patient. The facility terminated CNA 1 on the same day of the incident.On 10/19/11, at 2:20 p.m., Patient 1 was observed sitting in her wheelchair able to communicate her needs. At 2:50 p.m., during an interview regarding the incident, the patient stated with a sad tone of voice that CNA 1 had hit her. On 10/21/11, at 2:45 p.m., during an interview, Patient 2 stated CNA 1 entered the room and grabbed Patient 1?s arm without first asking permission to take her blood pressure. When the patient refused to allow CNA 1 to take her blood pressure, CNA 1 apparently hit Patient 1 and the patient began screaming, ?Don?t hit me.? A review of Patient 2?s medical record indicated she was initially admitted to the facility on 6/16/11, with diagnoses including respiratory failure and chronic airway obstruction. The History and Physical Examination completed on 9/10/11, indicated the patient had the capacity to understand and make decisions. The MDS assessment dated 9/13/11, indicated Patient 1 had no memory problems. On 10/19/11, a review of the personnel file revealed CNA 1 was hired on 5/18/11, and had no documented disciplinary actions during her employment.The facility?s undated policy and procedure on Reporting Abuse indicated the facility will not condone patient abuse by anyone, including staff members, physicians, consultant, volunteers and other individuals. The patient has the right to be free from physical and mental suffering.The facility failed to ensure Patient 1 had the right to be free from mental and physical abuse by failing to:Ensure Patient 1 was not physically abused by CNA 1, who while in the patient?s room to take her blood pressure, grabbed her arm and when the patient resisted, CNA 1 hit the patient on the shoulder area. As a result, the patient became agitated, was crying uncontrollably and was fearful of CNA 1. The above violation had direct or immediate relationship to the health, safety, or security of Patient 1. |
| 940000089 |
PACIFIC CARE NURSING CENTER |
940010164 |
B |
26-Sep-13 |
90DN11 |
4577 |
Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free from accident hazards as was possible by failing to: 1. Ensure residents were provided safe hot water temperature below 120 degrees Fahrenheit in 39 of 40 residents? bedrooms, and in 4 of 4 (that were measured) shower rooms.The unsafe hot water temperature placed all 86 residents in the facility at risk for burn, scalding, and tissue damage. On May 14, 2013, between 1:22 p.m. to 2:50 p.m., in the presence of the maintenance supervisor (Staff B), the temperature of the hot water delivered to plumbing fixtures were measured in 39 of 40 residents? bedrooms and 4 of 4 shower rooms and found to be out of the safe temperature range of 105- 120 degrees Fahrenheit. The following hot water temperatures were observed:The unsafe hot water temperatures in the hand washing sinks in residents? restrooms on the North side were as follows: Restroom to Room 1 -143.1 degrees Fahrenheit Restroom between Rooms 2 and 3 -141.2 degrees Fahrenheit Restroom to Room 4 -140.1 degrees Fahrenheit Restroom to Room 5 -141.1 degrees Fahrenheit Restroom between Rooms 6 and 7 -138.2 degrees Fahrenheit Restroom to Room 8 -135.0 degrees Fahrenheit Restroom to Room 9 -135.3 degrees Fahrenheit Restroom between Rooms 10 and 11 - 130.7 degrees Fahrenheit Restroom to Room 12 -130.3 degrees Fahrenheit Restroom to Room 14 -124.4 degrees Fahrenheit Restroom between Rooms 15 and 16 - 132.1 degrees Fahrenheit Restroom to Room 17 - 136.5 degrees Fahrenheit Restroom to Room 18 - 135.7 degrees Fahrenheit Restroom to Room 20 -141.8 degrees Fahrenheit Restroom to Room 21 -138.6 degrees Fahrenheit Restroom between Rooms 22 and 23 - 141.2 degrees Fahrenheit Restroom to Room 24 -143.8 degrees Fahrenheit Shower Room (between Rooms 2/3) ?137.8 degrees Fahrenheit Shower Room (between Rooms 10/11) ? 133.9 degrees Fahrenheit Shower Room (between Rooms 15/16) ? 130.8 degrees FahrenheitThe unsafe hot water temperatures in the hand washing sinks in residents? restrooms on the south side were as follows: Restroom to Room 25 -124.7 degrees Fahrenheit Restroom between Rooms 26 and 27 ? 133.7 degrees Fahrenheit Restroom between Rooms 28 and 29 ? 130.9 degrees Fahrenheit Restroom between Rooms 30 and 31 ? 131.6 degrees Fahrenheit Restroom to Room 32 -134.2 degrees Fahrenheit Restroom to Room 33 -139.2 degrees Fahrenheit Restroom between Rooms 34 and 35 ? 132.6 degrees Fahrenheit Restroom between Rooms 36 and 37 ? 129.6 degrees Fahrenheit Restroom to Room 38 -134.1 degrees Fahrenheit Restroom to Room 39 -131.5 degrees Fahrenheit Restroom between Rooms 40 and 41 ? 129.2 degrees Fahrenheit Shower Room (near Room 38) - 132.6 degrees FahrenheitThe review of the facility?s census report dated May 14, 2013, indicated that there were 86 residents physically present at the facility. On May 14, 2013 at 1:42 p.m., when interviewed, Maintenance Supervisor (Staff B) stated that the hot water in the residents? rooms and showers were not supposed to reach above 120 degrees Fahrenheit. On May 14, 2013, at 3:16 p.m., on a follow up interview, Staff B stated the facility did not have a policy and procedures regarding hot water temperatures in the residents? restrooms and or showers. Staff B also stated there was no documentation that the residents? restrooms and or showers? hot water temperatures were monitored.According to: http://www.accuratebuilding.com/services/legal/charts/hot_water_burn_scalding_graph.html Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 degrees, a five minute exposure could result in third-degree burns.The facility failed to ensure that the resident environment remained as free from accident hazards as was possible by failing to: 1. Ensure residents were provided safe hot water temperature below 120 degrees Fahrenheit in 39 of 40 residents? bedrooms, and in 4 of 4 (that were measured) shower rooms.The unsafe hot water temperature placed all 86 residents in the facility at risk for hot water burns, scalding, and possible tissue damage. The above violation had a direct or immediate relationship to the health, safety, or security of all 86 residents in the facility. |
| 940000049 |
PARAMOUNT MEADOWS NURSING CENTER |
940010998 |
AA |
23-Dec-14 |
2XYV11 |
23837 |
F309 ?483.25 Quality Care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. F315 ?483.25 (d) Urinary Incontinence. Based on the resident?s comprehensive assessment, the facility must ensure that- ?483.25(d) (2) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. F441 ?483.65 Infection Control 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. ?483.65 (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. On March 24, 2014 at 9:54 a.m., the Department received a complaint allegation about patient care provided to a resident (Resident 1).The complaint alleged that the facility?s staff ignored repeated complaints by Resident 1 that the indwelling catheter that was inserted into her urethra (a tube that connects the urinary bladder to the genitals for the removal of fluids from the body) was hurting her badly, and she was having bad back and side pain and diarrhea. The complaint also alleged the staff was rude and ignored her. The complaint indicated on March 19, 2014, the resident was sent to the hospital for having low blood pressure and was found to have a bad bladder infection. The resident died on March 20, 2014 because of this infection. On March 31, 2014 at 10:30 a.m., during a telephone interview with a family member (FM 1), she stated Resident 1 suffered from ?frequent back, side, and the indwelling urinary catheter site pain and would become worst when the catheter was pulled or tugged.? FM 1 reported she observed no device in place to secure the catheter tubing. Resident 1 reported to FM 1 the pain medication she was receiving had minimal pain relief. FM 1 stated she reported the resident?s complaints repeatedly to the primary physician and staff, but she stated, ?They made it seemed like there was nothing to worry about.? On April 1, 2014 at 8:30 a.m., an unannounced complaint investigation was conducted. During the tour of the facility, several residents were observed with indwelling urinary catheters with cloudy urine and sediment (solid matter in the urine), which can be indicative of UTI. Based on observation, interview and record review, the facility failed to ensure Resident 1, who had an indwelling urinary catheter (tube inserted into the bladder to drain urine) received appropriate care and services to prevent urinary tract infections (UTI) including: 1. Failing to assess the urine color and character, and report abnormalities to the physician, as indicated in the resident?s plan of care and the facility?s policy. 2. Failing to maintain a closed drainage system (use of a water- or air-tight system to drain a body cavity) as indicated in the resident?s plan of care and the facility?s policy. 3. Failing to use clamps (a urinary catheter securement device that keeps a catheter securely in place) to anchor the catheters to prevent urethral pain, discomfort and tissue damage, as indicated in the facility?s policy. 4. Failing to assess the effectiveness of the chosen interventions to treat Resident 1?s UTIs, and failing to consult with the resident?s physician and care planning team to consider an alternative intervention to treat UTIs or obtaining urine for urinalysis (UA) and culture and sensitivity (C/S). 5. Failing to implement the facility?s indwelling catheter or UTI risk care plan and policy and procedures.These and other deficient practices described in the findings resulted in Resident 1 complaining of back, side, vaginal pain in the indwelling catheter site, becoming unresponsive, and being transferred to a general acute care hospital (GACH). Immediately upon arrival to the GACH the resident became unstable requiring telemetry (heart monitoring) and transferred to the intensive care unit (ICU) with a diagnosis of urosepsis (a life threatening bacterial infection in the urinary tract). While in the ICU, the resident required mechanical ventilation (machine to assist with breathing), cardiopulmonary resuscitation (CPR) twice, intravenous (into the vein) medications such as Levophed (to help increase the blood pressure), had two episodes of cardiac arrest (the heart develops an abnormal rhythm and stops beating) and expired on March 20, 2014, less than 24 hours after admission to the GACH. A closed record review of Resident 1's Admission Face Sheet indicated the resident was a 66 year-old female who was admitted to the facility on January 9, 2014 from a GACH. The resident?s diagnoses included morbid obesity (excess body fat), muscle weakness, cellulitis (infection of the skin and deep underlying tissue) of both legs and sacral (triangular-shaped bone at the bottom of the spine) pressure sore (skin damage caused by pressure).A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated March 1, 2014, indicated the resident was independent in cognitive skills without memory problems, had the ability to make needs known and understand others. According to the MDS, Resident 1 was totally dependent upon staff and required two or more persons assist in bed mobility, transferring and toilet use, and was frequently incontinent of bowel (involuntary loss control of bowel). According to the National Institute of Health, the signs and symptoms of UTI included, but not limited to fever, pain with urination, pressure pain or spasm in the back or lower part the belly and cloudy, milky or sediment in the urine. Milky or sediment in the urine can be caused by bacteria or mucus in the urine and can produce the foul odor urine. In the elderly, altered mental status or confusion may be the only sign of UTI http://www.nlm.nih.gov/medlineplus. A plan of care, titled, ?Requires Use of Indwelling Urinary Catheter,? dated January 10, 2014, indicated the resident was at risk for UTI. The staff?s plan of approach included, but not limited to: monitoring and observing for change of condition such as; urine output, color, clarity, (clear or cloudiness of the urine), amount, and presence of sediment; report to physician as needed; obtain lab if ordered and report result to physician. A review of the laboratory report, dated January 16, 2014, and timed at 7:52 p.m., indicated the UA results; yellow cloudy urine; positive nitrite (indicative of presence of bacteria) and moderate amount of bacteria. The urine (C/S) results indicated Proteus Mirabilis (a rod-shaped bacteria found in putrid meat, abscesses, and fecal material responsible for complicated UTIs that sometimes causes bacteremia ?bacteria in the blood? ) was isolated which was resistant (without response to treatment) to Ciprofloxacin (an antibiotic). At the bottom of the C/S report, next to the column that indicated Ciprofloxacin resistant, the nurse wrote, ?Cipro 500 mg BID (twice a day) x 10 days Dr. ??.. (Physician [MD] 3?s name).? A review of a nurse?s note, dated January 16, 2014, and timed at 10:45 p.m., indicated the physician was called regarding the abnormal UA and C/S results awaiting a call back. Another nurse?s note dated January 17, 2014, and timed at 5:10 a.m., indicated the physician was made aware of UA and C/S results with new orders given and carried out.A review of MD 3?s telephone order, dated January 17, 2014, and timed at 5:10 a.m., indicated an order for Ciprofloxacin 500 milligrams (mg) twice daily for 10 days. A review of the Medication Record Administration (MAR) indicated Resident 1 received Ciprofloxacin 500 mg two times daily from January 17-25, 2014, which the Proteus organism was resistant to. There was no documented evidence during this period that the facility questioned or assessed the effectiveness of the chosen intervention, Ciprofloxacin, to treat Resident 1?s UTI, or consulted with the resident?s care planning team to consider an alternative intervention to treat the UTI. A review of a hospice care note, dated March 1, 2014, and timed at 5:30 p.m., indicated Resident 1 began hospice care on March 1, 2014 and hospice care discontinued on March 6, 2014 per FM 1?s request. The hospice nurse documented on March 1, 2014, Resident 1 was morbidly obese, with an indwelling urinary catheter draining yellow urine with mild sediment and cloudiness. According to the same note, a licensed vocational nurse (LVN 5) reported the resident had been having increased episodes of confusion and foul odorous urine with a possible urinary tract infection.However, a review of the nurse?s notes, dated from February 15, 2014-March 19, 2014, indicated Resident 1 had clear urine, without any documentation of the presence of sediment or foul smelling cloudy urine. There was also no documentation of the resident being confused. A review of MD 4?s telephone order, dated March 1, 2014, and timed at 6 p.m., indicated an order for Nitrofurantoin (an antibiotic to treat infection) 100 milligrams (mg) by mouth two times a day for seven days, which Resident 1 received. However, a review of the C/S, dated January 14, 2014, indicated that the pathogenic organism found in the urine was resistant to Nitrofurantoin. There was no documented evidence that the facility assessed the effectiveness of the chosen intervention, Nitrofurantoin, to treat Resident 1?s UTI, or consulted with the resident?s care planning team to consider alternative interventions to treat UTIs. There was no documentation that the facility consulted with the resident?s physician and care planning team to consider obtaining urine for urinalysis (UA) and C/S, after the hospice nurse documented the urine was cloudy with sediment and LVN 5 indicated the resident?s urine had a foul smell and her confusion had increased. A review of a physician?s order, dated March 11, 2014, indicated orders that included: indwelling urinary catheter for bladder retention (inability of the bladder to empty urine); change catheter every month on the sixth of the month and PRN (as needed), dislodgement, malfunction or blockage; catheter care daily; change the catheter drainage bag twice monthly on the sixth and 21st and PRN when soiled/ leaking; and irrigate with 40 milliliters (ml) normal saline daily/PRN if sediment are present. A review of the physician?s notes, nurse?s notes and the laboratory reports, indicated there was no documented evidence a urine sample was sent to the laboratory for U/A or C/S testing before or after the antibiotic was prescribed on March 1, 2014, to determine the presence of a pathogenic organism and/or what medications would best to treat the infection. According to an article by the National Kidney Foundation, at www.kidney.org, titled, ?Urinary Tract Infection,? the physician will test a sample of the urine for bacteria and blood cells, which is called a urinalysis (U/A). It further indicated a culture of the urine will tell the physician which bacteria are present and different antibiotics may be tested to see which works best against the bacteria. On April 29, 2014, at 1:10 p.m., during a telephone interview, the assistant administrator was asked for Resident 1?s urine lab reports in February 2014 and March 2014, the assistant administrator stated, ?We did not send the urine for testing.? A physician?s order, dated March 19, 2014, and timed at 12:15 p.m., indicated to transfer Resident 1 to a GACH for further evaluation of hypotension (low blood pressure), tachycardia (rapid heart rate 101), and congestion (accumulation of excess fluid and mucus in the lungs). The nurse?s note, dated and timed the same time, indicated the resident had altered mental status and the blood pressure was low at 85/57, heart rate was high at 105 beats per minute, and the respiratory rate was also high at 25 breaths per minute. A review of the GACH?s Emergency Room (ER) notes indicated the resident was admitted on March 19, 2014, at 1:31 p.m., with a presenting complaint of chest congestion, hypotension, and tachycardia and altered mental status (confused).According to the ER notes, Resident 1 arrived with an indwelling urinary catheter and the following laboratory specimens were sent: urinalysis UA; chemistry (a test to determine levels of electrolytes (sodium, potassium, chloride, and bicarbonate in the blood) and enzymes (to determine heart function, as well as any damage to the heart); and urine and blood C/S. On March 19, 2014 at 5:46 p.m., approximately four hours after admission to the GACH, the resident was diagnosed with UTI and sepsis (life threatening infection of the blood) with the probable source to be UTI. A review of the lab reports from the GACH, dated March 19, 2014, indicated the WBC (white blood cells) were elevated at 29.7 (reference range 3.8-10.8); neutrophils (type of white cells) were elevated at 89% (reference range 50-80%, if elevated can be indicative of an infection); neutrophil Abs (absolute level) elevated at 26.4 (reference range 2.2-4.8, an elevated result is indicative of infection, damage, or inflammation of tissue).A review of Resident 1?s UA lab results, dated March 22, 2014, and timed at 2 p.m., indicated the urine was yellow and cloudy, and positive for protein (can be a sign of kidney damage or UTI). The lab indicated the WBCs and blood in the urine were too many to count. According to WebMD, blood in the urine can be an indicative of trauma to the urinary tract and/or infection. The blood chemistry, dated March 19, 2014, indicated an elevated level of Lactic acid 2.60 (reference range 1.80). WebMD indicated an elevated Lactic acid level in the blood is an indication of severe sepsis/septic shock (life threatening due to the presence of bacteria in the blood).A review of the C/S results, dated March 22, 2014, and timed at 6:38 a.m., indicated Resident 1?s urine tested positive for Proteus Mirabilis (100,000 cfu), (the same organism that was identified on the C/S January 14, 2014); Escherichia coli ([E. coli] commonly found in the lower intestine), and Extended Spectrum Beta Lactamase 100,000 ([ESBL] bacteria that frequently cause diarrhea. According to the MAR, Resident 1 had several episodes of diarrhea in February and March 2014, requiring twelve administrations of Imodium (used to treat diarrhea) to control the resident?s diarrhea. The GACH?s sensitivity report results indicated Proteus Mirabilis was resistant to Nitrofurantoin, as was indicated on the C/S on January 14, 2014.A review of the MAR for the month of March 2014 indicated Resident 1 received Nitrofurantoin by mouth for a UTI from March 1-8, 2014.During a telephone interview on March 31, 2014, at 10:30 a.m., FM 1 stated that on February 21, 2014, she assisted a licensed vocational nurse (LVN 1) by holding the resident?s legs during the removal and insertion of the indwelling urinary catheter. She stated she observed Resident 1?s urine to be ?brown, dirty, and had a foul smell.? A review of the licensed nursing note, dated February 21, 2014, indicated Resident 1 had no complaint of pain and discomfort and the urine was described as clear and there was no documentation of the brown, foul smelling urine, or if the physician was notified as stipulated should be done in the resident?s plan of care and the facility?s policy and procedure.On April 1, 2014, at 10:20 a.m., LVN 1, the treatment nurse, stated he was responsible for all assessments regarding indwelling catheters, insertion, replacement, and urine collection for cultures or other urine specimen for studies. LVN 1 stated the urine in the catheter is monitored for sedimentation, leakage, clogged or kinked tubing and blood, potential sign of UTI. When LVN 1 was asked to demonstrate the procedure to flush an indwelling catheter or to collect a urine specimen, LVN 1 failed to demonstrate correct standard of practice according to the facility?s policy and procedure in flushing, irrigating, and collecting urine from indwelling urinary catheter. LVN 1 stated he disconnects the indwelling catheter from the catheter bag to collect urine specimen and to inject normal saline into the catheter, thereby breaking the closed system. LVN 1 was shown the sampling port (used for UA collection) on the catheter and stated he was not aware the catheter had a sampling port for collecting urine specimen or irrigating the indwelling catheter to maintain aseptic technique and a closed system. According to an undated facility?s policy and procedure titled, ?Prevention of Urinary Tract Infection-Indwelling Urinary Catheters,? a closed system will be maintained whenever possible. If it is necessary to disconnect the catheter from the drainage system, both the catheter and the drainage tubing will be clamped as close to the connection site as possible and the sterile technique used to protect open ends. If urine is needed for a specimen, the distal end of the catheter, or the sampling port, will be cleaned with a disinfectant and the urine aspirated (removal by suction of a fluid from a body cavity using a needle) with the sterile needle and/or syringe by a licensed nurse. On April 1, 2014, at 11 a.m., during an interview, the director of staff development (DSD) who is also the infection control nurse, stated she conducted ?some training? about UTI to the licensed staff and certified nursing assistants (CNAs). She also stated the licensed staff had been trained in the use of the sampling port in the indwelling urinary catheter for urine specimen collection.An interview with the registered nurse supervisor (RN1) on April 1, 2014, at 1:50 p.m., she stated residents admitted from outside hospitals with an indwelling urinary catheter were not checked for the catheter insertion date once admitted. On April 1, 2014, at 2 p.m., during an interview, certified nursing assistant (CNA1) stated the resident frequently refused treatments because of pain in the back and legs when repositioned in bed and cleaned due to multiple episodes of diarrhea (loose stool). CNA 1 stated, sometime in February or March 2014 (she was unable to remember the exact date), she observed the resident with ?dark brown urine that looked as if the diarrhea (liquid brown stool) was going into the urine bag,? which she reported to LVN 2 immediately. On April 10, 2014 at 12 p.m., during an interview, LVN 1 stated he did not require assistance in changing Resident 1?s indwelling urinary catheter. He stated ?No, I did not have anyone help me. She allowed me to do it by myself.? LVN 1 stated he does not recall the resident having brown, cloudy or foul smelling urine. LVN 1 stated during the interview he had not reviewed the facility?s undated policy and procedure titled, ?Prevention of Urinary Tract Infection-Indwelling Urinary Catheters.?On April 10, 2014 at 12:05 p.m., during an interview, LVN 3, another treatment nurse, stated Resident 1 was ?not easy to turn because she was overweight? and required two people to help with her treatments. On April 10, 2014, at 3:55 p.m., during an interview, CNA 2 stated around mid- February 2014 through March 2014, Resident 1 was complaining of pain in the private area where the catheter was inserted and she reported it to LVN 4. CNA 2 recalled LVN 4 coming in the resident?s room and telling the resident she was having pain because of the UTI. CNA 2 stated the resident required two or more person assist because she was obese. A review of Resident 1?s MARs for January 15-February 10, 2014, indicated the resident received three doses of Hydrocodone 5/325 mg, one dose of morphine sulfate 5 mg elixir and 27 doses of Norco 10/325 mg for pain. The MAR for February 11-March 10, 2014, indicated the resident received 28 doses of hydrocodone 10/325 mg. and 23 doses of Norco 10/325 mg. for pain, which are all strong narcotic pain medications. On April 21, 2014, at 10:30 a.m., RN 1 stated it was the facility?s nurses responsibility to call the physician and report abnormal lab results with the findings. A review of the facility?s undated policy, titled, ?Lab Result Reporting? indicated the purpose was to assure the abnormal results are reported promptly by the nurse calling and informing the physician. A review of a declaration, dated April 22, 2014, written by FM1, indicated Resident 1 complained constantly of pain at the catheter site in which FM1 reported to four RNs, five LVNs, and one physician that was listed by name on the declaration, but nothing was ever done. The facility?s undated policy and procedure titled, ?Prevention of Urinary Tract Infection for residents with indwelling urinary catheter? indicated an indwelling catheter will be secured to the resident?s legs and/or body (unless contraindicated) after insertion to prevent movement and urethral traction.The facility's undated policy and procedure titled, ?Change of Condition,? indicated to assure that appropriate care and documentation occurs when residents experience a change in condition, the procedure included, but not limited to: notifying the physician promptly, document assessment, and follow- up nursing assessment with monitoring until the condition standardized for at least 24 hours. A review of Resident 1?s Certificate of Death, in which the coroner signed on April 8, 2014, indicated the resident expired on March 20, 2014 at 2:27 a.m., less than 24 hours after admission to the GACH. The recorded cause of death included: cardiorespiratory failure (failure of the heart and lung to function to support the body?s need), urosepsis (a life threatening bacterial infection in the urinary tract), and septic shock (complication of an infection where the toxins damaged the tissues and caused low blood pressure and poor organ function).The facility failed to ensure its residents received appropriate care and services to prevent urinary tract infections (UTI) including:1. Failing to assess the urine color and character, and report abnormalities to the physician, as indicated in the resident?s plan of care and the facility?s policy. 2. Failing to maintain a closed drainage system (use of a water- or air-tight system to drain a body cavity) as indicated in the resident?s plan of care and the facility?s policy. 3. Failing to use clamps (a urinary catheter securement device that keeps a catheter securely in place) to anchor the catheters to prevent urethral pain, discomfort and tissue damage, as indicated in the facility?s policy. 4. Failing to assess the effectiveness of the chosen interventions to treat Resident 1?s UTIs, and failing to consult with the resident?s physician and care planning team to consider an alternative intervention to treat UTIs or obtaining urine for urinalysis (UA) and culture and sensitivity (C/S). 5. Failing to implement the facility?s indwelling catheter or UTI risk care plan and policy and procedures.The above violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was the direct proximate cause of death for Resident 1. |
| 940000049 |
PARAMOUNT MEADOWS NURSING CENTER |
940010999 |
A |
23-Dec-14 |
2XYV11 |
8998 |
F309 ?483.25 Quality of CareEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.An unannounced complaint investigation was conducted on April 1, 2014, while in the facility for an unrelated complaint. Based on interview and record review, the facility's staff failed to ensure one resident (Resident 2) received medications as ordered by a physician by failing to: 1. Implement and follow-up a gastrointestinal (GI) doctor's order for Protonix (a medication to treat reflux and acid damage to the esophagus [a passage from the mouth to the stomach]). 2. Implement the resident?s plan of care that indicated medication will be given as ordered. These failures resulted in Resident 2 having episodes of nausea and vomiting, requiring two transfers to a general acute care hospital (GACH). A review of Resident 2's Admission Face Sheet indicated the resident, a 59 year-old male, was admitted to the facility on July 19, 2013. According to the face sheet, the resident?s diagnoses included: developmental delay (being less developed mentally than normal for age), malignant neoplasm of kidney except pelvis (kidney cancer), Barrett's esophagus (damaged lining of the esophagus), diaphragmatic hernia (hole in the diaphragm), and esophagitis (inflammation of the esophagus). A review of a Minimum Data Set (MDS, a standardized assessment and care screening tool) admission assessment, dated July 19, 2013, indicated under Section C (brief interview for mental status) a summary score of 3, indicating severe cognitive impairment. Also under Section I (active diagnoses) of the MDS, included unspecified intellectual disabilities for Resident 2. A care plan for GERD/Barrett?s esophagus and GI bleeding, dated August 25, 2013, indicated the staff?s plan of approach included monitoring for nausea and vomiting and administering medications as ordered. A review of an article by the Mayo Clinic, titled, Diseases and Conditions of Barrett?s esophagus, indicated it is a condition in which the cells of the lower esophagus become damaged, usually from repeated exposure to stomach acid. The damage causes changes to the color and composition of the esophagus cells. The diagnosis can be concerning because it increases the risk of developing esophageal cancer. Frequent episodes of heartburn and acid reflux is common, thus medications to control acid reflux should be given. On April 2, 2014, in a telephone interview, Resident 2's family member (FM 2) stated the resident went to a clinic appointment, on March 7, 2014, at 3 p.m., to see a gastroenterologist. Prior to the visit, a registered nurse (RN 2), at the SNF, gave the family member a blank telephone order sheet to take to the clinic visit, for the physician to write new orders. While at the appointment, the gastroenterologist wrote an order to increase the Protonix 40 milligrams (mg), from once a day to twice a day, to relieve symptoms of acid reflux and maintain healing due to acid-related damage. Upon the resident's return to the SNF on March 7, 2014, the family member stated she handed the telephone order sheet, with the new Protonix order, to RN 2. The family member stated she called the next day (March 8, 2014) to follow-up on the new Protonix order and a staff member told the family member they were unaware of an increase in Protonix. The family member stated she called again on March 10, 2014, to make sure the resident was receiving the Protonix twice a day as prescribed by the physician. After reviewing Resident 2's clinical record, a registered nurse (RN 1) told the family she could not find a new order to increase the Protonix.A review of Resident 2's Medication Administration Record (MAR) revealed the Protonix 40 mg was given once a day, before breakfast, since August 2013. There was no documentation Protonix 40 mg was administered twice a day, as prescribed by the gastroenterologist on March 7, 2014.A review of the gastroenterologist?s report, dated March 7, 2014, and timed at 3 p.m., indicated Resident 2, did not take the Protonix twice a day, at the skilled nursing facility (SNF) and returned to the GACH with nausea and vomiting. Four days later, on March 11, 2014, at 3 p.m., an entry in the licensed nurse's progress note indicated Resident 2 had vomited a moderate amount of brownish coffee ground liquid. At 3:40 p.m., another entry indicated the resident was transferred to the GACH. The GACH's admission "History and Physical," dated March 12, 2014, indicated Resident 2 had an elevated fever and coffee ground vomiting. On March 13, 2014, the current medications listed on the hospital's "Progress Note" included Protonix 40 mg twice a day. On March 17, 2014, the resident was transferred back to the SNF. A review of the GACH?s discharge summary, dated March 17, 2014, indicated the resident was admitted with coffee-ground emesis and the treatment plan included administering proton-pump inhibitors ([PPIs] to reduce gastric acid). The discharge instructions under medications indicated: as per discharge MAR. According to the GACH?s Discharge Medication Reconciliation (MAR) Form, dated March 17, 2014, Protonix 40 mg twice a day was ordered to be given at 9 a.m. and 9 p.m.However, the resident did not receive Protonix twice a day upon his readmission to the facility on March 17, 2014.On March 23, 2014, and timed at 8 a.m., a licensed nurses' progress note indicated Resident 2 went to the hospital again for nausea and coffee ground vomiting. The resident received antibiotics and intravenous (IV/into the vein) Protonix, twice a day and was re-admitted back to the SNF on March 26, 2014. The Discharge Summary, dated March 26, 2014, indicated the resident was admitted for intractable nausea and vomiting and the course of treatment also included PPIs (Protonix/proton pump inhibitors) reduces the production of acid by blocking the enzyme in the wall of the stomach that produces acid. On March 27, 2014, while in the SNF, after 20 days from the time the GI physician ordered the Protonix to be increased to twice a day, and two GACH admissions later, Resident 2 received Protonix twice a day in the facility as prescribed by the gastroenterologist back on March 7, 2014, for a delay of 10 days of receiving it in the SNF. On April 10, 2014 at 5:02 p.m., in a concurrent record review and interview, the assistant director of nurses (ADON) reviewed the gastroenterologist report, dated March 7, 2014. The ADON could only locate one page of the three-page report (which indicated 1 of 3) written by the physician in the resident's medical record. The ADON stated, "Staff should have called the doctor and asked for the additional pages or orders." The ADON stated the facility provided the residents with blank telephone order sheets when they go for an outside doctor visit, either by ambulance or family transportation. She also stated when the resident returned to the facility the completed orders are given to the nurses. The ADON stated, "If I am the nurse that sends a patient out, I would endorse to the next nurse to look for the telephone order when the patient returns." On April 11, 2014 at 3:15 p.m., during a telephone interview, the gastroenterologist stated, "I wrote a note indicating the resident needed to have the Protonix 40 mg twice a day because it is a strong acid suppressor and he has a severe case of ulcerative esophagitis (inflammation of the esophagus [the muscular tube that carries food from the throat to the stomach]) that causes nausea and vomiting." The physician also stated, in his medical opinion if the resident was receiving Protonix 40 mg twice a day, as he prescribed, it would have decreased the amount of nausea/vomiting and re-admissions to the GACH.On April 19, 2014, at 11:15 a.m., during an interview, a registered nurse (RN 2) could not explain why there was only one of three pages from the March 7, 2014 gastroenterologist clinic visit. The facility's admission tracking history indicated Resident 2 went to the GACH six times, since July 2013, some admissions for recurring episodes of vomiting that required the use of Protonix. On April 21, 2014 at 7:30 a.m., in an interview, RN 1 stated since receiving Protonix 40 mg twice a day, Resident 2 no longer had episodes of vomiting and had not returned to the acute hospital.The facility failed to ensure Resident 2 received medications as ordered by a physician by failing to: 1. Implement and follow-up a gastrointestinal (GI) doctor's order for Protonix. 2. Implement the resident?s plan of care that indicated medication will be given as ordered. The above violations jointly, separately, or in any combination presented a substantial probability that death or serious physical or mental harm would result to Resident 2. |
| 940000090 |
Pacific Villa, Inc. |
940011194 |
A |
26-Jan-15 |
None |
10560 |
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility failed to provide assistance in walking in accordance with the comprehensive assessment for 1 of 17 sampled residents (Resident 5). This deficient practice resulted in a fall with injuries that included laceration on the forehead and a nasal (nose) non-displaced fracture (the bone is broken but still remains in place).Resident 5 had dementia (loss of brain function that occurs with certain diseases and affects memory, thinking, language, judgment, and behavior) and was assessed as requiring extensive assistance (resident involved in the activity, staff provide weight-bearing support [staff member supports some of the weight of the resident or performs part of the activity for the resident]) in walking, not having a steady balance during walking and turning around and facing the opposite direction while walking, and only able to stabilize himself with staff assistance. Resident 5 walked by himself (or with no staff beside him) in the hallway without staff intervening. A review of Resident 5's clinical record indicated the resident was admitted to the facility on 5/6/14, with diagnoses that included a personal history of fall, difficulty walking, muscle weakness (generalized), lack of coordination, abnormality of gait (manner of walking), epilepsy (seizure), dementia, unspecified episodic mood disorder (disturbance in a person's mood), and paranoid schizophrenia (a mental disorder which may result in some combination of hallucinations, delusions, and disorganized thinking and behavior). A review of the Nursing Admission Record, dated 5/6/14, at 6:30 p.m., indicated Resident 5 was noted with unsteady gait upon assessment and he was referred to physical therapy (PT) and occupational therapy (OT) for evaluation and treatment. A review of the Fall Risk Evaluation, dated 5/6/14, indicated Resident 5 was assessed as having a total fall risk score of 21 (a total score of 10 or above represents high risk for falls).A review of Resident 5's care plan titled "Needs Assistance with ADLs (activities of daily living)" dated 5/6/14, indicated goals which included the resident will not have fall incidents. The care plan did not indicate what level of assistance he needed (e.g. supervision, limited, extensive, or total assistance) and for which particular ADL (e.g. transfer ambulation, etc.). The approach plan included to assist as needed. A review of another plan of care, dated 5/6/14, indicated Resident 5 declined with functional mobility related to weakness. One of the interventions was to assist with ADLs. A review of the plan of care, dated 5/7/14, indicated Resident 5 was at high risk to experience complications related to the use of psychotropic medication (medications affecting mental activity, behavior, or perception, as a mood-altering drug), such as Ativan (an anti-anxiety medication) PRN (as needed). One of the approaches was to observe the resident's gait for steadiness and ability to position and turn. A review of the Interdisciplinary Care Review and Conference, dated 5/9/14, indicated Resident 5 was receiving PT services for difficulty walking and lack of coordination and OT services for muscle weakness. Resident 5 was identified as a fall risk due to his poor safety awareness and his need for cuing and re-direction due to confusion, disorientation, and short and long term memory problem related to dementia. The resident was assessed as needing extensive assistance with one person assist with ambulation and locomotion (act or power of moving from place to place). A physical therapist performed the Tinetti Performance Oriented Mobility Assessment (a task-oriented test that measures an older adult's gait and balance abilities, which included turning 360 degrees) on 5/12/14, and the results indicated Resident 5 was a high risk for falls by having a total score (balance and gait) of 12 (a score of less than 19 represents high risk). A review of the admission assessment MDS (Minimum Data Set, a resident assessment and care screening tool), dated 5/10/14, and the 14-day assessment MDS dated 5/18/14 indicated the following: a. Resident 5 was able to make his needs known and able to understand others.b. Resident 5 was moderately impaired in cognitive skills.c. Resident 5 was assessed as requiring extensive assistance with one person assist while walking in the resident's room (how resident walks between locations in his room) and walking in the corridor (how resident walks in corridor on unit), and during locomotion on unit (how resident moves between location in his room and adjacent corridor) and locomotion off unit (how the resident moves to and returns from off-unit locations [e.g., areas set aside for dining, activities or treatment]. If the facility has only one floor, how the resident moves to and from distance areas on the floor). d. Resident 5's balance during walking and turning around and facing the opposite direction while walking was not steady and he was only able to stabilize with staff assistance.According to the nursing notes dated 5/18/14 (a Sunday) at 10 a.m., Registered Nurse (RN 1) documented that a certified nursing assistant (CNA) reported that the resident fell on the floor in front of Room 25. RN 1 found Resident 5 lying with his face down. First aid treatment and cold compress were applied to the bleeding forehead of the resident. When asked what his name was, Resident 5 stated his name. When asked if he had pain, the resident stated right at his forehead.RN 1 documented that per the licensed nurse, they were doing their job functions when they saw Resident 5 turn around and lose his balance. The resident fell and hit his head on the railings of the hallway. A review of the nursing progress notes, dated 5/18/14 at 10:28 a.m., indicated the physician ordered Resident 5 to be sent to an urgent care facility for evaluation and treatment. At 11 a.m., the resident was picked up by an ambulance for transportation. At 2 p.m., the resident was re-admitted to the facility.The nursing progress notes indicated on 5/19/14 at 10 a.m., the licensed nurse called the urgent care to inquire if an x-ray of the nose was done and the staff in the urgent care stated Resident 5 did not have an x-ray and he was just evaluated for his laceration and monitored for any changes in his mental status. At 10:30 a.m., the licensed nurse called the physician because the patient complained of nasal (nose) deviation (abnormal shift) and an x-ray was ordered. At 10 p.m., the licensed nurse called the physician in regard to the x-ray result and the physician ordered an ENT (ear, nose, throat specialist) consult for evaluation of the resident's non-displaced nasal fracture. A review of the radiology (x-ray) result of the nose indicated Resident 5 had a non-displaced fracture mid nasal bones and there was soft tissue swelling. On 7/19/14 at 9:30 a.m., during an interview, the Rehab Director/Physical Therapist (PT) stated an extensive assistance meant the staff had to actually touch the resident to provide support during the activity. During the course of the interview, Resident 5's physical therapy initial assessment dated 5/6/14, was reviewed with the Rehab Director. The Rehab Director stated the resident was a high risk for falls and his safety was moderately impaired, which meant his balance was off, his muscles were weak, and he was at risk for falls. The Rehab Director stated the resident should not walk by himself without staff assistance beside him. On 7/20/14 at 10:25 a.m., during an interview, Resident 5 stated he remembered falling on the floor but he did not remember why he was walking and where he was going before the fall. Resident 5 stated he was walking by himself on the day of the fall and he was passing by staff at the hallway.At 10:30 a.m., during an interview, Certified Nursing Assistant (CNA) 1 stated he had seen Resident 5 walking in the hallway by himself, without staff assistance or beside the resident prior to the day of the resident's fall. CNA 1 stated after the resident fell, the resident used the wheelchair. At 11 a.m., LVN 3 stated that before the fall incident, Resident 5 liked to walk around and he was compliant and could be re-directed. LVN 3 was asked to explain what an extensive assistance in walking meant. LVN 3 answered extensive assistance meant the resident needed two to three person assist. At 11:30 a.m., during an interview, the MDS Coordinator stated extensive assistance in walking meant the staff had to touch and help the resident physically when the resident was walking. At 2:55 p.m., during an interview, CNA 2 stated that on the day Resident 5 fell, she saw the resident walking in the middle of the hallway by himself, no staff member was beside him, and his walk was steady. CNA 2 stated when the resident turned around, he became unsteady with his feet and he fell down. CNA 2 demonstrated the resident's act of turning by crossing her (CNA 2) feet. CNA 2 stated the resident sometimes refused care but he listened and could be re-directed. At 3:05 p.m., during an interview, Registered Nurse (RN) 1 stated he was in the nursing station and he went to see Resident 5 in the North Station hallway after a CNA informed him that the resident fell. RN 1 stated the resident was facing down on the floor and he helped LVN 4 and 2 CNAs, who were already at the resident's side, in turning the resident to a supine (lying face up) position. RN 1 stated there was blood on the resident's forehead so he got gauze and placed pressure on the site.On 7/22/14 at 10:25 a.m., during an interview, CNA 2 stated LVN 4 was passing medications nearby but LVN 4 was behind the medication cart and would not be able to catch Resident 5 from falling because the medication cart was blocking her (LVN 4).Therefore, the facility failed to provide assistance in walking in accordance with the comprehensive assessment for 1 of 17 sampled residents (Resident 5). This deficient practice resulted in a fall with injuries that included laceration on the forehead and a nasal (nose) non-displaced fracture (the bone is broken but still remains in place).This failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 940000046 |
PACIFIC PALMS HEALTHCARE |
940011818 |
A |
02-Dec-15 |
UPUY11 |
10204 |
F 323 ? 483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free from accident hazards as is possible: and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The Department received an entity reported incident (ERI) on 1/20/15, alleging a resident (Resident 1) was receiving care using a one-person assist, but required a two-person assist, and fell over the side rail out of the bed to the floor. Resident 1 complained of pain 8/10 at the right knee and leg. The physician was notified with and orders obtained for x-rays to be done. The x-rays were positive for a comminuted (the bone involved in the fracture is broken into several pieces) fracture at the right distal femur (long leg bone), with severe tissue swelling, age of an undetermined time and an acute fracture of the left distal femur. The facility failed by not: 1. Providing Resident 1, who had a high risk for falls, adequate assistance and supervision during care to prevent falls. 2. Assessing all the environmental hazards to prevent falls. 3. Providing a two-person assist, as stipulated in the resident?s assessment. 4. Ensuring the side rails were locked before Resident 1 used them as an enabler.These failures resulted in Resident 1 falling over the side rail from the bed and onto the floor sustaining facial trauma with bruising to the face, right elbow, bilateral knee, and fractures (broken bone) to the distal right femur and left femur (long thigh bone). The resident?s fall required a transfer to a general acute care hospital (GACH) for evaluation and treatment 13 hours later. While in the emergency room, Resident 1 complained of pain of 9.5, on a scale of 0-10, (0 being no pain, and 10 being the worse), after receiving Norco (narcotic pain medication). The resident was admitted to the GACH for three days due to severe pain requiring intravenous (IV) pain medications of Morphine sulfate (narcotic pain medication). On 2/3/15 at 7 a.m., a complaint investigation was initiated and the administrator was informed of the nature of the visit.A review of the Resident 1's Admission Face Sheet indicated the resident was a 71 year-old female, who was admitted to the facility on 9/23/09. The resident?s diagnoses included peripheral neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), obesity, and rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles).The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/9/14, indicated Resident 1 was alert and oriented, required a two-person extensive assistance with bed mobility and personal hygiene. According to the MDS, Resident 1 had functional limitation in range of motion to the lower extremities and was incontinent (loss of control) of both bowel and bladder functions. The MDS also indicated the resident was non-ambulatory for the last eight years due to a previous injury. A review of a care plan, titled, ?Potential for fall or injury,? dated 8/25/14, indicated Resident 1 had poor safety awareness and was dependent on staff for transferring. The staff?s intervention included to keep the environment free from hazards. The plan of care failed to specifically address the use of a low air loss mattress (LAL) and the side rails as other potential risk factor.Another plan of care, dated 8/25/14, and titled, ?Resident Refuses Care-?indicated the resident refused the assistance of a two-person assist for repositioning and turning while in bed. The care plan indicated the resident preferred specific nurses and would become sarcastic when risks and benefits were explained. The staff?s interventions included to anticipate the resident?s physical needs, but were vague and only stipulate to identify and try to eliminate the cause, but did not include how the staff would implement the plan of care intervention.A Fall Risk Evaluation, dated 12/8/14, indicated Resident 1?s score was 15 with a total score of 10 or above representing a high risk for falls. A review of a nurse?s note, dated 1/18/15, and timed at 2:15 a.m., indicated CNA 1 asked the resident to turn over to the left side. According to the note, the resident used the side rail to turn, but slid over the side rail and fell to the floor. The resident complained of pain (right knee and leg) of 8 on a pain scale of 8/10 (0 indicating no pain and 10 being the worst) that required pain medication of (Norco 10/325 mg) which was administered several times. The physician was notified and ordered several x-rays (bilateral hips, bilateral femur, bilateral humerus and the right ankle).The x-ray results, dated (1/18/15) and timed at 1:40 p.m., indicated an acute fracture of Resident 1?s distal left femur. At 3:05 p.m., 1/18/15, almost 13 hours later, the resident was transferred to the GACH. On 2/3/15 at 2:48 p.m., during an interview, CNA 1 stated at approximately 2 a.m., on 1/18/15, during the care of Resident 1, she pushed the resident to turn to the side while the side rail was up. Although the side rail was up, the resident fell out of the bed. CNA 1 stated the resident had a LAL mattress (used for pressure sore prevention) on the bed and it was slippery and almost at the level of the top of the side rail. When asked, CNA 1 stated she could not remember if she checked to see if the side rail was locked prior to giving care before pushing the resident to the side. CNA 1 also stated she did not ask another staff to assist with repositioning the resident, because the resident tend to refuse other staff?s help. On 2/3/15 at 3:30 p.m., Resident 1 was observed lying down on a low bed with bilateral side rails up. The resident stated CNA 1 did not check to see if the side rail was locked before she pushed her over to the side and that was why she fell on the floor. The resident stated when she fell on the floor she hit her face and leg, which resulted in bruising and a lot of pain. Resident 1 stated she was sent to the hospital, but did not have surgery. When she was asked about the need for a two-person assist to reposition her, she stated, ?I would refuse the other staff member, because they would stand around, and stare at me.? A review of an investigation form written by the charge nurse, dated 1/18/15, was incomplete. The charge nurse indicated ?not applicable? under the section for environmental hazards that could contribute to the resident?s fall incident, and the causal factors indicated ?unknown.? CNA 1?s statement under the cause of the incident and preventable factors to ensure the incident from recurring, was left blank. The investigation and the conclusion failed to indicate a thorough investigation of Resident 1?s fall incident. A review of the facility?s undated policy titled, ?Accidents and Incidents-Investigating and Reporting,? indicated all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the premises shall be investigated and reported to the administrator. On 2/3/15 at 3:14 p.m., during an interview, the director of nursing (DON) did not respond to questions asked as to why the environmental risk factors such as; side rails and slippery LAL mattress at the level of the side rails were not evaluated/considered and care planned for Resident 1 to reduce the risk of fall with injury to the resident. The DON also could not provide an answer as to why the resident?s fall incident was not thoroughly investigated. A review of an undated facility's policy and procedure titled, ?Fall Risk Assessment? indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls. The staff will seek to identify environmental factors that may contribute to falling. The staff and the attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable.A review of the x-rays taken on 1/18/15, at the GACH indicated the following: 1. Left femur: a non-displaced fracture of the distal femur. 2. Right femur: severely comminuted fracture of the distal femur. A computed tomography or computerized axial tomography scan ([CAT scan] combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images) of Resident 1?s right knee was performed at the GACH on 1/19/15 and indicated there was an extensive comminuted fracture of the distal third of the right femur, extending to the femoral condyle (one of a pair of large flared prominences on the distal end of the femur) and an oblique (left to right: transverse) fracture seen at the proximal tibia laterally. A review of the GACH?s Discharge Summary note, dated 1/21/15, and timed at 11:12 a.m., indicated Resident 1?s primary discharge diagnosis was status-post fall with a non-displaced fracture of the distal left femur and a severely closed comminuted fracture of the distal right femur requiring IV pain medications. The note indicated surgery was not indicated at that time, only a knee immobilizer. The resident was discharged on Dilaudid (opiate pain reliever) 4 mg by mouth every four whenever necessary for pain control. Resident 1 was discharged back to the facility on 1/21/15, three days after the fall incident. The facility failed to: 1. Provide Resident 1, who had a high risk for falls, adequate assistance and supervision during care to prevent falls. 2. Assess all the environmental hazards to prevent falls. 3. Provide a two-person assist, as stipulated in the resident?s assessment. 4. Ensure the side rails were locked before Resident 1 used them as an enabler. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000090 |
Pacific Villa, Inc. |
940011862 |
A |
02-Dec-15 |
None |
14401 |
F 323 ? ?483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free from accident hazards as is possible: and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. F279 ?483.20(d) Use A facility must use the results of the assessment to develop, review and revise the resident?s comprehensive plan of care.The facility failed by not: 1. Following its policy and procedures for smoking. 2. Following Resident 1?s plan of care in providing the necessary care and supervision to prevent accidents. 3. Implementing the plan of care and facility?s policy to prevent the resident?s many unsupervised falls. 4. Updating and revising Resident 1?s care plan to address current problems to prevent the resident from falling. As a result, Resident 1, who had a history of seizures (an abnormal electrical activity in the brain that can cause sudden loss of consciousness and uncontrolled movements of the body), falls, unsteady gait, and was identified as a high risk factors for falls, fell on 6/30/15, while smoking unsupervised. Resident 1 sustained blunt head trauma with a three centimeter (cm) right frontal hematoma (bleeding into the tissue) and abrasions (open scratched skin), requiring a transport to a general acute care hospital (GACH) by the paramedics. Resident 1 was hospitalized for seven days.A review of Resident 1's Admission Face Sheet indicated the resident was a 76 year-old female, who was admitted to the facility on 12/8/14. Resident 1's diagnoses included seizure disorder, history of multiple falls, generalized muscle weakness, unsteady gait, osteoporosis (a condition with brittle bones), coronary artery disease (heart disease caused by blockage of the artery) and schizophrenia (a mental disorder resulting in faulty perception, inappropriate actions and feelings).A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/8/15, indicated Resident 1 was able to understand others and make her needs known with moderate cognitive (ability to think and reason) impairment. According to the MDS, Resident 1 required extensive assistance (resident involved in activity with one staff providing support) with bed mobility, transferring, walking, hygiene and dressing. Resident 1 was occasionally continent (ability to control) of bowel and bladder, but was not on bowel program.A review of a "Fall Risk Assessment," indicated Resident 1 was identified at a high risk for falls. According to the assessment, a total score of 10 or above represents high risk for fall. On 1/22/15, 2/9/15, 5/8/15, and 6/30/15, the resident?s fall risk score was 14, a high risk for falls.A review of a "Resident Smoking Assessment," dated 1/22/15, 2/9/15 and 5/8/15, indicated Resident 1 required extensive assistance by the staff when smoking due to intermittent confusion, assistance with holding the cigarette, history of seizures, and had a balance problem.On 10/27/15 at 6:10 p.m., during a telephone interview, a registered nurse (RN 2) stated the facility's policy indicated smoking begins at 8:30 a.m. However, on 6/30/15 around 8 a.m., Resident 1 insisted on going to the patio before the scheduled smoke break. RN 2 stated, "It was not smoking time yet, but it is the resident's choice to smoke and we cannot stop her. During a change of shift report a staff reported to me that the resident was having a seizure." When RN 2 was asked who was supervising the resident smoking in the patio. RN 2 stated, "I do not remember who was monitoring the residents out in the patio."On 10/28/15 at 8 a.m., Resident 1 was observed unsupervised attempting to change her own diaper. Resident 1 was standing directly above a puddle of urine on the floor on the side of the bed, hunched over (due to a spine deformity) with body tremors and unsteady. Upon knocking, and asking permission to enter the room, the surveyors saw the resident's call light behind the head board of the bed, out of the resident's reach.On 10/28/15 at 2:53 p.m., in an interview, a certified nursing assistant (CNA 6), stated, "Resident 1 is spoiled, when she wants things done, she will do it. She likes to do things on her own." CNA 6 was asked about the residents smoking schedule, CNA 6 stated, "She does not want you to mess with her smoke breaks and she usually goes out to smoke before the scheduled smoke break in the morning and the facility's staff allows her." In an interview on 10/28/15 at 4:20 p.m., Resident 1 was asked about the fall incident on 6/30/15, and stated, "I was out smoking with a friend and I fell, I was taken to the hospital by the ambulance.? When asked if she was told that she could not smoke before the facility's scheduled smoke break time at 8:30 a.m., Resident 1 stated, "I usually smoke alone early in the morning. They use to tell me I cannot smoke before 8:30 a.m., but that was a long time ago. Now, the staff give me a cigarette, light it for me, and sometimes there is somebody there to supervise me, sometimes nobody."A review of the paramedic's emergency medical report, dated 6/30/15, indicated Resident 1 had a fall with a seizure. The report indicated the resident fell out of the chair sustaining blunt head trauma, with a hematoma to the head. The resident's blood pressure was recorded at 165/87 (normal reference 120/80), heart rate at 104 (normal reference range is 60-100 beats per minute [bpm]), and a respiratory rate at 19 (normal reference range 12-20 per minute). The resident's blood glucose level was checked at 122 (normal reference range 70-100 milligram per deciliter [mg/dl]). According to the paramedic's report, an intravenous ([IV] into the vein) line was placed and morphine sulfate was given (the amount not indicated) to Resident 1 for pain.According to the facility's investigation report, dated 6/30/15, Resident 1 had the following falls; 1. On 12/18/14 at 2:40 p.m., Resident 1 had an unwitnessed fall while trying to put on her diaper and lost her balance. The resident was found by the facility's housekeeper on the floor at the edge of doorway in her room with her pants at her knees.2. On 1/1/15 at 3:50 p.m., Resident 1 had an unwitnessed fall and was found sitting on the floor in her room by a CNA, after losing her balance while attempting to self-transfer to the wheelchair. On 1/26/15, after Resident 1's second fall, the resident's primary physician ordered a neuro consult, due to the resident's bilateral lower extremity weakness that was completed on 2/10/15. 3. On 6/30/15 at 8:09 a.m., after being wheeled to the facility's patio by the activity director (AD) to smoke, Resident 1's was left unsupervised after being given a lit cigarette, before the facility's scheduled smoke break. The resident had a seizure and fell to the concrete ground. Another resident alerted the facility's staff.A facility's investigation report, dated 6/30/15, indicated Resident 1's fall incident was witnessed by another (unnamed) resident, who informed the facility's staff Resident 1 might have had a seizure prior to the fall. As a result of the fall, Resident 1 sustained a blunt head trauma with a hematoma and abrasion measuring three cm to the right frontal area, resulting in 911 being called and requiring hospitalization.A review of the Resident 1's October 2015 Medication Administration Record (MAR), indicated on 6/30/15, timed at 1 a.m., and again at 7 a.m., prior to Resident 1's fall, the resident received Norco 5/325 (potent narcotic pain medication) milligrams (mg) tablet for complaint of back pain. The resident received Norco twice within the seven hour period prior to falling and having a seizure. According to the Davis Drug Guide, a book used to define medications, indications for clinical use, and safe practices, Norco is 5 milligrams of Hydrocodone (codeine derivative) and 325 milligrams of acetaminophen (Tylenol), Norco can result in lightheadedness, drowsiness and dizziness.4. On 8/5/15, Resident 1 had an unwitnessed fall and was found by a licensed vocational nurse (LVN 4) on the floor in her room after losing her balance, attempting to transfer unsupervised to a wheelchair. The resident required neurological monitoring (to assess mental status and weakness and injuries) for 72-hours. A right hip x-ray was done to rule-out broken hipbones, as ordered by the physician.On 10/29/15 at 1:55 p.m., during an interview, the activities director (AD) stated on 6/30/15 at 8 a.m., Resident 1, and other residents who were smokers were given lit cigarettes. The AD stated she was aware Resident 1 required supervision when smoking, but she left Resident 1 and the other residents, who were smoking unsupervised. The AD stated she went to assist other residents in the dining room to bring them to the patio. According to the AD, there was no specific direct care staff assigned to supervise the residents on 6/30/15 at 8 a.m., before the facility's scheduled smoke break at 8:30 a.m.A review of Resident 1's plan of care to prevent fall and injury were as follows: 1. A plan of care titled, "Supervision with smoking? dated 1/22/15, and updated on 5/8/15, indicated Resident 1 required supervision while smoking. The staff intervention included, allowing the resident to smoke according to the facility's policy with precautions for the safety of the resident and others. There was no documented staff intervention to address how Resident 1, who was non-compliant with the " Smoking Policy," would be monitored and supervised during Resident 1's unscheduled smoking breaks to ensure the resident and other residents and staff would be safe. 2. A plan of care titled, "Seizure Disorder,? dated 1/23/15, and revised on 5/8/15, indicated Resident 1 had a high risk for trauma and injuries due to the seizure disorder. The staff's intervention included to maintain 'vigilant' supervision at all possible times, monitor for seizure activity every shift, and obtain labs as ordered. According to the resident's last anti-seizure medication (Valproic Acid) laboratory level, dated 5/26/15, the level was low at 16.0 (normal reference range is 50-100 æg/mL).3. A review of another care plan initiated on 1/22/15, and revised on 5/8/15, and titled, "Needs assistance with activities of daily living (ADL)? related to Resident 1 requiring extensive assist with bed mobility, transferring, toilet use, and personal hygiene. The staff's interventions indicated to monitor the resident for tremors and an unsteady gait, assess the resident's functional status, and assist as needed and have the call light within reach.However, during an observation on 10/28/15 at 8 a.m., Resident 1 was observed with tremors to her bilateral upper and lower extremities while attempting to change her diaper without the staff's assistance.There was no documented evidence in Resident 1's plan of care to suggest that the resident's non-compliance with not calling for assistance with ADLs and "doing things her own way" was addressed to ensure that adequate supervision was provided to the resident to prevent accidents and falls with injury.4. A review of a care plan initiated on 1/22/15, and revised on 5/8/15, indicated Resident 1 was at risk for falls due to osteoporosis, generalized weakness, poor safety awareness, and a history of falls. The staff's interventions included to place the resident in front of the nurse's station or recreational areas, where staff was present for visual checks. However, Resident 1's room was observed located away from the nursing station and where the resident could not be visualized easily.On 10/30/15 at 9:07 a.m., during an interview, the director of nursing (DON) was unable to provide further evidence of effective safety measure to ensure Resident 1 was supervised to prevent repeated episodes of fall. The DON stated, ?Resident 1 required supervision when she goes out to smoke. She's very independent and often tries to do things on her own. " When asked why the resident who was non-compliant with the smoking policy and calling for assistance with care, did not have a plan of care to address how the resident could be best supervised and assisted, the DON answered, " That should have been addressed." The DON was asked who supervised the residents who smoke before the smoke break, the DON stated, "There is no specific staff assigned to supervise the residents before the scheduled smoke break, it is not put on the assignment sheet. However, if the activity staff or a CNA is available, or have a lighter assignment, he or she they can supervise the residents. The DON was asked if he had a record to indicate who was assigned to supervise the residents on 6/30/15 at 8 a.m., he stated, "I do not have a document."A review of the facility's undated, policy and procedure titled, ?Safety and Supervision," indicated, the interdisciplinary team ([IDT], a team of various facility staff collaborating on the resident's plan of care) shall analyze assessments, observations to identify any specific accident hazards or risk for the resident. The policy also stipulated the care team shall target interventions to reduce the potential for accidents. However, there was no documented evidence in Resident 1's record that the IDT collaborated to address the residents care needs to prevent repeated falls with injury. According to another facility's policy and procedure, dated 12/2009, titled, ?Care Plans Comprehensive," the comprehensive care plans are based on thorough assessment of the resident and are revised as the resident's condition change. The facility's policy and procedures were not implemented for Resident 1.The facility failed by not: 1. Following its policy and procedures for smoking. 2. Following Resident 1?s plan of care in providing the necessary care and supervision to prevent accidents. 3. Implementing the plan of care and facility?s policy to prevent the resident?s many unsupervised falls. 4. Updating and revising Resident 1?s care plan to address current problems to prevent the resident from falling. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result to Resident 1. |
| 940000090 |
Pacific Villa, Inc. |
940011864 |
A |
02-Dec-15 |
None |
10565 |
?483.25 F309 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.The facility failed a randomly selected resident (Resident 16) by not: Following-up on a physician?s recommendation, for eight months, to have two procedures, an esophagogastroduodenoscopy ([EGD] a test to examine the lining of the esophagus, stomach, and first part of the small intestine), and a colonoscopy (an exam that views the inside of the colon [large intestine] and rectum, after Resident 16 had an abnormal computed tomography ([CT] an imaging method that uses x-rays to create cross-sectional pictures) of the abdomen. The results showed thickening of the duodenal gastric antrum (stomach).According to the National Institute of Health, an article titled, "Gastric/Duodenal wall thickening," positive results of gastric thickening could be indicative of cancer. The article concluded a gastric or duodenal wall thickening was a significant finding and should be followed-up (http://www.ncbi.nlm.nih.gov/pubmed/8264011).This failure of not following-up on the GI physician's recommendation resulted in Resident 16 continuing to have severe abdominal pain requiring narcotic pain medication (Norco 5/325 milligram, an opioid/analgesic of 5 mg of hydrocodone [opioid synthesized from codeine] with 325 mg of acetaminophen used for moderate to severe pain) of 130 tablets over an 8 month period without a definitive diagnosis and treatment plan.A review of Resident 16's Admission Face Sheet indicated the resident was a 72 year-old male, who was admitted to the facility on 12/8/14. The resident diagnoses included chronic obstructive pulmonary disease([COPD] a lung disease marked by permanent damage to tissues in the lungs, making it difficult to breath), acute kidney failure (loss of your kidneys' ability to remove waste and help balance fluids and electrolytes in your body), unspecified dementia (loss of brain function that occurs with certain diseases and affects memory, thinking, language, judgment, and behavior), gastro-esophageal reflux disease ([GERD]a condition when the content of the stomach regurgitates [backs up or refluxes] into the esophagus, which can cause esophagitis[inflammation of the esophagus], difficult and painful swallowing, heartburn, mouth sores and feeling of something stuck in the throat, and nausea and vomiting), and chronic pancreatitis (inflammation of the pancreas causing swelling of the pancreas which causes abdominal tenderness and pain).A review of an annual Minimum Data Set (MDS), a resident assessment and care screening tool, dated 4/13/15, indicated Resident 16 was able to make needs known and understand others. According to the MDS, the resident was assessed as requiring limited assistance with bed mobility, transferring, locomotion on and off the unit, and eating.A review of Resident 16's care plan initiated on 12/8/14, and recently updated on 10/12/15, titled, "Alteration in comfort/ signs and symptoms of peptic ulcer disease (PUD)," a condition where open sores develop on the inside lining of the esophagus, stomach and the upper portion of the small intestine. The staff's interventions included to monitor for patterns of discomfort and/or gastric distress and precipitating factors, assess the type, intensity, and quality of pain, administer pain medication per the physician's orders, and notify the physician for any significant changes in the resident's medical condition.A review of a nurse practitioner's (NP) note, dated 1/13/15, indicated the resident's assessment included chronic pancreatitis, chronic liver cirrhosis, COPD, and cholecystitis (inflammation of the gallbladder, which if left untreated, can lead to serious, sometimes life-threatening complications, such as a gallbladder rupture). The NP's note indicated a cholecystectomy (removal of the gallbladder) was attempted on Resident 16, but was aborted due to excessive bleeding. The NP's note indicated the plan included to monitor changes in the resident's right upper quadrant pain, anorexia (an eating disorder), nausea and vomiting, fever, or jaundice (a condition in which a person's skin and the whites of the eyes are discolored yellow due to an increased level of bile pigments in the blood resulting from a liver disease), and a GI consult as planned.A review of a GI physician's progress note, dated 2/20/15, and timed at 3:37 p.m., indicated Resident 16 had a history of chronic pancreatitis, cirrhosis (condition in which the liver does not function properly due to long-term damage), GERD, and COPD ). The GI physician's note indicated he wanted the resident to have further studies done due to the resident's abnormal CT scan of the abdomen and he recommended for an EGD and colonoscopy procedures to be done.A review of Resident 16's primary physician's progress notes, dated 2/9/15, 3/4/15, and 4/4/15, indicated the resident had protein malnutrition, history of alcohol abuse, and status-post attempted cholecystectomy. There was no documentation that the GI physician's recommendation was acknowledged. A review of a nurse's note, dated 2/20/15, and timed at 5:55 p.m., indicated a licensed vocational nurse (LVN 7) called the GI physician to get an appointment for resident's colonoscopy, but was told that the GI physician would call back in a week to give the date for the colonoscopy. A review of the Resident 16's Interdisciplinary Annual Care Conference, dated 4/13/15, indicated the resident's plan of care, medications, diagnoses, diet, and activity preference were discussed. There was no documented evidence the GI physician's recommendation (2/20/15) for Resident 16 to have an EGD and colonoscopy, due the resident's abnormal CT scan with abdominal pain, was followed-up and the procedures had been done. On 10/30/15, at 1:55 p.m., during an interview, the social worker (SW) stated that all physicians? recommendations are followed-up by the licensed nurses. The SW also stated that once a physician's order was obtained, the licensed nurse makes the appointments and her responsibility was to arrange transportation for the appointment. On 10/30/15, at 2:10 p.m., during an interview, a licensed vocational nurse (LVN 1) stated it was the responsibility of the nurses to review the physician's progress notes and if a physician made a recommendation, the LVN would follow-up to obtain and carry out the physician's recommendations. LVN 1 reviewed Resident 16's clinical record and stated that a call was made by LVN 7 regarding the physician's GI procedure recommendation on 2/20/15, but there was no further documented evidence to indicate that the facility's staff followed-up on the GI physician's recommendations. A review of a physician's order, dated 12/8/14, indicated Norco 5/325 mg one tablet by mouth to be given every six hours PRN (whenever necessary) for severe pain, not to exceed (NTE) 3 GM/24 hours. On 10/30/15, at 4:50 p.m., during an interview, LVN 11 stated Resident 16 complained almost every day of general body pain in the month of October 2015.A review of Resident 16's Pain Assessment Flow Sheet, for the month of October 2015, indicated from 10/1-10/29/15, the resident complained of pain at 8/10 (0 being no pain and 10 being the worse pain) for 26 times, requiring a narcotic pain medication, Norco 5/325 mg. The prior months, 9/2015, from 9/1-9/30/15, Resident 16 complained of pain 28 times on a pain scale of 8/10. For the month of 8/2015 (from 8/1-8/31/15) indicated the resident complained of pain 25 times on a pain scale of 8/10. For the month of 7/2015 (7/1/15-7/31/15) the resident had 19 episodes of pain 8/10 requiring a narcotic pain medication. For the month of 6/2015 (6/1-6/30/15), Resident 16 had 11 episodes of pain 8/10 requiring a narcotic pain medication (Norco). On 10/30/15, at 5:05 p.m., during an interview, Resident 16 stated he had stomach pains every day of at least 7/10 on a pain scale. The resident stated he received medication for the stomach pain, but stated it did not always help.A review of Resident 16's controlled drug record (Individual patient narcotic record) and the Medication Administration Record (MAR), indicated the resident was administered Norco 5/325 mg one tablet by mouth as needed for severe pain. A monthly recap of the Norco 5/325 mg doses received indicated Resident 16 received the following:March 2015 - 3 tablets April 2015 - 0 May 2015 - 3 tablets June 2015 - 22 tablets July 2015 - 23 tablets August 2015 - 23 tablets September 2015 - 28 tablets October 2015 - 28 tabletsOn 10/30/15 at 6:10 p.m., during a concurrent interview and record review, LVN 7 stated that he called the GI physician on 2/20/15, to follow-up on the physician's recommendation for an EGD and colonoscopy. LVN 7 reviewed his written note, dated 2/20/15, and timed at 5:55 p.m., which indicated he spoke to the GI physician and was told by the GI physician he would call back the following week for a date for the colonoscopy procedure for Resident 16. LVN 7 stated he endorsed the above information to the night shift licensed nurse regarding the GI physician would be calling back in a week, but it was not reflected on LVN 7's note. There was no further documentation to indicate it was followed up. On 10/30/15, at 6:18 p.m., during an interview, LVN 7 stated he had called the GI physician earlier that day, before 5 p.m., to follow-up on the recommendation for Resident 16's EGD and colonoscopy. LVN 7 stated he left a message at the physician's office and was waiting for a return call. According to the facility's undated policy titled, "Lab and Diagnostic Test Results - Clinical Protocol,? the physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The policy stipulated the staff would process and arrange for the tests and procedures.The facility failed to: Follow a physician?s recommendation for eight months, for Resident 16 to have two procedures, resulting in Resident 16 having severe abdominal pain and requiring narcotic pain medication of 130 tablets over an 8 month period without a definitive diagnosis and treatment plan.The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000090 |
Pacific Villa, Inc. |
940012360 |
A |
28-Jun-16 |
EW3811 |
10954 |
F223 ? 42 CFR 483.13(b). The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. On 4/3/15, at 6:22 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 1's allegation that she had a sexual relationship with a certified nursing assistant (CNA 1). Based on interview and record review, the facility failed to prevent Resident 1 from being sexually abused by failing to: 1. Ensure CNA 1 did not take advantage of Resident 1?s mental and emotional condition to gain sexual favors. 2. Ensure CNA 1 understood the appropriate conduct for staff-to-resident relationship. Resident 1, who was diagnosed with dementia (loss of brain function that occurs with certain diseases and affects memory, thinking, language, judgment, and behavior) and schizophrenia (a mental illness), had a sexual relationship with CNA 1 in the facility. When CNA 1, a 28-year-old male, discontinued the relationship, Resident 1 felt used and stupid. This deficient practice resulted in Resident 1 having severe emotional distress, depressed mood, feelings of worthlessness, shame, humiliation, rage, and guilt, and verbalization of being better off dead. A review of Resident 1?s clinical record indicated the resident was a 70-year-old female, who had the following admission dates: XXXXXXX, XXXXXXX, and XXXXXXX. The admission diagnoses for 12/8/14 included unspecified psychosis (a loss of contact with reality) not due to a substance or known physiological condition; major depression disorder, single episode unspecified; schizoaffective disorder, unspecified (a mental disorder characterized by abnormal thought processes and deregulated emotions); and dementia in other diseases classified elsewhere with behavioral disturbance. The Minimum Data Set (MDS - a standardized assessment and care plan tool), dated 2/16/15, indicated Resident 1 was able to make her needs known and understand others, and able to correctly state the year, month, day of the week and her current location. The resident's cognition was intact. The resident did not present the behaviors of inattention, disorganized thinking, and altered level of consciousness or psychomotor retardation. The resident did not have episodes of rejecting care, wandering, or physical abuse or verbal abuse towards self or towards others. A review of Resident 1's care plan, dated 2/16/15, indicated that the resident was prone to behavior changes manifested by angry outburst due to schizoaffective disorder. The facility's goal was for staff to approach the resident calmly and un-hurriedly, provide the resident with reality awareness; allow the resident to ventilate her feelings, and provide diversional activities. A review of Resident 1's care plan, dated 2/16/15, indicated that Resident 1 exhibited depression manifested by the expression of anger. The planned intervention was for facility staff to attempt to refocus the resident's attention to something positive when the resident was depressed, encourage activities of resident's choice and preferences, and to stay with the resident when she was depressed. The Resident 1's physician's orders, dated 3/5/15, indicated to administer her Remeron (an antidepressant) 7.5 milligrams tablet by mouth twice a day for depression manifested by verbalization of hopelessness. A review of a licensed clinical psychologist's written statement, signed and dated 4/2/15, indicated the psychologist approached Resident 1 inside her room to provide supportive therapy because the resident had previously displayed moderate symptoms of depression and anxiety, including depressed mood, tearfulness, negative thinking and statements of hopelessness, psycho-motor (relating to movement associated with mental process) agitation, emotional reactivity (involuntary and usually overly intense reaction to an external emotional stimulus, which often leads to feeling victimized by your emotions), and irritability. The psychologist's written statement, dated 4/2/15, indicated that Resident 1 was upset about something and she was afraid to tell the psychologist because the psychologist would not like her (the resident) anymore. The resident became extremely distraught and began sobbing loudly. After the psychologist encouraged the resident to open up and share what was bothering her, and assured her that she would not be judged, the resident continued to exhibit signs of severe emotional distress, sobbing, wailing, and rocking back and forth, and stated that she had been having a sexual relationship with CNA 1. The psychologist's written statement, dated 4/2/15, indicated Resident 1 described her relationship with CNA 1, which involved oral and sexual contact. Resident 1 reported that the relationship had been going on regularly for a couple of months. The resident at this point was highly emotionally reactive, sobbing uncontrollably, and repeating negative statements, such as "I'm so ashamed," "I thought he loved me, but he was just using me!" "I'm just a stupid old lady, how could I be so stupid?" The psychologist's written statement, dated 4/2/15, indicated Resident 1 expressed feelings of worthlessness, shame and humiliation regarding this alleged relationship. The psychologist was concerned about the resident's mental state, and inquired as to whether the resident was having thoughts of self-harm or suicide. The resident stated, "I'm so ashamed and angry at myself, I would be better off dead!" The psychologist's written statement, dated 4/2/15, indicated an assessment of Resident 1?s suicide risk was conducted. The resident denied the intent, plan or means to commit suicide or self-harm. The psychologist documented that based on the resident's psychiatric history, her current emotional state, and the serious nature of the allegations; the psychologist was concerned about the risk of suicide or self-harm. The facility placed the resident on one-on-one monitoring for the next 24 hours to ensure her safety. On 4/3/15 at 6:58 p.m., when interviewed in the presence of a licensed vocational nurse (LVN 1), Resident 1 was able to state the details regarding her stay at the facility. Resident 1 refused to discuss further when asked if there was any facility staff that attempted or did anything inappropriate to or with her. On 4/3/15 at 7:48 p.m., when interviewed, the director of nursing (DON) stated that the psychologist informed him (the DON) that on 4/2/15, Resident 1 informed her (the psychologist) that the resident had a sexual relationship with a facility staff (CNA 1). The DON stated he interviewed Resident 1 on 4/2/15, in which the resident stated that the sexual relationship started a few months ago (according to the psychologist's written statement, dated 4/2/15, the relationship was going on for a couple of months). The resident stated that one day while she was in her room feeling a little bit sad, CNA 1 walked in talked to her, letting her know that everything was going to be ok, and afterwards they gave each other a hug. According to the DON, during his interview with Resident 1, the resident stated that during other occasions, CNA 1 would return to her room and they (CNA 1 and Resident 1) would hug and kiss, and CNA 1 would touch her breast and genitals. Resident 1 stated that one day, CNA 1 asked her to go into the restroom with him, in which she followed, and she then gave CNA 1 an oral sex. Resident 1 stated that the sexual relationship continued on other dates when the two would hug and kiss each other. Resident 1 stated that she liked CNA 1, that she had feelings for him, that she thought there was something between them, and this was the reason she did not report the relationship to other facility staff. According to the DON, Resident 1 stated that it was the first time in 17 years since her husband died that she had sexual feelings for someone else. The resident repeatedly stated that she cared for CNA 1 and she felt stupid for having feelings for CNA 1. The resident stated that she felt used and dealt with her feelings when CNA 1 became aloof and stopped his visits with her. The resident later opened-up to the psychologist. A review of CNA 1's written statement, dated 4/9/15, regarding the allegation of sexual relationship with Resident 1 indicated, "I (CNA 1's name) felt like I had to be there for that patient and she touched me and I did not like it at all. She touched me and kissed me and performed sexual act, even though it was consensual, I did not like it one bit." The Psychotropic Summary Sheet for the use of the Remeron (an antidepressant) indicated Resident 1 had zero episodes for March 2015 but 36 episodes for April 2015 of manifesting the behavior of verbalization of hopelessness. The Psychological Services Progress Note, dated 5/5/15, indicated Resident 1 continued to have conflicted emotions regarding recent traumatic incidents. The resident was irritable and agitated due to ongoing trouble processing and coping with post-traumatic stress in the wake of recent incident involving a staff. The Psychological Services Progress Note, dated 5/21/15, indicated Resident 1 was highly emotional and agitated due to recent traumatic events. The resident continued to process the recent trauma that she experienced, and described myriad (extremely great number) emotions she was feeling, including rage, guilt, shame, and sadness. The resident was helped to understand that these were all typical responses to such an event, and her feelings were validated. According to the undated facility's policy and procedure titled, "Abuse and Neglect Prohibition," each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation, and that mental abuse included but not limited to, humiliation, harassment and threats of punishment or deprivation. The facility's Visitation policy and procedures, dated 2006, indicated, "All alert resident has the right to have consensual relations with a person of their choosing at any time. On 4/30/15 at 5:13 p.m., during an interview, the administrator stated that there was no policy and procedure addressing the residents' consensual sexual relationships. The administrator stated, in the presence of the DON, the facility did not have a specific policy and procedure regarding staff relationship with a resident. The facility failed to prevent Resident 1 from being sexually abused by failing to: 1. Ensure CNA 1 did not take advantage of Resident 1?s mental and emotional condition to gain sexual favors. 2. Ensure CNA 1 understood the appropriate conduct for staff-to-resident relationship. 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. |
| 940000089 |
PACIFIC CARE NURSING CENTER |
940012781 |
B |
29-Nov-16 |
Q74R11 |
6148 |
F225 ? 42 CFR 483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Based on observation, interview, and record review, the facility failed to: 1. Report an injury of unknown source to the Department immediately or within 24 hours. 2. Report the result of the facility?s investigation to the licensing and certification agency (the Department) within 5 working days. Resident 2 was observed by a certified nursing assistant (CNA 1) to have a new purplish discoloration on his lower eye area on 7/10/16. The cause or source of the injury was unknown. The facility did not report the resident's injury of unknown source to the Department immediately or within 24 hours and did not report the results of their investigation to the Department within 5 working days of the incident. This deficient practice had the potential to jeopardize the residents' safety. On 8/25/16 at 10:10 a.m., while the surveyor was conducting a complaint investigation, Resident 1 stated, during an interview, that his roommate's (Resident 2) left eye area had black and blue discoloration. Resident 1 stated that he did not know what happened (how Resident 2 sustained the discoloration). Resident 1 showed a picture of Resident 2 on his cellphone to the surveyor. The surveyor observed that Resident 2 had a slight bruise on his left lower periorbital (surrounding the eye) area. Resident 1 stated Resident 2 was transferred to a different room. On 8/25/16 at 1:43 p.m., during an interview, the director of nursing (DON) stated that a certified nursing assistant (CNA 1) reported that Resident 2 had a black discoloration on his left eye area on 7/10/16. The DON stated that Resident 2 was transferred to a different room that was closer to the nursing station so that the resident could be monitored. The DON stated that Resident 2 did not remember what happened. On 9/28/16 at 3:46 p.m., during an interview, the administrator (ADM) stated that if the facility should report (to the Department) an injury of unknown origin/source, then the facility should. On 9/28/16 at 4:22 p.m., during an interview, the DON stated that if there was an injury of unknown source, the facility should report it to the Department. The DON stated that the facility did not report the injury of unknown source to the Department because Resident 2 could not remember what happened. According to the DON, Resident 2 stated that maybe he had hit his head in the bedrails. The DON stated that the resident's bruise may be the side effect of the anti-coagulant medication (a medication that prevents the formation of blood clots). The DON stated there was no indication or any sign that the resident was abused. On 9/30/16 at 1:29 p.m., during an interview, CNA 1 stated that on 7/10/16, during her morning rounds, she noticed that Resident 2 had a new purplish discoloration on his left eye area. CNA 1 stated that she reported it immediately to a licensed vocational nurse (LVN 2). A review of Resident 2's clinical record indicated the resident was a 95-year-old male, who was admitted to the facility on 12/31/15, with diagnoses that included dementia (mental disorder with symptoms of decreased intellectual functioning that interferes with normal life) and diabetes (metabolic diseases in which there is high blood sugar levels over a prolonged period). A review of Resident 2's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 5/29/16, indicated the resident's cognition (ability to think and reason) was severely impaired. The MDS indicated the resident was unable to walk and he required extensive assistance (resident involved in activity; staff provide weight-bearing support) with bed mobility and transfers. A review of the facility's investigation report, dated 7/10/16 and timed at 8:30 a.m., indicated that Resident 2 had a purplish discoloration on his left periorbital. A review of Resident 2's SBAR (Situation, Background, Assessment Recommendation - a tool to share patient information in a clear, complete, concise and structured format; improving communication efficiency and accuracy) notes, dated 7/10/16 and timed at 9:42 a.m., indicated that Resident 2 had a left periorbital discoloration of unknown origin. A review of Resident 2's interdisciplinary (IDT) progress notes, dated 7/11/16 and timed at 2 p.m., indicated that the resident was unable to recall exactly how he sustained the left periorbital discoloration. Resident 2 stated that he might have stayed on his left side for so long while he was sleeping. The IDT notes indicated that Resident 2 was at risk for easy bruising due to the use of anti-coagulant medications. The facility's policy and procedure titled, "Abuse Reporting and Prevention," dated 3/16, indicated: a. It is the policy of this facility to ensure that alleged violations by anyone in the facility involving abuse including injuries of unknown sources are reportedly immediately to the administrator or abuse coordinator. The administrator, or his/her designee, will report each alleged abuse to the Ombudsman's office and Department of Public Health immediately or within 24 hours. b. All alleged allegations and all substantiated incidents will be reported to the Department of Public Health and to all other agencies as required by the State law. The results of the investigation must be reported within 5 working days of the incident. The facility failed to: 1. Report an injury of unknown source to the Department immediately or within 24 hours. 2. Report the result of the facility?s investigation to the licensing and certification agency (the Department) within 5 working days. The above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 940000079 |
PICO RIVERA HEALTHCARE CENTER |
940012944 |
A |
6-Feb-17 |
W8LS11 |
16737 |
F323 ? 42 CFR 483.25(h) (2). Accidents and Supervision.
The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents.
Based on observation, interview and record review, the facility failed to provide adequate supervision for Resident 5 who was assessed as being at risk for falls by failing to:
1. Provide frequent visual monitoring to Resident 5 while she slept in the wheelchair in accordance with the resident?s plan of care so as to prevent her from falls and to provide supervision while she attempted to transfer herself from the wheelchair to the bed.
2. Ensure the wheelchair brake was locked to keep the wheelchair in place when Resident 5 transferred independently in and out of the wheelchair to prevent the resident from falls.
3. Determine the reason for Resident 5?s preference in sleeping in her wheelchair.
5. Offer Resident 5 alternatives to sleeping in the wheelchair to prevent a fall.
4. Place a star sticker by the Resident 5's name outside her door and by her personal areas to alert staff that the resident was at risk for falling as indicated in the facility?s policy.
These deficient practices resulted in a fall whereby, Resident 5 sustained a fracture (broken bone) of the right wrist. The resident was transferred to a general acute care hospital for treatment, had a surgical procedure to restore the alignment of the wrist bones under general anesthesia (a medically induced coma), and had a decline in the use of her right hand and arm.
On 10/24/16 at 8:53 a.m., during the initial tour of the facility, Resident 5 was observed with a wrist brace on her right hand and wrist.
During a concurrent interview, a licensed vocational nurse (LVN 2) stated that Resident 5 was on the facility's falling star program (the facility's falls prevention program) because she had two unwitnessed falls. LVN 2 stated that the first unwitnessed fall was on July of 2016 (7/19/16) and the second unwitnessed fall happened in August of 2016 (8/2/16). LVN 2 stated Resident 5 sustained a right wrist fracture after the second fall and the resident was sent to the hospital for treatment.
During the interview, LVN 2 stated that there was no star sticker next to Resident 5's name outside her room or inside her room. LVN 2 stated there should have been a star sticker outside Resident 5's room since the resident was on the falling star program.
On 10/26/16 at 6:59 a.m., during an interview, LVN 4 stated she was assigned to Resident 5 on 8/2/16. LVN 4 stated that Resident 5 slept in her wheelchair on 8/2/16 and a certified nursing assistant (CNA 1) left Resident 5 unsupervised because she had to answer another resident's call light. LVN 4 stated that Resident 5 needed to be supervised because sleeping in a wheelchair had a greater risk for falls.
On 10/27/16 at 6:57 a.m., during an interview, CNA 1 stated she was assigned to Resident 5 at the time the resident fell on 8/2/16 and that she was sitting at the hallway across the resident?s room. CNA 1 stated Resident 5 did not like to sleep in her bed and that she slept in her wheelchair (inside her room). CNA 1 stated that she told LVN 4 that she was going into another resident?s room to answer a call light. CNA 1 stated she heard a scream from the inside of Resident 5?s room while she answered another resident?s call light and she saw the charge nurse (LVN 4) running towards the resident?s room. CNA 1 stated that Resident 5 now preferred to sleep in bed. CNA 1 left her post resulting in Resident 5 not being visually monitored while sleeping in her wheelchair as stated in the plan for care to prevent falls.
On 10/27/16 at 8 a.m., during an interview, Resident 5 stated that she was afraid to walk because of her right arm and because she might hurt herself. The resident stated that she preferred to stay in bed most of the time (after the fall on 8/2/16).
A review of Resident 5's admission record (face sheet) indicated the resident was an 86-year-old female, who was admitted to the facility on XXXXXXX 16 with diagnoses that included muscle weakness, difficulty in walking, major depressive disorder (persistent feeling of sadness and loss of interest) and dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities).
A review of Resident 5's fall risk assessment, dated 5/24/16, 7/19/16, and 8/2/16, indicated that Resident 5 was assessed as being at high risk for falls. Resident 5's fall risk assessment score ranged from 14 to 18 (a score of 8 or more represented a high fall risk).
A review of Resident 5's care plan titled, "Falling star program," dated 5/24/16, indicated Resident 5 was at risk for falls related to her "stubborn arrogant behavior," and that the resident preferred to sleep in her wheel chair. The facility staff's interventions included frequent visual monitoring.
A review of Resident 5's interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) conference record, dated 5/25/16, indicated that Resident 5 had a preference to sleep in her wheelchair and that the resident strongly refused to sleep on her bed.
A review of Resident 5's "Rehab fall risk assessment" dated 5/25/16 indicated that the resident did not demonstrate proper safe sitting and standing balance.
A review of Resident 5's joint mobility screening, dated 5/25/16, indicated the resident had full range of motion ([ROM] full movement potential of a joint) to both upper arms and hands.
A review of Resident 5's physician orders, dated 5/28/16 at 1 p.m., indicated for staff to place Resident 5 on fall precautions.
A review of Resident 5's Minimum Data Set (MDS, a resident assessment and care-screening tool) dated 5/30/16, indicated Resident 5?s cognition (ability to think and reason) was moderately impaired and the resident required extensive assistance (resident involved in the activity; staff provide weight-bearing support) from staff for activities of daily living (ADLs).
A review of Resident 5's multidisciplinary progress record, dated 7/18/16, and timed at 11:15 p.m. and on 7/19/16 at 2:15 a.m., indicated Resident 5 was sleeping in her wheelchair and refused to go to bed. The multidisciplinary progress record indicated that on 7/19/16 at 5 a.m., the resident went back to sit in the wheelchair after receiving assistance in using the bathroom. At 6 a.m., LVN 4 checked the resident?s blood sugar level. The resident was awake while sitting in the wheelchair.
A review of the facility's document titled "Interview record," dated 7/19/16 at 7:10 a.m. indicated LVN 4 stated that while making rounds with the on-coming (day) shift, Resident 5 was found on the floor. The interview record indicated Resident 5 stated she wanted to get up independently but she fell.
A review of the facility?s report titled, ?Investigation/Incident/Accident Known/Unknown Origin,? dated 7/19/16 (untimed), indicated Resident 5 stated she was sleeping in bed and when she woke up, she tried to stand up but she fell. Resident 5 is alert and very independent and she did not like to ask for help.
A review of Resident 5's Interdisciplinary Team (IDT) Conference Record, dated 7/19/16, indicated, that the resident was found lying on the floor (an unwitnessed fall) next to her bed. The IDT record indicated Resident 5 stated that she tried to transfer herself into the wheelchair, which was parked next to the bed, but the wheelchair rolled back. The care plan interventions included providing visual checks, educating the resident to use the call light, and educating the resident to lock her wheelchair especially before and after getting in and out of the wheelchair.
A review of the facility?s document titled, ?Incident Follow-up Re-education,? dated 7/19/16 indicated the facility staff needed to check on Resident 5 frequently.
A review of Resident 5's rehabilitation screen post fall incident screen report, dated 7/19/16, indicated that on 7/19/16, Resident 5's wheelchair was unlocked while the resident attempted to transfer and fell. The report indicated that the therapist assessed Resident 5 and noted that Resident 5 needed to be supervised when transferring due to Resident 5's inability to demonstrate proper safe sitting and standing balance.
A review of Resident 5's physical therapist (PT) discharge summary notes, dated from 5/25/16 to 8/1/16, indicated that on 5/25/16, Resident 5 ambulated on level surfaces with a distance of 30 feet using a two wheeled walker with supervision. The discharge summary note, dated 7/31/16 indicated that Resident 5 was able to ambulate a distance 150 feet using two wheeled walker with supervision. The discharge summary note, dated 8/1/16, indicated that Resident 5 was able to ambulate a distance of 125 feet using a two wheeled walker with supervision.
A review of Resident 5's licensed progress notes, dated 8/2/16, indicated LVN 4 documented that Resident 5 was sleeping in her wheelchair from 12 a.m. to 1:09 a.m. LVN 4 documented that at 1:10 a.m., a certified nursing assistant (CNA 1), who was assigned to supervise Resident 5, was called to a different room to answer a call light.
A review of the licensed progress notes, dated 8/2/16 and timed at 1:15 a.m., indicated that LVN 4 documented that she heard a noise and found Resident 5 sitting on the floor with her right wrist swollen and with a small cut that was bleeding. The progress notes indicated that Resident 5 was assisted back to bed and her right wrist was immobilized.
A review of the facility?s documents titled, ?Interdisciplinary Team Conference? and the ?Nursing Post-Fall Assessment and Follow Up?, dated 8/2/16, indicated Resident 5 was sleeping in her wheelchair inside her room prior to the fall and then the resident tried to stand up from her wheelchair.
A review of the facility's document titled, "Interview Record" dated 8/2/16 at 1:30 a.m., indicated LVN 4 interviewed Resident 5 and the resident stated she was sleeping and then tried to get up and fell, and hit her head and right wrist.
A review of the licensed progress notes, dated 8/2/16 and timed at 2:20 a.m., indicated that Resident 5 was experiencing severe pain on a scale of 8 out of 10 (zero represents no pain at all, while 10 represents the worst imaginable pain) to her right wrist. At 2:45 a.m., the resident was transferred to a general acute care hospital (GACH).
A review of Resident 5's GACH record titled, "Consultation," and dated XXXXXXX16 indicated that Resident 5 had a mechanical fall at the nursing home while attempting to sit down on an unlocked wheelchair. Resident 5 was presented to the emergency room (ER) with multiple skin lacerations to the forearms, acute head injury, rib fracture, chest pain. A right wrist x-ray showed bilateral distal radius and ulnar (both bones in the forearm situated away from the center of the body) fractures.
A review of the Resident 5's GACH record titled, "Department of Diagnostic Imaging," dated 8/2/16, indicated that Resident 5's right wrist had a displaced angulated fracture (fracture in which the fragments of bone are at angles to one another) of the distal radius and a complex fracture (a fracture with significant soft tissue injury) of the distal ulna.
A review of Resident 5's GACH record titled, "Operative report" and dated 8/3/16, indicated that Resident 5 had a right wrist open type I fracture (open fracture with a puncture wound of less than or equal to 1 centimeter in length with minimal soft tissue injury, minimal wound contamination or muscle crushing). The operative report indicated that Resident 5 underwent general anesthesia (medically induced coma and loss of protective reflexes resulting from the administration of one or more general anesthetic agents) and underwent an irrigation and debridement (I&D, the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of open fracture with closed reduction (a method for treating fractures that is performed without opening the skin) and casting of a distal radius fracture.
A review of Resident 5's GACH record titled "Discharge Summary" indicated that the resident had an acute head injury, rib fracture, and a right arm fracture. Resident 5 was discharge back to the facility on XXXXXXX16.
A review of Resident 5's second admission record (face sheet) indicated the resident was re-admitted to the facility on XXXXXXX16 with diagnoses that included muscle weakness, history of falling, and fracture of the lower end of the right radius (the right wrist).
A review on the Resident 5's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 8/17/16, indicated that Resident 5 had severe impairment in cognitive skills for daily decision-making and required extensive assistance from staff for activities of daily living (ADLs).
A review of Resident 5's joint mobility screening, dated 10/7/16, indicated that Resident 5 had severe (greater than 50%) loss to her right upper extremity (UE).
On 10/27/16 at 9:09 a.m., during an interview, a registered nurse (RN 1) stated that he was aware that Resident 5 liked to sleep in her wheelchair because Resident 5 was more comfortable in her wheelchair. RN 1 stated that Resident 5 was at a higher risk for falling because sleeping in her wheelchair was not safe. RN 1 stated that the licensed nurses did not create a care plan or an investigation to identify the reason why Resident 5 preferred sleeping on a wheelchair. RN 1 stated that Resident 5 had a regular mattress prior to the falls. RN 1 stated that there were no other alternatives offered to Resident 5 other than sleeping in her wheelchair. RN 1 stated that the facility did not visually monitor Resident 5 but the resident needed frequent supervision.
On 10/27/16 at 10:05 a.m., during an interview, an occupational therapist (OT 1) stated that after readmission to the facility, Resident 5 preferred not to walk anymore because of her right arm and the resident instead spent most of her time in her bed.
On 10/27/16 at 12:07 p.m., during an interview, the director of nursing (DON) and LVN 2 stated that they were aware that Resident 5 preferred to sleep in her wheelchair since her initial admission to the facility until XXXXXXX16. The DON and LVN 2 stated that Resident 5 was at higher risk for falling due to sleeping in her wheelchair and she needed frequent monitoring. The DON and LVN 2 stated that there was no care plan or reasons explored as to why Resident 5 preferred to sleep in her wheelchair prior the falls. The DON and LVN 2 stated that there were no other alternatives offered to Resident 5 other than for Resident 5 to sleep in her wheelchair.
During the interview, the DON stated that the facility did not have any system in place on visual monitoring for residents at risk for falls. The DON and LVN 2 stated that Resident 5 liked to stay in bed most of the time after her readmission to the facility.
A review of the facility's undated policy and procedure titled, "Fall," indicated that the facility required staff to develop a comprehensive care plan to prevent any recurrences and to meet Resident's specific needs.
A review of facility's undated policy and procedure titled, "Falling star program" indicated that facility required staff to place a "Colorful Star," in personal resident areas.
The facility failed to provide adequate supervision for Resident 5 who was assessed as being at risk for falls by failing to:
1. Provide frequent visual monitoring to Resident 5 while she slept in the wheelchair in accordance with the resident?s plan of care so as to prevent her from falls and to provide supervision while she attempted to transfer herself from the wheelchair to the bed.
2. Ensure the wheelchair brake was locked to keep the wheelchair in place when Resident 5 transferred independently in and out of the wheelchair to prevent the resident from falls.
3. Determine the reason for Resident 5?s preference in sleeping in her wheelchair.
5. Offer Resident 5 alternatives to sleeping in the wheelchair to prevent a fall.
4. Place a star sticker by the Resident 5's name outside her door and by her personal areas to alert staff that the resident was at risk for falling as indicated in the facility?s policy.
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 940000089 |
PACIFIC CARE NURSING CENTER |
940013141 |
A |
21-Apr-17 |
L3YT11 |
8531 |
42 CFR 483.24(d) Accidents. The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible.
On 2/13/17 at 2:05 p.m., an unannounced visit was conducted at the facility to investigate and entity reported incident regarding quality of care and resident safety.
Based on observation, interview and record review, the facility failed to ensure that Resident 1?s environment was free from accident hazards as is possible by failing to:
1. Remove from Resident 1?s immediate area a lighter while the resident was receiving oxygen therapy (the inhaling of oxygen under pressure, often inside a pressurized chamber, as a treatment for respiratory conditions) in accordance with the facility?s policy and procedure.
Resident 1, who was receiving oxygen therapy in his room and who was assessed as an independent smoker, had his lighter in his possession at the bedside. Resident 1 accidentally dropped his lighter on the over bed table while emptying his pouch and the lighter suddenly sparked and caused a flame.
This deficient practice resulted in Resident 1 sustaining a second degree burn (a burn involving the epidermis [outer layer of the skin] and dermis [inner layer of the skin] and usually forming blisters [a collection of fluid underneath the top layer of skin] that may be swollen and painful) on his right eyebrow, right side corner of his nose, right outer nostril (outer openings of the nose), right inner cheek, right upper lip, right index finger, left index finger, left fourth finger, and left little finger.
On 2/13 /17 at 2:32 p.m., during an interview, Resident 1 stated that while he was receiving his oxygen therapy in his room and emptying the contents of his small pouch (on 2/12/17), the coins and his lighter fell on the over bed table and the lighter suddenly sparked. Resident 1 stated that he heard a hissing sound and saw a flame. Resident 1 stated he pulled his oxygen nasal cannula (a device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows. The other end of the tube is connected to an oxygen supply) from his nose and turned off his oxygen concentrator (a device which concentrates the oxygen from a gas supply [typically ambient air] to supply an oxygen enriched gas stream). Resident 1 stated that he had some blisters on his hands because he was trying to put the fire out with his hands and blanket. Resident 1 stated that he always had a lighter with him because he smoked outside the facility.
A review of Resident 1's Admission Record indicated that Resident 1 was 62-year-old male, who was admitted to the facility on XXXXXXX14 and was re-admitted on XXXXXXX16. Resident 1's diagnoses included hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs).
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/22/16, indicated that Resident 1's cognitive skills for daily decision-making was intact. The MDS indicated that the resident required limited assistance from the staff with bed mobility, transfer and extensive assistance for dressing, toilet use, personal hygiene and bathing. The resident was assessed with functional limitation in range of motion (limited ability to move a joint that interferes with daily functioning) on one side of upper and lower extremities.
A review of Resident 1's Physician Order, dated 10/21/15, indicated that the resident may have oxygen therapy at two (2) liter per minute as needed (PRN).
A review of Resident 1's Smoking Risk Assessment, dated 11/16/16, indicated that the resident received an assessment score of seven (7). A score of (7) indicated that the resident was an independent smoker. The assessment form indicated that if a score is 10 or greater, then the resident should be considered as being at high risk for potential injury.
A review of Resident 1's record titled, "Situation-Background-Appearance-and Review" Communication Form (SBAR, a technique that can be used to facilitate prompt and appropriate communication), dated 2/12/17, indicated that Resident 1 had a burn on his right face and hands.
A review of Resident 1's Treatment Flowsheet (Treatment Record), starting 2/12/17, indicated that Resident 1's right eyebrow, right side corner of his nose, right nostril, right upper inner cheek, right upper lip, right index finger, left index finger, left fourth finger, and left little finger were treated with Silvadene cream (an antibiotic used on the skin for second or third degree burns it helps to prevent or treat serious infection) twice a day for seven (7) days.
A review of the undated facility's policy and procedure titled "Oxygen Administration," indicated the following:
i. Remove all potentially flammable items (e.g., lotions, oils, alcohol, smoking articles, etc.) from the immediate area where oxygen is to be administered.
Ii. Remove any woolen blankets, nylon, and/or rayon clothing, etc., from the immediate area where oxygen is to be administered.
Iii. Instruct the residents, his/her family, visitors and roommate (if any) of the oxygen safety precaution.
On 2/13/17, at 2:56 p.m., during an interview, the certified nursing assistant (CNA 1) stated that on 2/12/17 around 6:50 a.m., Resident 1 called for assistance. CNA 1 stated that when she got in the room, she saw Resident 1 had a black mark around his right eye and the room smelled like something just burned. CNA 1 stated that she called the charge nurse and cleaned Resident 1's face and hands using a small warm towel.
On 2/15/17 at 11:59 a.m., during an interview, CNA 2 stated that a resident on oxygen therapy should not possess matches and lighters as a safety precaution. CNA 2 stated that licensed nurses knew that Resident 1 had his lighter with him.
On 2/15/17 at 12:34 p.m., during an interview, the registered nurse (RN 1) stated that when she found out that Resident 1 had in his possession a lighter on 2/12/17, she asked Resident 1 after the incident on 2/12/17 to give his lighter to her for safety. RN 1 stated that she was not aware that independent smokers were allowed to keep their smoking paraphernalia (smoking materials, such as lighter, cigarettes etc.).
On 2/15/17 at 1:19 p.m., during an interview, the director of nursing (DON) stated that Resident 1 was assessed as an independent smoker. The DON stated that Resident 1 did not have a care plan addressing how, when, where and who was responsible to ensure that the resident's smoking paraphernalia would not be a potential fire hazard. The DON stated that resident safety was more important than resident rights. The DON stated that the facility would be changing its policy and procedure regarding smoking.
On 2/15/17 at 2:50 p.m., during an interview, the Medical Director (MD) stated that he was aware of what happen to Resident 1 on 2/12/17. The MD stated that it was just common sense that if residents are on oxygen therapy, the facility should not allow any resident to have access to a lighter. The MD stated that he was not sure if he did approve the facility's policy and procedures regarding smoking.
On 2/16/17 at 2:20 p.m., during an interview, the director of staff development (DSD) stated that if the oxygen is in use, staff should be aware that per standard of practice there should be no matches, lighters or anything that could cause fire in the resident?s immediate area.
On 3/8/17 at 12:39 p.m., during a telephone interview, the DON stated that the policy and procedures regarding steps to follow if a resident and/or if resident's roommate was using oxygen was not followed. The DON stated that it was important to follow the policy and procedures to prevent fire incident.
The facility failed to ensure that Resident 1?s environment was free from accident hazards as is possible by failing to:
1. Remove from Resident 1?s immediate area a lighter while the resident was receiving oxygen therapy (the inhaling of oxygen under pressure, often inside a pressurized chamber, as a treatment for respiratory conditions) in accordance with the facility?s policy and procedure.
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. |
| 940000089 |
PACIFIC CARE NURSING CENTER |
940013261 |
A |
9-Jun-17 |
987Q11 |
22365 |
F309 CFR ? 483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
F279 CFR ?483.20(k) Comprehensive Care Plan
(1) The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following:
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ?483.25.
F281 CFR ?483.20(k)(3)
(3) The services provide d or arranged by the facility must?
(i) Meet professional standards of quality.
F250 CFR ?483.15(g) Social Services
(1) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
On 1/19/17, at 11:35 a.m., an unannounced visit was made to the facility to investigate a complaint related to quality of care involving Resident 1.
Based on interview and record review, the facility failed to provide the following care and services needed for Resident 1, who had right and left vascular (pertains to the blood vessels [arteries, carry blood that is rich in oxygen away from the heart and veins, carry blood that is reduced in oxygen toward the heart]) great toe (big toe) gangrene (death of tissue, a dangerous condition that could end someone's life that happens when the blood flow to a large area of tissue cells is cut off):
1. Assess Resident 1's left and right great toe gangrene from 10/30/16 (admission date) to 1/4/17 (transfer date), for a total of more than two months.
The facility policy and procedures indicated weekly assessments of the wound that include location; size; exudates (a fluid substance can be pus-like or clear fluid that leaks out from a wound), color, odor and approximate amount; necrotic tissue (dead tissue); pain related to the gangrene; and description of wound edges and surrounding tissue.
2. Develop a care plan that was consistent with Resident 1's specific risks for infection relating to vascular great toe gangrene.
3. Refer Resident 1 to a podiatrist (a physician devoted to the study and medical treatment of disorders of the lower extremities [hips, knees, and ankle joints, and the bones of the thigh, leg, and foot]) for consultation according to the primary physician's order on 11/18/16 and 12/28/16.
4. Provide oversight to ensure assessment and delivery of care were consistent with professional standards of practice and physician?s orders were carried out.
These deficient practices resulted in delayed identification of infection (a change in resident condition) to Resident 1's right and left gangrenous great toes and provision of medical interventions that led to Resident 1 experiencing intractable (unmanageable) pain level of seven out of ten (7/10) in a pain rating scale of zero to ten (zero indicating no pain and ten indicating worst pain). Resident 1 was transferred to the general acute care hospital (GACH) emergency room (ER) on XXXXXXX17 at 4:50 p.m. Resident 1 was given local (uses injectable medicine to block sensations of pain from a specific area of the body) anesthetics (a substance that induces insensitivity to pain) and narcotics (controlled drugs affecting mood or behavior used medically to relieve strong pain) to relieve the pain then was admitted to the Intensive Care Unit (ICU, a specialized department in the hospital where seriously ill residents are cared for by specially trained staff) under serious condition on 1/5/17. The vascular surgeon (a specialist who diagnose and manage disorders that affect the arteries, veins and lymphatic systems [a network of tissues and organs that help rid the body of toxins, waste and other unwanted materials]) and podiatrist recommended for Resident 1 to undergo bilateral (both) below the knee amputation (an operation to remove all or part of a limb or extremity) due to Resident 1?s feet were not salvageable (could not be saved or fixed).
A review of Resident 1's record titled, "Resident Face Sheet (admission record)," undated, indicated Resident 1 was readmitted to the facility on XXXXXXX16, with diagnoses that included difficulty walking, muscle weakness, hypertension (a long term medical condition in which the pressure in the arteries is persistently elevated) and end stage renal disease (when the kidneys are no longer able to work at a level needed for day-to-day life).
A review of Resident 1's record titled, "Comprehensive Resident Assessment," dated 10/30/16, indicated Resident 1 came to the facility with left and right great toe gangrene. There was no documented assessment of the left and right great toe gangrene upon admission on 10/30/16.
A review of Resident 1's record titled, "Physician Order Report," dated 10/30/16, indicated to treat and cleanse the left and right great toe gangrene with normal saline (salt in water), pat dry, apply betadine solution (used on the skin to treat minor wounds and decrease risk of infection), cover with dry dressing every day for 30 days and to reassess (left and right great toe gangrene).
A review of Resident 1's record titled, "Resident Care Plan, Risk for Skin Breaks/Pressure Ulcer (or pressure sore, areas of damaged skin caused by staying in one position for too long)," developed 10/31/16, indicated Resident 1 was admitted with right and left great toe gangrene. Included in the approach plan for the staff to do skin checks every day, notify charge nurse of any changes in skin condition, and notify the physician of any significant change in skin condition. There was no indication in the care plan how the staff would assess and monitor Resident 1's right and left great toe gangrene for signs (evidence of disease [infection] that can be detected by someone other than the resident affected by the disease) and symptoms (evidence of disease that is experienced by the resident affected by the disease) of infection.
A review of the facility policy and procedures titled, "Comprehensive Care Planning," dated 1/2017 indicated that the facility will develop a care plan for each resident. The care plan will address effective and resident-centered care (specific to Resident 1's care needs) that meets professional standards for quality of care (ethical [pertaining to right and wrong in conduct] or legal duty [the responsibility to others to act according to the law] of a professional to exercise the level of care, diligence [careful and persistent work or effort], and skill prescribed in the code of practice of his or her profession, or as other professionals in the same discipline would in the same or similar circumstances).
A review of Resident 1's record titled, "Minimum Data Set (MDS, a resident assessment and care screening tool)," dated 11/6/16, indicated Resident 1 was assessed to be cognitively (refers to mental abilities) intact. The MDS indicated Resident 1 required extensive assistance (resident performed part of the activity; staff provided support with bearing weight; at times full staff performance of activity) with most activities of daily living (routine activities that people tend do every day involving personal care and functional mobility [the manner in which people are able to move around in the environment or move from place to place]).
A review of Resident 1's record titled, "History and Physical (H&P)," dated 11/18/16, indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1's diagnoses included coronary (pertaining to the heart) artery disease (CAD, decreased blood flow to the heart due to major blood vessels [coronary arteries] that supply the heart with blood, oxygen and nutrients become damaged or diseased due to plaque [fat deposits] build up), peripheral vascular disease (PVD, a disorder causing narrowing or occlusion of the blood vessels (artery or veins) located outside the brain and heart), diabetes (a disorder that affects the body's ability to use blood sugar resulting to high levels of sugar in the blood) and bilateral great toe gangrene.
According to the American Heart Association, last reviewed 04/21/2014, http://www.heart.org/HEARTORG/Conditions/Cholesterol/WhyCholesterolMatters/Atherosclerosis_UCM_305564_Article.jsp#.WO6P92egu1s indicated, "Plaque may partially or totally block the blood's flow through an artery in the heart, brain, pelvis, legs, arms or kidneys." "The arterial wall becomes markedly thickened by these accumulating cells and surrounding material. The artery narrows and blood flow is reduced, thus
decreasing the oxygen supply." "...if the oxygen supply to the extremities is reduced, gangrene can result."
According to the National Institute of Diabetes and Digestive and Kidney Diseases, no date, https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/foot-problems indicated, "Diabetes also can lower the amount of blood flow in your feet. Not having enough blood flowing to your legs and feet can make it hard for a sore or an infection to heal. Sometimes, a bad infection never heals. The infection might lead to gangrene."
"Gangrene and foot ulcers that do not get better with treatment can lead to an amputation of your toe, foot, or part of your leg. A surgeon may perform an amputation to prevent a bad infection from spreading to the rest of your body, and to save your life."
A review of Resident 1's record titled, "Non-Pressure Sore Skin Problem Report," dated from 10/31/16 - 1/2/17, under "Description (include size/extent)," there was no documented description of Resident 1's left and right great toe gangrene.
A review of the facility?s policy and procedures titled, "Pressure Sore Management," dated 7/2015 indicated, "Arterial Ulcer/ Wound is ulceration (wound) that occurs as the result of arterial (pertaining to artery) occlusive disease (blockage or narrowing of an artery) when non-pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis (death). Inadequate blood supply to the extremity may initially present as intermittent claudication (crampy leg pain due to insufficient blood flow to the area caused by blocked arteries supplying that area)."
"Key Procedural Points: Assess the pressure ulcer(s) for location, size (measure length, width, and depth), sinus tracts (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess [is a collection of pus, a thick fluid that usually contains germs/bacteria] formation), undermining (deep tissue damage underneath intact skin at the wound margin/edge), tunneling (a track of tissue loss that extend in any direction away from the wound through soft tissue and muscle), exudates, necrotic tissue, and the presence or absence of granulation tissue (new tissue that form on the surface of a wound during the healing process) and epithelialization (the process of covering an open skin surface with epithelium [outside layer of cells]). Determine the ulcer's current stage (the level) of development. Assess the resident for pain related to the pressure ulcer. A weekly assessment of the pressure ulcer is to be done by the treatment nurse."
"Interventions: The documentation will include the date observed, location, and staging (level), size (Perpendicular measurement of the greatest extent of length and width of the ulceration), depth; and the presence, location and extent of any undermining or tunneling/sinus tract; exudate, if present; type (such as purulent [pus-like]/serous [clear fluid]), color, odor and approximate amount; pain, if present, wound bed: color and type of tissue/character including evidence of healing (e.g. [that is] granulation tissue), or necrosis (slough [yellowish, thick] or eschar [dry, thick, leathery, brown or black]): and description of wound edges and surrounding tissue (e.g. rolled edges, redness, induration [hardness], maceration [softened by extended exposure to wetness or moisture]) as appropriate."
A review of Resident 1's record titled, "Physician and Telephone Orders," dated 11/18/16 and 12/28/16, indicated Resident 1's Primary Physician's (PP1) order for podiatry follow up with in-house podiatrist. There was no podiatry consult found in Resident 1's clinical record.
A review of Resident 1's record titled, "Licensed Personnel Weekly Progress Notes," dated 1/4/17, at 3:43 p.m., indicated PP1's covering physician (PP2) came to see Resident 1 on 1/4/17 and Resident 1 complained of bilateral foot pain of 7/10 that was not relieved with pain medications. There was no documented assessment of Resident 1's left and right great toe gangrene. The notes indicated PP2 ordered to transfer Resident 1 to the hospital. The notes indicated Resident 1 left the facility by regular ambulance at 4:50 p.m. on 1/4/17.
A review of Resident 1's record titled, "Transfer Record," dated 1/4/17, indicated Resident 1 was transferred to GACH for intractable pain 7/10.
A review of Resident 1's hospital record titled, "Emergency Department (ED) Encounter," dated 1/4/17, at 11:57 p.m., indicated Resident 1 presented to the ED with bilateral lower extremity (BLE) pain "from toes to her thighs" with pain 7/10. Resident 1's physical exam indicated, "Multiple black necrotic toes with significant malodor (a very unpleasant smell) with tenderness (pain) diffusely (spread out or scattered widely) to the legs." The ED notes dated 1/5/17 at 1:23 a.m., indicated Resident 1 was given morphine injection (narcotic pain reliever used to treat moderate to severe pain) 4 mg intravenously (IV, given directly into a vein). The ED notes indicated Resident 1 was admitted to ICU under serious condition on 1/5/17 at 2:57 a.m.
A review of Resident 1's hospital record titled, "GACH Medications," indicated Resident 1 received the following additional pain medications:
1. On 1/5/17, at 3:15 p.m., Lidocaine (a local anesthetic [numbing medication], used to block nerve signals in the body) injection 0.1 milliliter (ml).
2. On 1/6/17, at 6:45 p.m., hydromorphone (Dilaudid, a centrally acting [medication that act in the brain or spinal cord to block or slow the transmission of pain information] pain medication of the opioid class [narcotic]) injection 0.5 mg.
3. On 1/7/17, at 6:30 a.m., 10:43 a.m., 12:51 p.m., and 1 p.m., morphine injection 1 mg
A review of Resident 1's hospital record titled, "Podiatry Progress Note," dated 1/7/17, indicated a diagnosis of sepsis (a severe complication of an infection) with plan that included IV (intravenous, given directly into a vein) antibiotics (medication used in the treatment and prevention of bacterial infections). The podiatrist indicated, "Per vascular (surgeon), revascularization (restoration of blood flow to the body part that has suffered inadequate blood supply) is high risk. Given patient's (Resident 1) comorbidities (other diseases or disorders) and significant vessel disease, we do not think feet are salvageable (could not be saved or fixed) at this time. Agree with vascular surgery recommendations for bilateral below the knee amputation."
A review of Resident 1's hospital record titled, "Nephrology (a specialty of medicine that focuses on the diagnosis and treatment of diseases of the kidney) Progress Note,? dated 1/22/17, indicated Resident 1 declined surgery and opted for Hospice (care services that focuses on improving the quality of life for the residents and their families faced with a life-limiting illness).
During an interview on 1/20/17 at 3:08 pm., Registered Nurse (RN1) stated that PP1 ordered to follow-up with in-house podiatrist for Resident 1. RN1 stated that she verbally told Social Worker (SW1) regarding the podiatry appointment. RN1 stated that she was not sure if the podiatrist came and examined Resident 1. RN1 reviewed Resident 1's clinical record and stated she could not find documentation that the podiatrist had seen Resident 1.
During an interview on 1/20/17 at 3:55 p.m., SW1 stated Resident 1 was not seen by the podiatrist because the in-house podiatrist was on vacation and that no one was covering for the in-house podiatrist. SW1 stated he did not call any podiatrist to follow-up Resident 1.
During an interview on 1/20/17 at 4:10 p.m., the Director of Nursing (DON) stated that if the in-house podiatrist was not available, the social worker or licensed nurse should have notified PP1 to make a referral to other podiatrist.
During a telephone interview on 2/21/17 at 10:10 a.m., PP1 stated that he ordered podiatry consult to make sure that Resident 1's bilateral great toe gangrene were not infected. PP1 stated that he was not aware that Resident 1 was not seen by a podiatrist. PP1 stated that if he was informed that Resident 1 was not seen or could not have a follow-up by a podiatrist, PP1 stated he would have come and check to make sure Resident 1's bilateral great toe gangrene were not infected.
During a telephone interview on 2/21/17 at 11 a.m., SW1 stated that he was responsible for making appointments in regard to in-house or outside physician referrals. SW1 stated he did not coordinate with PP1 in regard to podiatry consult for Resident 1. SW1 stated that Resident 1 had no podiatry consult from 11/18/16 to 1/4/17.
A review of the facility's policy and procedures titled, "Social Services Program," dated 7/28/15, indicated the facility will provide medically related social services to assure that each resident can achieve and maintain his/her highest practicable physical, mental, or psychosocial well-being.
During a telephone interview on 3/3/17 at 12:32 p.m., pertaining to Resident 1's assessments of the left and right great toe gangrene from 10/30/16 to 1/4/17, Licensed Vocational Nurse (LVN1) stated that she should have measured the length, width, and depth of Resident 1's left and right great toe gangrene based on the facility?s policy and procedures to make sure it was not spreading to other tissue. LVN1 stated that every time she provided the treatment to Resident 1's left and right great toe gangrene, she asked Resident 1 regarding the pain level. LVN 1 stated that she did not document the pain level in the treatment record.
During a telephone interview on 3/23/17 at 1:48 p.m., the DON stated that the facility follows the policy and procedures on Pressure Sore Management for arterial ulcer/wound assessment. The DON stated that she expected LVN 1 to do a thorough and exact assessment of Resident 1's wound based on the facility?s policy and procedures. The DON stated that documentation of the wound assessment should have included the location, size, drainage, odor, pain level, and signs of infection including redness to surrounding tissues.
During a telephone interview in regard to Resident 1's care plan, Risk for Skin Breaks/Pressure Ulcer on 3/23/17 at 3:30 p.m., for specific interventions on how the staff would assess and monitor Resident 1's right and left great toe gangrene for signs and symptoms of infection, the DON stated Resident 1's care plan will be improved to be more specific to Resident 1's bilateral great toe gangrene problem.
During an interview on 6/1/17, at 8:10 a.m., the DON stated she and the Assistant DON were in-charge of assuring that resident assessments and physicians? orders were carried out efficiently, accurately, and in a timely manner.
During an interview in regard to oversight to ensure resident assessments were done accurately, on 6/5/17, at 2:10 p.m., the DON stated it was not identified early on that Resident 1?s gangrene assessment was not in accordance with the policy and procedures. When asked regarding oversight to ensure physician?s orders for podiatry were carried out timely, the DON stated the order for podiatry for Resident 1 was a ?routine (regular scheduled visit)? order. When asked if the urgency of the referral order was verified with the ordering physician, the DON stated the physician would indicate otherwise, ?Stat (now)? or ?ASAP (as soon as possible)? if not routine order. When asked for the facility's policy and procedures for completeness of physician?s referral order, the DON stated the facility had no policy and procedures specific for referral order.
Therefore, the facility failed to provide the following care and services needed for Resident 1, who had right and left vascular great toe gangrene:
1. The facility failed to assess Resident 1's left and right great toe gangrene from XXXXXXX16 (admission date) to XXXXXXX17 (transfer date), for a total of more than two months in accordance with the facility policy and procedures.
2. The facility failed to develop a care plan that was consistent with Resident 1's specific risks for infection relating to vascular great toe gangrene.
3. The facility failed to refer Resident 1 to a podiatrist for consultation according to the primary physician's order on 11/18/16 and 12/28/16.
4. Provide oversight to ensure assessment and delivery of care were consistent with professional standards of practice and physician?s orders were carried out.
These deficient practices resulted in delayed identification of infection of Resident 1's right and left gangrenous great toes and provision of medical interventions that led to Resident 1 experiencing intractable pain level of seven out of ten (7/10). On 1/4/17, Resident 1 was transferred to the GACH emergency room. Resident 1 was given local anesthetics to relieve the pain then was admitted to the Intensive Care Unit under serious condition on 1/5/17. The vascular surgeon and podiatrist recommended for Resident 1 to undergo bilateral below the knee amputation. Resident 1 declined surgery and opted for Hospice.
The above violations presented a substantial probability that death or serious physical harm would result to Resident 1. |
| 950000041 |
POMONA VISTA CARE CENTER |
950008969 |
B |
01-Feb-12 |
3WD611 |
5551 |
The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Based on interview and record review, the facility failed to implement its abuse reporting policy by failing to:1. Immediately notify the Administrator and the Director of Nursing (DON) that Staff 1 had physically abused Resident A. This resulted in a delay in protecting the resident, and the initiation of an investigation, which placed Resident A at further risk of abuse.On October 27, 2011, an unannounced visit was made to the facility to investigate a facility reported incident of alleged resident abuse. Review of Resident A?s medical record revealed that the resident was admitted to the facility on April 2, 2010, with diagnoses that included dementia, anxiety dysphagia (difficulty in swallowing), gait disturbance, deep vein thrombosis (a blood clot that forms in a vein deep in the body.) and diabetes mellitus (a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin to meet its needs).According to the Minimum Data Set (MDS- a standardized assessment and care planning tool) dated September 1, 2011, Resident A had severely impaired cognitive (Mental) skills, a short and long term memory problem, but had no difficulty in hearing or speech, and was sometimes able to make himself understood and to understand others. The assessment further indicated that the resident had demonstrated trouble in concentrating, and exhibited physical and verbal behavior symptoms such as hitting, kicking, pushing, threatening and screaming at others. The MDS also indicated that Resident A required limited assistance in bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed) and was totally dependent on staff in dressing, eating, toilet use and personal hygiene. During an interview with Staff 2 on October 27, 2011, at 2 p.m., she stated that on October 15, 2011, around 8:40 p.m. while passing by Resident A?s room, she observed Staff 1 hitting Resident A with an open hand between the stomach and the legs while the resident was in bed. When she went in to the room and asked Staff 1 what was happening, Staff 1 stated, ?I need to test his blood sugar, please help me.? Staff 2 spoke to the resident in the resident?s native language, Spanish; to calm him down and to allow Staff 1 to test his blood sugar. The resident was upset and tried to pull his bed cover up over his body and face.The resident eventually allowed Staff 1 to test the blood sugar. After the blood sugar test was completed, Staff 2 assessed the resident for injuries and did not find any. Staff 2 further stated that she did not inform anyone of the incident because she was scared and worried that no one would believe her. She finally decided to report to the Administrator on October 17, 2011, two days later. She was aware that any abuse of any kind needed to be immediately reported to the administrator. Staff 2 provided a written declaration during the interview.An interview was conducted with the Administrator and the DON on October 27, 2011, at 2:30 p.m.According to the DON, Staff 1 who was the on-call Charge Nurse for the 3 p.m. to 11 p.m. shift was suspended immediately after the receipt of the abuse report on October 17, 2011 pending the investigation of the allegation of abuse. The DON also stated that Staff 1 was surprised and denied the allegation of abuse. The DON further stated that Staff 1 was subsequently terminated on October 25, 2011.A review of the facility?s Employee Separation Form dated October 25, 2011, indicated Employee 1 was terminated due to improper conduct.Further review of Employee 1?s Employee File indicated he had no ?write-ups? in regards to his behavior. He was initially suspended on October 17 2011, and terminated on October 20, 2011. According to the facility?s ?Employee separation form?, the last day staff 1 worked at the facility was October 16, 2011.According to the Administrator and the DON all employees should report any abuse that they witness immediately so that an investigation could be initiated as soon as possible.A review of the facility?s summary of findings dated October 20, 2011, indicated that the facility was unable to substantiate the allegation; however, Staff 1 was removed from the facility due to a history of behavior the facility had identified as rude and abrupt with other co-workers.On October 17, 2010, at 4 p.m., a review of the facility's Reporting Suspected Crimes under Federal Elder Justice Act revised on September 2011, indicated ?if the reportable event does not result in serious injury, the staff members shall report the suspicion no later than 24 hours after forming the suspicion. The facility failed to implement its abuse policies and procedures by failing to: 1. Immediately notify the Administrator and the DON that Staff 1 had physically abused Resident A. This resulted in a delay in protecting the resident, and the initiation of an investigation, which placed Resident A at further risk of abuse.This violation had a direct relationship to the health, safety and security of Resident A. |
| 970000188 |
Pasadena Care Center, LLC |
950009456 |
B |
23-Aug-12 |
QEB611 |
11678 |
Abuse F223- The resident has the right to be free from verbal, sexual, physical and mental abuse. Reporting Abuse - F225 The facility must ensure that all alleged violations involving mistreatment, or abuse, are reported immediately to the administrator of the facility and their officials in accordance with the State law through established procedures (including to the State survey and certification agency).On August 2, 2011, at 9:30 a.m., an unannounced visit was made to the facility to investigate an allegation that Staff 2 sexually abused Resident A. Based on interview and record review, the facility failed to ensure that: that: 1. Resident A was not subjected to sexual abuse by Staff 2. Staff 2 massaged and fondled Resident A?s breast and penetrated her vaginal area with his fingers. Additionally, Resident A, who was a quadriplegic with cognitive deficit but able to recall events sometimes after cueing and totally dependent on staff, was observed with Staff 2?s penis in her mouth, sucking on it.2. A criminal background check was conducted on Staff 2 prior to hire in accordance with the facility?s policy and procedure 3. Staff 1 who was aware of the facility?s abuse reporting policy, immediately reported to the director of nurses and the administrator the sexual abuse that she witnessed by Staff 2 towards Resident A. Staff 1 waited four days to report the sexual abuse thereby, creating a potential for further sexual abuse by Staff 2. A review of Resident A?s medical record indicated Resident A was admitted to the facility on February 19, 2007, and re-admitted on October 2, 2007, with diagnoses that included coronary heart disease , hypertension, cerebrovascular accident (stroke), quadriplegia (paralysis of both arms and both legs) and contractures of both hands.According to the Minimum Data Set (MDS- a standardized comprehensive assessment tool) dated June 3, 2011, Resident A was able to complete the brief interview for mental status, usually understood others and made herself understood. According to the MDS assessment, Resident A was totally dependent on staff in all activities of daily living (ADL?s) that included bed mobility, transfer, toilet use and personal hygiene. Additionally, the History and Physical Examination form dated July 21, 2011, indicated that Resident A did not have the capacity to understand and make decisions. On August 2, 2011, at 10 a.m., during an interview with the administrator and the director of nursing (DON), they presented a copy of the facility?s investigative report dated July 29, 2011. During the interview, the administrator stated that the investigation was still in progress and that there were no other investigative reports available at this time. The administrator further stated that the alleged abuser (Staff-2) was placed on suspension and the witness did not report the alleged sexual abuse immediately because she was afraid that something might happen to her. During an interview with Staff 1 on August 2, 2011, at 10:30 a.m., she stated that on July 24, 2011, between 8:30 and 9 a.m., when she entered Resident A?s room, she noted that the privacy curtain between beds A and B was partially drawn. She knew that Staff 2 was in the room performing range of motion on Resident A, but as she walked towards the resident in the next bed, she observed Staff 2 was standing next to Resident A?s left side, with his hand in between Resident A?s legs and the resident was not wearing any undergarments. Staff 1 stated that as she walked back towards the door she also observed Staff 2 fondling Resident A?s left breast. Staff 1 further stated as she walked back in to the room again she observed Resident A performing oral sex on Staff 2. Staff 1 stated that she walked out of the room immediately and called Staff 2 for assistance in an attempt to stop the ?sexual abuse.? However, Staff 2 did not respond to her call immediately. Staff 2 stayed in the room with Resident A for approximately thirty minutes and as soon as Staff 2 came out of the room she immediately went back to the room and talked to Resident A regarding the incident. According to Staff 1, Resident A denied the abuse. Staff 1 further stated she should have reported the incident immediately to her supervisor but she was scared that something might happen to her. Staff 1 stated that she finally decided to report the incident to the director of nursing on July 29, 2011. Staff 1 provided a written declaration during the interview.According to the Pasadena Police Department Crime Report dated 9/9/11, Pasadena Police Department officers responded to the facility regarding a possible sexual assault and spoke with the director of nursing. The DON stated that she was approached by one of her employees Staff 1, regarding a possible sexual assault of one of the residents at the location by a fellow staff member. The DON informed the detectives that on 7/24/11, Staff 2 was supposedly providing physical therapy to Resident A. Staff 1 walked into the room and saw Staff 2?s hand between Resident A?s legs, and Resident A was not wearing any undergarments. When Staff 1 walked into the room a second time, Staff 2?s hand was observed on Resident A?s naked breast. The third time Staff 1 walked in to the room, she saw Resident A performing fellatio on Staff 2. Staff 1 then stated that she called out to Staff 2 to ask for help with a resident, but he ignored her request. Staff 2 was in the room for approximately 30 minutes. The crime report further indicated that the DON stated that when she asked Staff 1 why she did not report the incident right away she replied that she was afraid of Staff 2.Review of the crime report dated 9/9/11, revealed that the detectives attempted to speak to Resident A, but she did not remember the events that had taken place. She did not know the date, time, or day of the week and could not tell the detective her name. The report further indicated that it was apparent that that the resident did not have the mental capacity to recall any of the past incidents and could not provide a statement. According to the Crime report dated 10/27/11, Staff 1 was interviewed by the detective. Staff 1 stated that as she walked into the room where Staff 1 was providing physical therapy to Resident A, the curtains were drawn around Resident A?s bed but not completely closed. Staff 2 apparently did not notice that she had entered the room. When she first entered the room she saw Staff 2?s ungloved hand on Resident A?s vagina. Resident A was wearing a hospital gown that was pulled up to her waist and she was also wearing an adult diaper with one of the sides not attached and Staff 2?s hand was on her vagina (touching skin to skin). Staff 1 stated that she did not say anything because she was ?in shock? at what she had seen and she continued to attend to her resident who was in the second bed. Staff 1 further said when questioned by the detective, that Staff 2?s fingers were penetrating Resident A?s vagina. Staff 1 left the room and did not report what she had seen to anyone. A short while later, Staff 1 went back into the room and saw Staff 2?s left arm on Resident A?s left breast on top of her hospital gown. Staff 1 left the room again and a short while later, Staff 1 entered the room a third time and said she was going to retrieve a toothbrush for a resident and Staff 2 had the keys for where the supplies are kept and she went in the room to ask Staff 2 for the keys. Staff 1 then saw Staff 2 standing on the left side of Resident A?s bed and the guard rail was down. Staff 1 then saw Staff 2?s penis in Resident A?s mouth, and Resident A was moving her mouth as if she was performing oral sex on Staff 2. Staff 1 stated that she did not know if this had been going on for a while between Staff 2 and Resident A.According to the interview with the administrator on August 2, 2011, at 9:30 a.m., she stated that Staff 2 was placed on suspension immediately pending the investigation and the Department was also notified by fax.During an interview with Resident A on August 2, 2011, at 10 a.m., Resident A stated that she did not remember anything about the abuse. Resident A also stated that she was never sexually abused in the facility. Resident A was observed to be confused and disoriented to time and place during the interview. Attempts to contact Staff 2 on August 2, 2011, at 11:30 a.m., and March 8, 2012, at 11 a.m. were unsuccessful. There was no voicemail or message machine available to leave a message for Staff 2. However, the Pasadena Crime report dated September 9, 2011, indicated that an interview was conducted with Staff 2. The Crime report indicated that Staff 2 stated that he ?at no time touched Resident A inappropriately, and never touched her vagina or breast and that Resident A never performed fellatio on him.? A review of Staff 2 employee?s file indicated that he was hired by the facility on September 26, 2002; however, the employee file did not contain documented evidence that the facility performed a criminal background check prior to hire. Further review of the employee file contained documentation that Staff 2 was suspended on July 28, 2011, by the director of nursing pending an investigation of the alleged sexual abuse. However, on July 30, 2011, Staff 2 was terminated from his employment at the facility due to his failure to cooperate with the investigation of abuse and because he violated his suspension by appearing at the facility after strict instructions not to come on the facility premises.A review of the facility?s policy and procedure on abuse dated May 2, 2011, indicated that sexual abuse includes oral copulation, penetration of a genital or anal opening by a foreign object. Patients shall not be subjected to abuse by anyone, including, but not limited to, facility staff, other patients, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends of other individuals. Staff should report abuse or allegations of abuse without fear of reprisal. Any incidences or occurrences that may constitute abuse shall be recorded on the incident Form and to be reported to the director of Nursing, Facility Administrator, Facility Abuse Coordinator (if different from the facility Administrator) immediately after/or no later than 24 hours after the identification of the unusual occurrence or events constituting abuse or probable abuse. And prior to hiring any employee, the facility shall ensure provisions covering employment screenings for potential history of abuse, neglect or mistreatment of resident?s. The facility failed to ensure that: 1. Resident A was not subjected to sexual abuse by Staff 2. Staff 2 massaged and fondled Resident A?s breast and penetrated her vaginal area with his fingers. Additionally, Resident A, who was a quadriplegic with cognitive deficit and totally dependent on staff, was observed performing oral sex Staff 2?s penis in her mouth, sucking on it.2. A criminal background check was conducted on Staff 2 prior to hire in accordance with the facility?s policy and procedure 3. Staff 1 who was aware of the facility?s abuse reporting policy, immediately reported to the director of nurses and the administrator the sexual abuse that she witnessed by Staff 2 towards Resident A. Staff 1 waited four days to report the sexual abuse thereby, creating a potential for further sexual abuse by Staff 2. These violations had a direct relationship to the health, safety, and security of Resident A. |
| 950000081 |
PARK AVENUE HEALTHCARE & WELLNESS CENTER |
950009584 |
B |
06-Nov-12 |
QZGM11 |
6066 |
F241-DignityThe facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. On October 7, 2009, the Department received a report that Resident A made an allegation that Staff 1 referred to Resident A as ?crippled? and that Staff 1 and Staff 2 spoke Spanish in front of Resident A on October 3, 2009. On October 8, 2009, at 12:30 p.m., an unannounced visit was made to the facility to investigate the complaint.Based on interview and record review, the facility failed to ensure that a resident was treated with dignity and respect by failing to: 1. Ensure that Staff 1 did not call Resident A demeaning names associated with the Resident?s physical limitations such as crippled and bedridden, during a conversation while care was being provided to Resident A.2. Ensure that Staff 1 and Staff 2 communicated with Resident A in a manner that promoted and enhanced the resident?s dignity according to the facility?s policy titled ?Resident Accommodation of Needs,? when Staff 1 and Staff 2 communicated in Spanish between themselves (a language that was not spoken or understood by Resident A) while providing care to Resident A.As a result, Resident A stated that he was shocked and felt humiliated when Staff 1 and Staff 2 spoke Spanish while care was being provided to him, and when Staff 1 stated in a conversation that she did not have her legs cut off and that she was neither crippled nor bedridden as he (referring to Resident A ).The review of the ?History and Physical? dated February 7, 2009, indicated that Resident A had the capacity to understand and make decisions. The admission information indicated that Resident A was readmitted to the skilled nursing facility (SNF) on September 3, 2009, with diagnoses that included end stage renal (kidney) disease, anemia (low iron), and amputation below both the knees (both lower legs missing). The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated September 14, 2009, indicated that the resident had no memory problems, was independent with cognitive (mental) skills for daily decision-making, made self-understood, was able to understand others, spoke and communicated (in English) clearly, and needed extensive assistance for all activities of daily living. A review of the licensed nurse?s notes dated October 3, 2009, at 10 p.m. indicated that Resident A came to the charge nurse and stated ??CNA, she told me that she was glad that she could walk around unlike me, because I don?t have legs and she is glad, she is not bed bound (bedridden) like me? A review of the social worker progress notes dated October 5, 2009, (unspecified time) indicated that Resident A reported to the social worker that on October 3, 2009, at 7 p.m., the CNA made a comment to him that she did not have both her legs cut off like him (Resident) and that she was neither a cripple nor bedridden. The resident stated he was shocked and humiliated.On October 8, 2009 at 3:05 p.m., during an interview with Staff 1, she stated that on October 3, 2009, at about 7:05 p.m., Resident A came to the laundry room. Staff 1 stated she never said anything regarding being crippled or not having any legs. Staff however, admitted that she (Staff 1) and Staff 2 were having a conversation in Spanish when the resident came to the laundry room. When Resident A asked if his clothing was cleaned, Staff 2 informed the resident (in English) that his clothing had not been cleaned. Then; Staff 1 and Staff 2 resumed their conversation in Spanish, in the presence of Resident A. Resident A later left the laundry room while Staff 1 and Staff 2 continued their conversation.During an interview on October 8, 2009, at 3:55 p.m., Resident A stated that on October 3, 2009, (at an unspecified time) he went to the laundry room and during a conversation, Staff 1 stated, ?Well at least I don?t have my legs cut off?. Staff 1 also stated that she was neither crippled nor bed-ridden and spoke the Spanish language which he did not speak or understand. Resident A stated that he reported this to the director of nurses (DON) on October 4, 2009. Resident A stated that Staff 1 should have been fired for making that statement.A review of the facility's undated policy Titled ?Resident Accommodation of Needs? indicated that the "Facility staff interacts with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains each resident?s dignity.? A review of Staff 1?s employee file indicated that Staff 1 was hired by the facility on May 27, 2009. Further review revealed that on March 14, 2011, Staff 1 was involuntarily discharged from employment due to failure to meet performance standards (unspecified).The facility failed to ensure that the resident was treated with dignity and respect by failing to: 1. Ensure that Staff 1 did not call Resident A demeaning names associated with the resident?s physical limitations, such as crippled and bedridden, during a conversation while care was being provided to Resident A.2. Ensure that Staff 1 and Staff 2 communicated with Resident A in a manner that promoted and enhanced the resident?s dignity according to the facility?s policy titled ?Resident Accommodation of Needs,? when Staff 1 and Staff 2 communicated in Spanish between themselves (a language that was not spoken or understood by Resident A) while providing care to Resident A.As a result, Resident A stated that he was shocked and felt humiliated when Staff 1 and Staff 2 spoke Spanish while care was being provided to him and, when Staff 1 stated in a conversation that she did not have her legs cut off and that she was neither crippled nor bedridden as he (referring to Resident A ).These violations had a direct relationship to the health, safety and security of residents in the facility, and particularly to Resident A. |
| 950000081 |
PARK AVENUE HEALTHCARE & WELLNESS CENTER |
950009804 |
A |
19-Apr-13 |
M2VJ11 |
15028 |
F157 483.10(b) (11)-Notification of changes. A facility must immediately inform the resident; consult with the resident?s physicians; and if known, notify the resident?s legal representative or an interested family member when there is:1. A significant change in the resident?s physical, mental, or psychosocial status (i.e. deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.F281 483.20(k)(3)(i):- The services provided or arranged by the facility must- (i) Meet professional standards of quality. On March 29, 2011, at 1:10 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident neglect.Based on record review and interview the facility staff failed to: 1. Identify and recognize that Resident 1?s slurred speech was one of the warning signs of an impending stroke that constituted a medical emergency and to immediately call 911, as indicated in the facility?s policy and procedure and the National Stroke Association (2012). Instead, Resident 1?s family member arrived at the facility and consequently identified the emergent nature of Resident 1?s condition and called 911 services herself. The failure of the facility to act timely resulted in a delay and timely treatment which could have minimized damage to the brain and improved the resident?s outcome.2. Immediately notify the attending physician of any abnormalities exhibited by Resident 1, (slurred speech) as indicated in the CVA (cerebrovascular accident-Stroke) plan of care which identified Resident 1 as being at risk of having a repeat CVA.Resident 1?s closed clinical record indicated that she was a 62 year old female who was admitted to the facility on July 23, 2010, with diagnoses that included hypertension (high blood pressure), intermediate coronary syndrome (chest pain of variable character, severity, duration, radiation, timing and causation from one attack to another or even during attacks), and hemiplegia (paralysis affecting only one side of the body). The care plan dated July 23, 2010, indicated that Resident 1 was at risk for a repeat cerebrovascular accident (CVA- stroke or sudden death of brain cells due to a lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain) due to a history of CVA and hypertension. The care plan goal indicated that the resident would have no repeat CVA daily for 90 days. The listed nursing interventions included to administer medications as ordered, monitor vital signs, and to notify the resident?s physician of any abnormalities.The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated February 1, 2011, indicated that the Resident had clear speech, was able to complete the brief interview for mental status, make herself understood, and understood others. The MDS further indicated that the Resident required limited assistance with bed mobility, transfer, locomotion on and off the unit, toilet use, and personal hygiene, and required extensive assistance with dressing and bathing.A review of the licensed personnel weekly progress notes from February 1, 2011, through March 9, 2011, indicated that the resident was verbally responsive, and able to verbalize her needs. There was no indication in the licensed nurse notes that the resident had slurred speech or difficulty speaking. Additionally, the licensed nurse notes in the Weekly Summary dated March 7, 2011, indicated the resident was alert, oriented, and able to make her needs known and had no change in communication.On March 14, 2011, at 7:50 a.m., the licensed personnel progress note indicated that Resident 1 had slightly slurred speech (a sign of an impending stroke) prior to breakfast, but was alert and oriented, able to follow commands, had stable vital signs and would be monitored. However, the licensed nurse?s notes did not contain any documentation to indicate that 9-1-1 was called and that the physician was notified of Resident 1?s sudden change in speech condition. One hour and twenty-five minutes later, at 9:15 a.m., the licensed nurse documented in the progress note, that the Resident was observed with worsening slurred speech and that the physician was then paged and was waiting for the physician to call back. However, the note did not indicate if 9-1-1 was called.At 9:35 a.m., (after an additional twenty minutes), the licensed nurse documented in the progress notes that the physician was notified of the resident's slurred speech and ordered to send the resident to an acute care hospital for further evaluation. However, a review of the medical record did not contain the time the telephone order was received on March 14, 2011, to send the resident to the acute hospital emergency room for further evaluation. The proposed order did not contain a signature of the nurse receiving the order, the time of the order, or a physician?s signature.The licensed personnel progress note dated March 14, 2011, at 9:45 a.m., also indicated that a family member came to the facility to see Resident 1 because she was concerned about the resident's condition and called the emergency medical services (9-1-1) herself. The note further indicated that while the licensed staff was giving report to the transport staff (non-emergency medical transport service staffed by two emergency medical technicians trained in basic emergency medical care), 9-1-1 paramedics (emergency medical transport service staffed by two paramedics qualified to render advance life support to residents, under the directions of a hospital base station) came, picked up the resident, and transported the resident to the hospital.The emergency medical services report dated March 14, 2011, at 9:54 a.m., revealed that the resident was found sitting in a wheelchair with slurred speech and a right facial droop. The resident, however, was alert and oriented with normal and clear respirations.A review of the acute hospital emergency department physician's report dated March 14, 2011, dictated at 1:49 p.m., indicated upon physical examination, the resident was noted with a right facial droop and slightly slurred speech. The resident?s diagnoses included a possible acute stroke, a prior history of stroke, and controlled hypertension.A review of the resident?s Magnetic Resonance Imaging (MRI) of the brain results dated March 14, 2011, revealed that the resident suffered a small bilateral occipital lobe acute cortical infarct (tissue death on the visual processing center of the brain due to a local lack of oxygen) and mild bilateral medial temporal lobe acute periventricular infarct (tissue death on the sensory center of hearing, language perception, emotion, and memory of the brain due to a local lack of oxygen). The report indicated the resident also had a left midbrain and anterior right pons acute ischemia (insufficient supply of blood). According to the Acute Hospital Discharge Summary dated March 31, 2011, Resident 1 remained in the acute hospital for 17 days and her final diagnoses included an acute cerebrovascular accident with left-sided hemiplegia, dysphagia, status post gastrostomy tube placement, hypertension, and hyperlipidemia. Resident 1 did not return to the facility per the family?s request and was transferred to another facility. During an interview with Family Member 1 on March 29, 2011, at 8:25 a.m., she stated that she called Resident 1 on March 14, 2011, on the telephone and she was talking with slurred speech and she knew something was wrong. She then told the facility to transfer Resident 1 to the acute hospital emergency room because something was wrong with her mom. She spoke to Employee 1 and she had a ?Whatever attitude about it?. When she arrived to the facility her mom, Resident 1, was sitting in the hallway and her face was to the side and she could tell she had suffered a stroke. The family member stated that Resident B informed her that Resident 1 (her mom) was screaming the night before because she couldn?t talk. Family Member 1 also stated that she found her mom coughing and having trouble breathing and told the facility staff to transfer her to the hospital. They told her that they had to wait for doctors? orders so she called 9-1-1- herself. 9-1-1 came and took her mom to the hospital. At the hospital Family Member 1 was told that her mom had suffered a stroke and that she was in a coma. During an interview with Resident 2, on March 29, 2011, at 1:10 p.m., she stated that on March 13, 2011, at approximately 8 or 9 p.m., she noticed that Resident 1 who usually talks with her couldn?t talk anymore and was crying. She asked her what was wrong and Resident 1 mumbled and cried and she (Resident 2) could not understand what she (Resident 1) was saying. Resident 1?s speech was not normal. She then pressed Resident 1?s call light button for help, but she did not remember if anyone came to the room or not. Resident 1 stopped crying and fell asleep. The next day on March 14, 2011, Resident 2 stated that she did not hear Resident 1 talk but remembered that Employee 2 came in the room and asked Resident 1 if she wanted to go out of the room. Resident 1 said yes, and they took her out into the hallway.During an interview with Employee 2 on March 30, 2011, at 7:10 a.m., she stated that Resident 1 was permanently assigned to her, and when she went to check on her on March 13, 2011, she noticed that Resident 1?s voice sounded different than usual, and her speech was slower. When she helped her to the bathroom, Resident 1 told her that she did not feel good and that she was dizzy. Employee 2 then reported this to Employee 1 and she took Resident 1?s vital signs. Her blood pressure was 185/117. The blood pressure was retaken by Employee 4. Employee 2 further stated that at the start of her shift (7 a.m. to 3 p.m.) on March 14, 2011, Resident 1?s speech was slower than usual and was hard to understand and she reported this to Employee 1. Employee 1 then instructed her (Employee 2) to get the resident up and take her to get some fresh air. Both Employee 1 and Employee 2 transferred the resident to the wheelchair and took her to the activity room after breakfast. During an interview with Employee 1 on March 30, 2011, at 7:40 a.m., she stated she noted the Resident with slurred speech on March 14, 2011, at around 7:40 a.m. Employee 1 stated the resident kept on telling her that she was doing "okay" and that she did not want to go to the hospital. Employee 1 further stated she then reported the resident's change of condition to the registered nurse (RN) supervisor.On March 30, 2011, at 8:05 a.m., during an interview with Employee 3, she stated that when Employee 2 reported to her that Resident 1 had slurred speech she assessed the Resident around 8 a.m., and the Resident's speech was understandable and was not slurred and the resident was awake, alert, and oriented. The resident told her she was doing "okay" and refused to go to the hospital. However, a review of the medical record did not contain documented evidence regarding the resident?s refusal or that the daughter or physician were informed that the resident refused to go to the hospital. Employee 3 also stated that when the Paramedics came, the resident was still in the wheelchair, awake, alert and oriented and was in no acute distress when the ambulance took her. However, a review of the paramedic emergency medical services report dated March 14, 2012, at 9:54 a.m., indicated that the resident was found sitting in a wheelchair with slurred speech and a right facial droop, and the resident, was alert and oriented with normal and clear respirations. The facility's undated policy and procedure titled "Change of Condition Management Guideline" indicated the licensed nurse will conduct an assessment of resident's health status in determining if the change of condition is life threatening or not. If the change of condition is life threatening, the licensed nurse will start necessary treatment as indicated by the Resident's condition and notify the primary physician, call 911 as indicated, family, responsible party, and administrator/director of nursing as appropriate. The policy indicated change of condition may be subtle and slow to develop, severe and develop quickly, and may be physical, mental, or psychosocial in nature (i.e. slurred speech).According to the National Stroke Association (2012), warning signs and symptoms of stroke include sudden numbness or weakness of face, arm or leg - especially on one side of the body, confusion, trouble speaking (slurred speech) or understanding, trouble seeing in one or both eyes, trouble walking, dizziness, loss of balance or coordination, and severe headache with no known cause. If any of these symptoms suddenly appear, call 9-1-1 immediately and seek emergency medical attention because early and timely treatment minimizes damage to the brain and improves resident outcome. The NSA also indicates that recurrent strokes often have a higher rate of death and disability because parts of the brain already injured by the original stroke may not be as resilient. According to Canadian best practice recommendations, "people who suddenly experience the warning signs of stroke should treat those signs as a medical emergency and immediately call 911. They should not wait to see a family doctor, they should not 'sleep it off' and they should not drive themselves to the hospital." The article also noted that there are several possible reasons why residents with stroke do not call an ambulance; the study found that many residents and people around them may not recognize the symptoms of stroke or understand the importance of timely treatment. "So the message we have to get out is a) recognize the symptoms and b) don't take that chance. Because it could be the difference between walking out of the hospital of your own accord in a week or two versus ending up in permanent long-term care," said Patrice Lindsay of the Canadian Stroke Network, who is a stroke survivor. (Retrieved from http://www.cbc.ca/news/health/story/2012/07/12/stroke-ambulance.html) Recognizing that a stroke may be taking place is the first step in caring for the Resident. (Retrieved from http://www.nursingceu.com/courses/325/index_nceu.html Therefore, the facility staff's failure to immediately identify that there was a medical emergency, promptly call 9-1-1 and notify the attending physician and the family member of a sudden and marked change in the resident?s medical condition (slurred speech) which was indicative of an impending recurrent stroke resulted in a delay in services and timely treatment that could have minimized damage to the brain and improve resident outcomes. The above violation presented a substantial probability that death or serious physical harm would result. |
| 970000075 |
Pasadena Meadows Nursing Center |
950010488 |
B |
20-Feb-14 |
QOR211 |
5812 |
Health & Safety Code Section 1418.21. (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements:(1) The information shall be posted in at least the following locations in the facility:(A) An area accessible and visible to members of the public.(B) An area used for employee breaks.(C) An area used by residents for communal functions, such as dining, resident council meetings, or activities.(2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order:(A) The full name of the facility, in a clear and easily readable font of at least 28 point.(B) The full address of the facility in a clear and easily readable font of at least 20 point.(C) The most recent overall star rating given by CMS to that facility, except that a facility shall have seven business days from the date when it receives a different rating from CMS to include the updated rating in the posting. The star rating shall be aligned in the center of the page. The star rating shall be expressed as the number that reflects the number of stars given to the facility by CMS. The number shall be in a clear and easily readable font of at least two inches print.(D) Directly below the star symbols shall be the following text in a clear and easily readable font of at least 28 point: "The above number is out of 5 stars."(E) Directly below the text described in subparagraph (D) shall be the following text in a clear and easily readable font of at least 14 point: "This facility is reviewed annually and has been licensed by the State of California and certified by the federal Centers for Medicare and Medicaid Services (CMS). CMS rates facilities that are certified to accept Medicare or Medicaid. CMS gave the above rating to this facility. A detailed explanation of this rating is maintained at this facility and will be made available upon request. This information can also be accessed online at the Nursing Home Compare Internet Web site at http://www.medicare.gov/NHcompare. Like any information, the Five-Star Quality Rating System has strengths and limits. The criteria upon which the rating is determined may not represent all of the aspects of care that may be important to you. You are encouraged to discuss the rating with facility staff. The Five-Star Quality Rating System was created to help consumers, their families, and caregivers compare nursing homes more easily and help identify areas about which you may want to ask questions. Nursing home ratings are assigned based on ratings given to health inspections, staffing, and quality measures. Some areas are assigned a greater weight than other areas. These ratings are combined to calculate the overall rating posted here."(F) Directly below the text described in subparagraph (E), the following text shall appear in a clear and easily readable font of at least 14 point:"State licensing information on skilled nursing facilities is available on the State Department of Public Health's Internet Web site at: www.cdph.ca.gov, under Programs, Licensing and Certification, Health Facilities Consumer Information System."(3) For the purposes of this section, "a detailed explanation of this rating" shall include, but shall not be limited to, a printout of the information explaining the Five-Star Quality Rating System that is available on the CMS Nursing Home Compare Internet Web site. This information shall be maintained at the facility and shall be made available upon request.(4) The requirements of this section shall be in addition to any other posting or inspection report availability requirements.(b) Violation of this section shall constitute a class B violation, as defined in subdivision (e) of Section 1424 and, notwithstanding Section 1290, shall not constitute a crime. Fines from a violation of this section shall be deposited into the State Health Facilities Citation Penalties Account, created pursuant to Section 1417.2.(c) This section shall be operative on January 1, 2011. Based on observation, and interview, the facility failed to comply with a California Health & Safety Code requirement by failing to: Post the most current overall facility rating information determined by the Centers for Medicare and Medicaid Services (CMS). During an initial tour of the facility on September 24, 2013, at 7:00 a.m., the evaluator observed that the facility?s most current overall facility rating information determined by the Centers for Medicare and Medicaid Services (CMS) was not posted either at the consumer board by the nursing station or at the front lobby entrance where the department head names were posted. During an interview with the administrator on September 30, 2013, at 2:30 p.m., he stated it was an oversight that the information was not posted. The failure of the facility to post their federal rating deprived the consumers of the available information to assist in making an informed choice or decision whether to admit a resident to the facility. The facility failed to comply with a California Health & Safety Code requirement by failing to: Post the most current overall facility rating information determined by the Centers for Medicare and Medicaid Services (CMS). Failure of the facility to post the facility?s rating information (Five-Star Quality Rating) determined by the Centers for Medicare and Medicaid Services (CMS) in the required areas for review by the residents, staff, and the public, constitutes a class B violation, as defined in subdivision (e) of Section 1424. |
| 970000188 |
Pasadena Care Center, LLC |
950011688 |
A |
01-Sep-15 |
EIIZ11 |
9788 |
Code of Federal Regulations section 483.13(b) F223 The patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.During an unannounced visit to the facility on July 13, 2011, in response to an entity reported incident, the evaluator spoke with the director of nurses who stated Employees A, B, and C, were on suspension till further notice for the alleged application of a physical restraint on Patient 1 on July 9, 2011. The facility failed to ensure that Patient 1 and Patient 3 were free from verbal and physical abuse by failing to: 1. Ensure Employee C did not physically tie Patient 1 to her wheelchair, with a twisted sheet and a soft belt, which she brought from home, and call her derogatory names such as ?bitch? and a ?hooker? from the street.? 2. Ensure Employee A and B, who had oversight of the unit, did not laugh in agreement, as Employee C tied Patient 1 to a wheelchair with a twisted sheet and a soft belt which Employee C had brought from home.3. Ensure Employee A, did not mistreat, taunt and verbally abuse Patient 3 by telling him he didn?t know anything and to mind his own business? and by saying ?He was just a resident because no one would believe a resident over nurse.? 4. Ensure Employee B did not purposefully taunt, verbally abuse and wake Patient 3, by making a loud noise, then calling him a ?Prick? and laughing at him. Because of his intent to report their abuse of Patient 1. A review of her medical record indicated Patient 1 was a 61 year-old female admitted to the facility on June 21, 2011, with admitting diagnoses including dementia with psychosis, a form of mental illness, agitation, and insomnia. An attempt to interview Patient 1 on July 13, 2011, at 1:00 p.m., revealed she could not recall anything that happened regarding an allegation of verbal abuse and an application of a physical restraint. The patient was observed ambulatory and did not appear combative at the time. No physical bruising of any kind was observed. During an interview with Employee D on November 15, 2011, at 3:43 p.m., she stated she saw Employee C put a restraint on Patient 1 while in her wheelchair and call her ?a bitch? and ?a hooker from the street?. She further stated she saw the restraint on her from 1 am till 5 am (4 hours), while Patient 1 was in front of the nurses? station. The evaluator then asked Employee D why she did not immediately report the allegation of abuse to her administrator or director of nurses. Employee D replied she was going to report the incident then she decided to let Resident 3 report the incident since she heard him state he would tell the administrator on Monday, so she decided to stay out of it. When asked if she felt intimidated by Employee C she said, ?No?. During an interview with Employee B, on November 10, 2011, at 2:55 p.m., she stated Patient 1 was wandering around and went to another patient?s room. Then she said Employee A told her to put a lap buddy on Patient 1, and at 1 a.m. she gave her a hypnotic.Patient 1?s licensed nurses progress notes, contained an entry dated July 9, 2011, on the night shift (11pm to 7am) indicating that the resident got out of bed, and was ambulating thru the hallways and another patient, Patient 2 complained of Patient 1 wandering into her room trying to steal her belongings and choke her. The entry concludes with Patient 1 being given 2 milligrams of Lorazepam. (an antianxiety drug used for the management of anxiety disorders). However during an interview with Patient 2 on November 9, 2011 at 1:30 p.m., she stated no one has ever entered her room trying to steal her belongings and choke her. Patient 2 was admitted to the facility on 6/9/11, with diagnoses that included degenerative disk disease of the spine, joint derangement, muscle weakness, urinary retention, and bilateral lower extremity weakness, s/p fall back injury and peptic ulcer disease. The most recent comprehensive assessment of Patient 2 indicated she passed the brief interview for mental status and had no cognitive impairment.A second entry in the medical record of Patient 1 in the licensed nurses? notes dated July 9, 2011, at 1 a.m. indicated Patient 1 punched her certified nursing assistant in the chest and was still wandering around though being monitored by a nursing staff.During an interview with Patient 3 on October 3, 2011, at 1:30 p.m., he stated that on July 9, 2011, around 2 am, he heard someone crying and saw Patient 1 tied up with a twisted sheet to her wheelchair and left alone in the hallway. Patient 3 then asked Employee B why Patient 1 was tied up. Employee B told him he did not know anything and to mind his own business. Patient 3 then approached the administrator on Monday (July 11, 2011), to report the incident to her.Patient 3 was admitted to the facility on 6/4/09, with diagnoses that included COPD exacerbation, osteoarthritis, psychosis, and depression. The nursing assessment and evaluation form dated 11/30/10 indicated Patient 3 had clear speech, understands verbal communication and is aware of time and place. The History and physical examination indicated Patient 3 has the capacity to understand and make decisions.A review of the facility?s internal investigation, indicated on 7/9/11, Patient 3 reported that he was awakened at approximately 1:30 a.m. by loud sobbing. He then got out of bed to investigate where it was coming from. He found Patient 1 in front of the west station, bound to a wheelchair. She was restrained around her chest and arms, her waist and her legs. Patient 1 was bound with restraints and a twisted sheet. Patient 3 questioned the nurses at the station as to why Patient 1 was bound? Employee B responded to ?mind his own business, and go back to bed.? She then went to Patient 1 and began to take off the restraints with the help of Employee C. Patient 3 stated he was going to report the incident to the administrator on Monday. The report further indicated Employee A was also at the station and stated to Employee B, she would show her ?How to fix it,? and not to worry about Patient 3 because he is just a resident, and that they wouldn?t believe a resident over a nurse.?The internal investigation further noted Employee D saw Employee C sit Patient 1 down close to the west station and restrain her with restraints she had in her own bag from home. While Employee C she was tying Patient 1 to the chair, she was calling her a ?bitch?, and a ?hooker? from the streets. Employee C tied her arms and torso to the chair and tied her around her waist. She was tied around both of her lower legs to the wheelchair. Employee C not only used the restraints she had in her bag, but used a twisted sheet to bind her to the wheelchair. Both Employee A and Employee B were present at the station and aware of Employee C restraining Patient 1, their only response was to laugh. The report further indicated a body check did result in locating a small discoloration on an arm. (The report did not disclose which arm). The report also indicated Employee D felt intimidated by her co-workers at the time and feared retaliation from her charge nurse and co-workers.The investigation report, indicated Employees A, B, and C, were suspended immediately on July 11, 2011. Employee B was then terminated on July 20, 2011. Attempts by the Evaluator to contact Employees A and C, resulted in phone messages left on November 9, 2011 that were never returned. During an interview with the administrator on November 9, 2011, at 3:00 p.m., she stated that Employees A, B, and C, were all terminated on July 20, 2011. A review of the facility?s undated policy and procedure titled ?Policy on Adult/Elder Abuse? indicates it is the facility?s policy that the residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion from anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, visitors or other individuals. The facility prohibits mistreatment, neglect, and abuse of residents and misappropriation of property. A review of the facility?s undated policy and procedure titled ?For Restraints Within?, indicated restraints that are administered within the facility will have clear orders from the physician. The facility failed to ensure that Patient 1 was free from verbal and physical abuse by failing to : 1 Ensure Employee C did not physically tie Patient 1 to her wheelchair with a twisted sheet and a soft belt which she brought from home, and call her derogatory names such as ?bitch? and a ?hooker? from the street.? 2 Ensure Employee A and B, who had oversight of the unit, did not laugh in agreement, as Employee C tied Patient 1 to a wheelchair with a twisted sheet and a soft belt Employee C had brought from home.3 Ensure Employee A, did not mistreat, taunt and verbally abuse Patient 3 by telling him he didn?t know anything and to mind his own business? and by saying ?He was just a resident because no one would believe a resident over nurse.? 4 Ensure Employee B did not purposefully taunt, verbally abuse and wake Patient 3, by making a loud noise, then calling him a ?Prick? and laughing at him. Because of his intent to report their abuse of Patient 1. The facility?s failure to ensure Employees A, B, and C did not conspire together in agreement to verbally and physically abuse Patient 1 and Patient 3, and to cover up their abuse, presented a substantial probability that death or serious physical harm would result. |
| 970000188 |
Pasadena Care Center, LLC |
950011747 |
B |
25-Sep-15 |
EIIZ11 |
1794 |
Code of Federal Regulations section 483.13(c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Based on interview, and record review, the facility failed to implement their abuse policy to ensure that Employee D immediately reported an allegation of abuse, of Resident 1 that she witnessed, to the facility administrator. Findings: During an interview with Employee D on November 15, 2011, at 3:43 p.m., she stated that on July 9, 2011, around 1 am, she saw Employee C put a restraint on Resident 1, while she was sitting in her wheelchair and overheard her call Resident 1 ?a bitch? and ?a hooker? from the street.? She further stated she saw the restraint (twisted sheet and soft belt) on Resident 1, all night, from 1 a.m. till 5 a. m., during which time she stayed in front of the nurses? station. The evaluator then asked Employee D why she did not immediately report the allegation of abuse to her administrator or director of nurses. Employee D replied she was going to report the incident, then she decided to let Resident 3 report the incident, since she heard him state he would tell the administrator on Monday, therefore, she decided to stay out of it. When asked if she felt intimidated by Employee C she said no. A review of the facility policy and procedure for abuse reporting indicates any allegation of abuse to a resident must be immediately reported to the administrator or the director of nurses.The facility?s failure to ensure that Employee D immediately reported an allegation of abuse of Resident 1 that she witnessed to the facility administrator had an immediate relationship to the health, safety, or security of patient?s. |
| 950000081 |
PARK AVENUE HEALTHCARE & WELLNESS CENTER |
950012144 |
B |
23-Mar-16 |
0WEZ11 |
4051 |
Based on observation, interview, and record review, the facility staff failed to assist and dress Patient 1 appropriately before taking him to the patio. This resulted in the violation of the patient's right to be treated with dignity and respect.Findings: On October 26, 2011, at 7:10 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding Employee to Resident Abuse involving Patient 1. A review of the Face Sheet of Patient 1 indicated the patient was admitted to the facility on March 5, 2004, with diagnoses that included mental disorder and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated July 22, 2011, indicated the patient was able to complete the brief mental status interview, sometimes understood others and sometimes made self understood, and required extensive assistance with most activities of daily living (ADL). The MDS further indicated the patient was incontinent of bowel and bladder.A review of a care plan dated on October 19, 2011, indicated the resident had ADL self-care deficit due to cognitive loss and aging process and was at risk of developing complications associated with decreased ADL self-performance. The care plan goal indicated the patient would maintain existing self-performance and would not develop any complications for three months. The listed nursing interventions included to provide activities that promote hygiene, grooming, and increased interest in personal appearance, provide clean clothes, and undress and dress the patient appropriately.During an interview on October 26, 2011, at 9 a.m., Certified Nursing Assistant (CNA) 2 stated she saw CNA 1 pushing Patient 1 to the patio with his diaper exposed and pants down to his feet. CNA 2 further stated, she and another CNA (CNA 3) assisted the patient and pulled his pants up. According to CNA 2, she reported this incident to the charge nurse and the director of nursing (DON).During an interview on October 26, 2011, at 9:30 a.m., CNA 3 stated she witnessed CNA 1 put her hands around Patient 1's waist and put pressure to have the patient walk faster to the patio while his pants were down to his feet then walked away without pulling up the patient's pants.On October 26, 2011, at 9:50 a.m., during an interview, the Unit Manager for Station 3 stated CNA 1 had been counseled and disciplined for her performance.During an interview on September 24, 2014, at 8:55 a.m., CNA 1 stated, she was about to clean some feces on the hallway floor when she saw Patient 1 with his pants down to his feet. CNA 1 stated she brought the patient to the patio to get some help from CNA 2, but did not pull his pants up first. According to CNA 1, she did her best and tried to do two things at once. On September 24, 2014, at 1:35 p.m., the DON stated that the incident was embarrassing for the patient and did not promote the patient's dignity.The facility policy and procedure titled "Federal Bill of Residents' Rights" dated February 1, 1996, indicated residents have the right to receive care from the facility in a manner and in an environment that promotes, maintains, or enhances the resident's dignity and respect in full recognition of their individuality.Another facility policy titled "Resident Rights - Quality of Life" dated January 1, 2012, indicated facility staff would treat cognitively impaired residents with dignity and sensitivity. When caring for these residents, facility staff will address the underlying or root causes for behavior, and will not challenge or contradict the resident's beliefs or statements.The facility failed to ensure Patient 1 was treated with consideration, dignity and respect by not pulling up Patient 1's pants up before taking him to the patio. The above violation occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional distress to Patient 1. |
| 950000084 |
PILGRIM PLACE HEALTH SERVICES CENTER |
950012592 |
A |
23-Sep-16 |
86OS11 |
7547 |
F323 483.25(h) FREE OF ACCIDENTS HAZARDS/SUPERVISON/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 3/28/14 at 2:15 p.m., an unannounced visit was conducted to investigate a facility self-reported incident that Resident A had a nasal fracture (a break or crack in the bones of the nose) and a fractured left fifth metacarpal (bone at the base of the little finger between the knuckle and the wrist) due to a fall incident from the wheelchair on 3/20/14. The facility failed to provide adequate supervision and assistance device to prevent falls for Resident A who had three fall incidents by failing to: 1. Implement its policy and procedures to provide supervision to Resident A, who was assessed at high risk for fall. 2. Implement the Plan of care to provide Resident A with a safety alarm when in a wheelchair. 3. Revise the Plan of Care to prevent further falls from the wheelchair. As a result of the fall, Resident A had fractures to her nose and left fifth finger from her third fall from her wheelchair. A review of the Admission Face Sheet indicated Resident A was a 93 year old female who was admitted to the facility on 12/19/13, with diagnoses that included difficulty in walking, epilepsy (seizure) and dementia (decline of mental abilities such as thinking, reasoning and memory). A review of the Initial Fall Risk Assessment (a nursing tool which uses a scoring system to evaluate resident's risk of fall) dated 12/20/13, indicated Resident A scored 11. The Quarterly Fall Risk Assessment dated 2/22/14, indicated the resident's score was 15. The Fall Risk Assessment indicating a total score of 10 or above represented a high risk for fall. A review of the quarterly Minimum Data Set assessment (MDS-a standardized assessment and care planning tool) dated 3/17/14, indicated Resident A had a short term memory recall ability, used a wheelchair for locomotion on and off the unit, required one person physical support due to an unsteady balance without staff assistance while walking and during transfers between bed and chair or wheelchair. On 3/28/14 at 2:30 p.m., Resident A was observed sitting in a wheelchair while in her room. Her forehead, the nose bridge and cheeks had multiple brownish red colored wound scabs (a dry, rough protective crust that forms over a cut or wound during healing). She had a finger splint (prevents the injured finger from bending) on her left fifth finger. A monitoring alarm was on the back left side of her wheelchair. Resident A stated she did not have the monitoring alarm device until after she fell from her wheelchair at the facility's back parking lot. Resident A stated she propelled her wheelchair to the exit door toward the facility's back parking lot. She got up from her wheelchair and attempted to walk on the sidewalk, but she lost her balance and fell face down on the ground. Resident A stated she fell several times from the wheelchair at the facility. On 3/28/14 at 3:58 p.m., Resident A?S medical record was reviewed with the Director of Nursing (DON). The DON stated Resident A had injuries from three separate incidents of fall from the wheelchair. The Licensed Nurses' Notes indicated Resident A sustained a laceration to her right cheek on her first fall on 3/3/14, when she was found lying on the floor on the right side of her bed. The Care Plan for fall dated 3/3/14, indicated Resident A was to be provided a "Safety alarm" in her wheelchair as needed, but an undated, un-initialed "Dc" (discontinue) note was written across it. The DON stated "Safety alarm" is a monitoring device that makes a loud sound when the magnetic pull cord was disconnected from the alarm unit. The DON stated "Safety alarm" prevents falls as it helps alert the staff whenever Resident A gets up from her wheelchair unassisted. There was no documentation when and why the "Safety alarm" was discontinued for Resident A. The DON was unable to provide documented evidence the "Safety alarm" was applied to Resident A's wheelchair to prevent further falls. The licensed Nurses? Notes dated 3/13/14, indicated Resident A had a second fall incident from her wheelchair. She sustained a wound on top of her head after she was found on the floor in her bathroom. The Care Plan for fall, dated 3/13/14, indicated, Resident A's interventions were to apply treatment as ordered and to do a neuro check (assess resident for changes in level of consciousness). The Care Plan interventions were not revised on 3/13/14, to prevent Resident A from further falls and injuries from the wheelchair. The third fall incident from the wheelchair happened on 3/20/14, when Resident A went out to the facility's back parking lot. She was found sitting on the pavement next to her wheelchair with abrasions on her cheeks and forehead, and a laceration on her nose bridge. She was transferred to the acute care hospital on 3/20/14. Resident A was readmitted to the facility on 3/20/14 at 10:15 p.m., with diagnoses of a nasal fracture and fractured left fifth metacarpal (finger bone). During an interview on 3/28/14 at 4:30 p.m., the DON stated the incident report dated 3/13/14, indicated the recommendations to prevent reoccurrence of Resident A falling from the wheelchair included frequent visual check (unspecific) and not to leave Resident A unattended were not transcribed in the plan of care. The DON stated the facility's policy to prevent falls indicated staff to supervise the resident who was assessed at high risk for falls. DON stated staff members were not aware Resident A was to be supervised while up in a wheelchair because the plan of care dated 3/13/14, did not indicate it and/or was not updated. During a phone interview on 3/31/14 at 10:45 a.m., Certified Nursing Assistant (CNA 1) stated the Licensed Vocational Nurse (LVN 1) announced through a walkie talkie that Resident A was not in the north dining room on 3/20/14 at 4:55 p.m., for dinner. CNA 1 stated Resident A was last seen in the activity room on 3/20/14 at 3:50 p.m. CNA 1 did not look for Resident A until she was told by a tenant from the assisted living on 3/20/14 at 5:10 p.m. that Resident A fell at the facility's back parking lot and he called 911. CNA 1 was not informed by staff that Resident A was to be monitored to prevent further injuries and falls when the resident was up in her wheelchair. CNA 1 stated Resident A did not have an alarm applied to her wheelchair before she fell at the facility's back parking lot on 3/20/14. A review of the facility's Policy and Procedures for Fall Prevention dated October 2010, indicated, staff should monitor the residents to reduce the incidents of falling or the consequences of falling. The facility?s failed to: 1. Implement its policy and procedures to provide supervision to Resident A, who was assessed at high risk for fall. 2. Implement the Plan of care to provide Resident A with a safety alarm when in a wheelchair. 3. Revise the Plan of Care to prevent further falls from the wheelchair. These failures resulted in Resident A to sustain fractures to her nose, left fifth finger from her third fall. The above violations presented an imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 950000084 |
PILGRIM PLACE HEALTH SERVICES CENTER |
950013078 |
A |
24-Mar-17 |
YYJZ11 |
9946 |
483.25
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
On 7/18/16 at 12:00 p.m., an unannounced visit was made to the facility to conduct an investigation regarding Resident 1.
Based on interview and record review, the facility failed to provide appropriate care and intervention for Resident 1. The facility did not notify Resident 1's physician of the resident's multiple hypoglycemic (blood glucose less than 70 mg/dl [milligrams/deciliter) attacks promptly and did not implement the facility's "Nursing Care of the Resident with Diabetes Mellitus" policy and procedure. Resident 1 was transferred to an acute hospital due to an altered state of consciousness, difficulty breathing, and low blood sugar.
A review of the Admission face sheet indicated Resident 1 was admitted to the facility on XXXXXXX16 with diagnoses that included: pneumonia (infection that inflames the air sacks in the lungs), difficulty walking, muscle weakness, pressure ulcer (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and or/ friction), Type 2 diabetes mellitus (too much sugar in the blood), end-stage renal disease (kidneys no longer able to work), renal dialysis (artificial process of eliminating waste from the blood), heart failure, chronic obstructive pulmonary disease (a group of lung diseases that block airflow), and heart pacemaker (device placed in the chest to help control abnormal heart rhythm).
A review of the admission care plan dated 06/26/16 indicated that Resident 1 was an alert diabetic. The care plan's goal for Resident 1 indicated: no hypoglycemic complications. The staff was to observe for signs and symptoms that indicated hypoglycemia.
A review of Resident 1's care plan for the risk of blood sugar fluctuations related to Diabetes Mellitus dated 06/26/16 indicated that the goal for Resident 1 was for blood sugar to be within normal limits of 70-110 mg/dl. The interventions for the nursing staff were:
- Monitor for hypoglycemic reactions: headache, sweating, tachycardia (abnormally rapid heart rate), nervousness, and change in level of consciousness to coma.
- Check blood sugar as ordered or as needed.
- Give medications as ordered and note its effectiveness.
The physician's order dated 06/26/16 indicated Resident 1's medications included Glipizide (oral medication which reduces blood sugar levels) 10 milligrams (mg) taken daily for diabetes mellitus.
A review of Resident 1's 6/27/16 Medication Administration Record (MAR) indicated the following:
1. At 6:30 a.m. = the blood sugar was 103 mg/dl.
2. At 11:30 a.m. = the blood sugar was 81 mg/dl.
3. At 4:30 p.m. = the blood sugar was not done due to the resident was still out to a dialysis appointment.
A review of Resident 1?s Dialysis Assessment Sheet dated 06/27/16, completed by the dialysis center, indicated Resident 1 arrived at the dialysis center (time not indicated) with a blood sugar of 49 mg/dl (low). Resident 1 was given dextrose (a form of glucose- time, and route of medication administration were not documented). Resident 1's blood sugar increased to 170 mg/dl. Resident 1 returned to the facility at 8:45 p.m., the blood sugar was checked at this time with the result of 61 mg/dl.
There was no documented evidence the facility staff reviewed the dialysis assessment sheet from the dialysis center identifying Resident 1 was treated for hypoglycemia (low blood sugar).
A review of the licensed nursing progress notes dated 06/27/16 at 9:51 p.m. indicated Resident 1 drank 100% of Ensure (nutritional shake). No blood sugar result documented. Vital signs taken were within normal results.
A review of Resident 1's MAR and licensed nursing notes dated 06/28/16, indicated:
1. At 6:30 a.m. - Blood sugar check - 59 mg/dl (Low). There was no documented evidence the staff administered orange juice for the low blood sugar as ordered by the physician.
2. At 7:00 a.m. - Resident 1 refused breakfast.
3. At 8:15 a.m., 2 ounces of orange juice was given to Resident 1, Resident 1 was awake, alert, and oriented. There was no evidence the blood sugar was checked 15 minutes after the orange juice administration in accordance to the facility's policy and procedure.
4. At 8:30 a.m., Resident 1 complained of shortness of breath stating, "Lord I can't breathe." Oxygen saturation was 94 %. Albuterol (breathing treatment) 2 puffs were administered. There was no documented evidence Resident 1's physician was notified.
5. At 9:00 a.m. = Glipizide 10 mg medication was given by mouth.
According to "drugs.com" dated 10/15/15, Glipizide should be taken 30 minutes before breakfast. Glipizide may cause low blood sugar levels that make you anxious, sweaty, weak, dizzy, or drowsy. The risk of low blood sugar may be increased by skipping meals.
https://www.drugs.com/glipizide.html
Review of the nursing notes dated 06/28/16 indicated:
- At 11:00 a.m., two Certified Nursing Assistant's (CNAs) noticed Resident 1 was restless. The CNAs called for help and vital signs were taken: blood pressure 138/86, heart rate 118, respirations 18, temperature 97.9, and oxygen saturation of 95 % with oxygen administration.
- At 11:10 a.m., Resident 1's blood sugar was 39 mg/dl (low=last blood sugar check was at 6:30 a.m. [59 mg/dl]). Resident 1 was given 1 mg Glucagon (medication used for severe low blood sugar) injection in the muscle. There was no evidence the physician was notified of the resident's low blood sugar.
- At 11:20 a.m., Resident 1's blood sugar was 51 mg/dl (low).
- At 11:25 a.m., RN 1 called 911 paramedics.
- At 11:30 a.m., two blood sugar readings were documented, 59 mg/dl and 65 mg/dl (low).
- At 11:35 a.m., 911 paramedics arrived at the facility.
- At 12:15 p.m., Resident 1's Secondary Contact (SC) was called by the facility and made aware that Resident 1 had a change of condition due to an episode of non-responsiveness (not able to speak, minimal movement, and sluggish).
- At 12:30 p.m., SC arrived at facility and told Resident 1 "Hey you're not looking good." Resident 1 responded, "No not good."
- At 12:50 p.m., Resident 1 was taken to the hospital via 911 paramedics.
A review of the hospital notes dated 06/30/2016 indicated Resident 1 was admitted with low blood sugar of 68 mg/dl, possible sepsis (life threatening complication of infection), severe malnutrition, hypertension (high blood pressure), and elevated troponin (proteins found in heart muscle). Resident 1 was administered various emergency medications to help increase the blood sugar but could not be stabilized, Resident 1 also "had dialysis and continued to be hypoglycemic [low blood sugar]."
A review of the Nursing Care for Resident 1 with Diabetes Mellitus policy and procedure with a revision date of December 2015 indicated the management of hypoglycemia:
1. For asymptomatic (no symptoms) and responsive residents with hypoglycemia (less than 70 mg/dl or less than the physician-ordered parameter):
a) Give the resident an oral form of rapidly absorbed glucose (4 ounces of juice or 5 to 6 ounces of soda).
b) Recheck blood glucose in 15 minutes:
i) If blood sugar is less than 70 mg/dl repeat oral glucose and recheck blood glucose in 15 minutes.
ii) If no improvement, notify physician for further orders.
2. For symptomatic (lethargic, drowsy) but responsive (conscious) residents with hypoglycemia (less than 70 mg/dl or less than the physician-ordered parameter):
a) If unable to swallow:
i) Immediately administer oral glucose paste to the buccal mucosa, intramuscular glucagon, or 50 % dextrose in the vein.
ii) Recheck blood glucose in 15 minutes.
On 07/18/16 at 12:35 p.m., an interview was conducted with Registered Nurse 1 (RN 1). RN 1 stated on 06/28/2016 at 8:30 a.m., the Licensed Vocational Nurse 1 (LVN 1) informed her Resident 1 was having difficulty breathing. On the same date at 11:00 a.m., LVN 1 informed RN 1 that Resident 1 was "not really responsive." RN 1 stated she tried to arouse Resident 1 by speaking to him but Resident 1 was only able to open his eyes, not able to speak, and had minimal movement. RN 1 stated Resident 1 was "lethargic" (drowsy).
On 7/18/16 at 3:56 p.m., an interview was conducted with the Director of Nursing (DON). DON stated that when a resident's blood sugar reaches 59 mg/dl, the doctor should be notified and that nurses should reassess residents who are given orange juice for hypoglycemia; she stated that the nurse should have rechecked the blood sugar for the low blood sugar episode (59 mg/dl) that occurred at 6:30 a.m., on 06/28/16 to make sure Resident 1 was better.
The DON stated that the doctor should have been notified about the notes written by the dialysis center staff that was on the Dialysis Assessment sheet (Resident 1's arrival to the dialysis center with a blood sugar of 49 mg/dl). The DON stated that the staff failed to provide Resident 1 with enough interventions to reverse the hypoglycemic state and that the staff should not have administered Glipizide (on 6/28/16 at 9 a. m., after Resident 1 had not eaten her breakfast) because it lowers the blood sugar.
The facility?s staff failed to intervene and notify the physician in a timely manner when Resident 1was hypoglycemic. As a result, Resident 1 was transferred to an acute hospital due to an altered state of consciousness, difficulty breathing, and low blood sugar.
The above violation presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 950000083 |
PENN MAR THERAPEUTIC CENTER |
950013177 |
B |
3-May-17 |
MTDH11 |
3188 |
?483.12(b) Staff Treatment of Residents (F226)
The facility must ensure that ?
1) The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences.
Based on observation, interview, and record review, the facility failed to protect the facility's residents from possible abuse, neglect, and/or mistreatment by failing to:
Implement their policy and procedure to perform background checks for the facility's employees (EMP) before they got hired. Five of five employee files reviewed (EMP 1, 2, 3, 4, and 5), out of 86, did not have a background check before they were hired.
On 3/16/16 at 6 p.m., an unannounced recertification survey was conducted.
During an interview with the director of staff development (DSD), on 3/16/17 at 4:20 p.m., regarding the facility?s policies and procedures regarding abuse prevention, she stated she does not screen the criminal backgrounds of all the employees that the facility hires. The DSD stated if they are licensed staff such as a registered nurse (RN), licensed vocational nurse (LVN), licensed psychiatric technicians (LPT), or CNA, she will check their license or certificate to see if there is a record on the state licensing boards. For non-licensed staff in housekeeping, maintenance, dietary, and activities department, the DSD stated that she would only check their professional and/or personal reference.
During an interview, on 3/18/17 at 3 p.m., with the DON, she stated she was unaware that all staff should have a background check when they are hired.
During a record review of the employee files for EMP 1 who was hired as a LPT on 10/17/16, there was no background screening done. For EMP 2 who was hired as a CNA on 10/17/16, there was no background screening done. For EMP 3 who was hired as a CNA on 11/7/16, there was no background screening done. For EMP 4 who was hired as a CNA on 11/7/16, there was no background screening done. For EMP 5 who was hired on 11/28/16 as a CNA, there was no background screening done.
A record review of the facility's undated policy and procedure titled, "Background Screening Investigations," indicated the facility conducts employment background screening checks, reference checks on individuals making application for employment with the facility. The staff development director, or designee, will conduct employment background checks, reference checks on persons making application for employment with this facility. Such investigations will be initiated within three days of employment or offer of employment.
The facility failed to:
1. Protect the residents from employees who might have had history of abuse, neglect, and/or mistreatment of residents.
The above violation jointly, separately, or in any combination had a direct or immediate relationship to the health, safety, or security of residents in the facility. |
| 950000083 |
PENN MAR THERAPEUTIC CENTER |
950013179 |
B |
3-May-17 |
MTDH11 |
6094 |
?483.75(m) Disaster and Emergency Preparedness
The facility must ensure that ?
1. All employees are trained in emergency procedures when they begin to work in the facility, periodically review the procedures with existing staff, and carry out unannounced staff drills using those procedures.
Based on interview and record review, the facility failed to train their staff regarding what to do in case of an emergency:
1. The dietary staff was the only ones aware of where the key was located to open the dry food storage area where the emergency food was stored.
2. The facility's staff was unaware where the emergency menu was located in case of an emergency.
3. The facility's staff was unaware of how to get the water out of the hot boiler tanks (a water tank used for storing hot water for space heating or domestic use) and purify it in case of an emergency.
Findings:
On 3/16/16 at 6 p.m., an unannounced recertification survey was conducted.
During an observation of the initial kitchen tour, on 3/16/17 at 7:30 p.m. with registered nurse (RN 1), the door to get into the kitchen and the dry food storage, and the six door fridge inside the kitchen were locked and nobody from the facility?s staff that were on duty knew where the keys were. RN 1 did not know where the keys to the kitchen, dry food storage area and the six door fridge were located.
During an interview, on 3/16/17 at 8:20 p.m., with the Administrator (ADM) she stated she had to get a hold of someone in the dietary department to find out where the keys were located to open the kitchen and the dry food storage area and the six door fridge. The ADM stated she did not know where the keys where located. The ADM stated there was theft in the kitchen that is why they locked up everything at night.
During a concurrent observation with the ADM, on 3/16/17 at 8:20 p.m., the dry food storage room housed the emergency food supply. The food was being stored on metal racks in the back towards the left side of the storage room.
During an interview with the dietary dishwasher (DW), on 3/16/17 at 8:40 p.m., she stated she knew where the keys where located for the dry food storage area and for the six door fridge. She said they kept the keys on top of the stove's hood. The DW stated dietary staffs were the only ones that knew where the keys were located.
During an interview on 3/18/17 at 7:05 p.m., with the dietary supervisor (DS), she stated there was only one copy of the keys for the dry storage area and it was kept on top of the stove's hood inside the kitchen.
During an interview, on 3/18/17 at 7:09 p.m., with the ADM she stated kitchen staffs were the only ones that knew where the key was located for the kitchen and the dry storage area. The ADM stated maybe the key should be accessible to everyone and she will ask her dietary consultant for some guidance. The ADM stated maybe we would notify the charge nurses on the floor to where the kitchen and dry storage room key is located.
A review of the facility's Disaster and Preparedness Plan Tool dated 3/17/17 indicated the emergency food supplies were stored in the dietary storage room area.
During an observation with the ADM in the dry storage room on 3/16/17 at 8:20 p.m., the Food for Disaster Menu was posted on a bulletin board in the dry storage room.
During an interview with the DS on 3/18/17 at 6:50 p.m., she stated she did not think any other staff knew where the disaster menu was located. The DS stated she might be the only one who knew where it was located.
During another interview, on 3/18/17 at 7:10 p.m., with the ADM she was unaware where the emergency menu was located. The ADM stated the food menu for a disaster should be available to all staff.
During initial tour of the facility with a registered nurse (RN 1), on 3/16/17 at 6:35 p.m., RN 1 stated that the emergency water supply was in the facility's staff break room and stored against the wall on the water bottle racks. RN 1 confirmed that there were some bottles that were empty (four of 27 five gallon bottles). RN 1 stated that staff must be drinking from the supply.
During an interview, on 3/17/17 at 8:25 p.m., a certified nursing assistant (CNA 1) stated that the emergency water supply was located in the employee break room and has not had a disaster drill in a while. CNA 1 also stated that staff uses the water from the emergency water supply.
During another interview, on 3/18/17 at 2:45 p.m., CNA 2 stated that the emergency water supply was in the break room and the staff drinks from the same supply.
During an observation and concurrent interview, on 3/18/17 at 6:50 p.m., the dietary supervisor (DS) stated that the facility had two boilers outside by the kitchen. The DS stated she was never trained on how to get the water out of the boiler in an emergency disaster situation. The DS did not know if she would have to purify the water from the boiler tank before drinking. The DS stated she did not see the instructions that were posted on one of the boiler tanks and did not know where the items needed to get the water out of the boiler were located. Next to the boiler with the instructions was a five gallon bucket with a lid. Upon opening the bucket there was tubing inside for syphoning. There was no chemical for treatment of the water for purification for drinking.
During an interview, on 3/18/17 at 8:05 p.m., the maintenance assistant (MA) stated that he did not know how much water was needed to be kept aside for emergency water supplies. The MA stated he was not trained for emergency preparedness with regards to the water supply and that he would drink the water straight from the boiler tank before any purification was completed.
The facility failed to:
1. Protect all residents in case of an emergency by not training and having accessibility to the emergency food supply
The above violation jointly, separately, or in any combination had a direct or immediate relationship to Resident 1?s health, safety, or security. |
| 950000081 |
PARK AVENUE HEALTHCARE & WELLNESS CENTER |
950013193 |
A |
12-May-17 |
2S5H11 |
12666 |
483.21 (b) (3) (i)
(b)Comprehensive Care Plans
(3)The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
?483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices.
On 2/3/2017 at 1:00 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding the death of a resident (Resident 1).
Resident 1 had a change of condition on 1/31/17. Registered Nurse (RN 1) contacted the physician who gave telephone orders to obtain a urine specimen. RN 1 attempted two catheterizations, both failing, but causing severe damage to the urethra and leading to the transfer of Resident 1 to a general acute care hospital (GACH).
Based on observation, interview, and record review, the Department determined that the facility failed to provide Resident 1 with necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with his comprehensive assessment and plan of care to meet the needs of the resident, including but not limited to:
1. Ensure that Resident 1 was catheterized correctly (insertion of a flexible tube into the urinary system to obtain a urine sample) in accordance with the facility's policies and professional standards.
2. Ensure that there was a valid physician's order to catheterize Resident 1 in accordance with the facility?s policy and professional standards.
3. Ensure that Resident 1's physician was notified of the unsuccessful catheterization attempt due to resistance when inserting the catheter in accordance with professional standards.
4. Ensure that there was a valid physician's order to attempt a second catheterization to Resident 1 in accordance with the facility?s policy and professional standards.
These deficient practices resulted in injury to Resident 1's urethra [part of the urinary system that drains the urine from the urinary bladder (part of the urinary system that collects the urine from the kidneys) to outside the body] and bleeding from Resident 1's penis.
Findings:
A review of Resident 1's admission face sheet indicated Resident 1 was admitted to the facility on XXXXXXX15 with diagnoses that included, but not limited to, respiratory failure (inadequate gas exchange by the lungs that causes difficulty breathing), dependence on respirator (requiring a machine for life support because of inability to breathe effectively) and tracheostomy (tube inserted into the windpipe).
A review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment and care planning tool, dated 11/22/16 indicated Resident 1 had severely impaired cognitive skills for decision making, required total dependence with toilet use, bathing, always incontinent (loss of control) of bowel and bladder.
A review of Resident 1's "Change in Condition Assessment" dated 1/31/17 at 8:00 a.m. indicated Resident 1 had a fever of 101.2 degrees Fahrenheit (F), blood pressure of 119/80, and pulse of 98 beats per minute. Resident 1's physician ordered a chest x-ray (photograph to look inside the chest), CBC (complete blood count, a blood test used to evaluate overall health), Chem 7 (group of blood tests that provides information about the body's metabolism) and an UA (urine analysis) with a C&S (culture and sensitivity, a test to determine the type of bacteria that may have caused the infection and indicates what antibiotics would be effective to treat the infection).
On 2/3/17, a review of Resident 1's "Physician Telephone Orders" dated 1/31/17 [no time documented] indicated the following orders:
1. Chest X-ray
2. CBC, Chem 7, UA C&S
3. Sputum C&S
4. May straight cath (catheterize) to obtain urine
The Physician telephone order was not signed by any physician.
During an interview with Licensed Vocational Nurse (LVN) 1 on 2/3/17 at 3:05 p.m., LVN 1 stated that Resident 1 was noted with fever at the end of the shift. LVN 1 also stated that he called the attending physician and the attending physician made the above orders:
During an interview with Registered Nurse (RN) 1 on 2/3/17 at 2:20 p.m., RN 1 stated that he performed the first straight catheterization (a tube is inserted into the urethra to drain urine from the bladder then removed versus an indwelling catheter in which a tube is inserted which has an inflatable balloon attached to it, to prevent the tube from coming out and is left in to drain the urine) to Resident 1 on 1/31/17 around 8-9 a.m. but was unable to collect urine due to resistance when he inserted the catheter half-way into Resident 1's penis. RN 1 stated that he did not inform Resident 1's physician that he encountered resistance and was not able to obtain the urine sample. RN 1 stated that the order did not indicate to catheterize Resident 1 only once. RN 1 stated on his own discretion, he attempted a second catheterization at 11:30 a.m. RN 1 stated that he again encountered resistance during his second catheterization and no urine was obtained. RN 1 stated when he withdrew the catheter some clotted blood came out from the tip of Resident 1's penis. RN 1 stated 10 minutes after his second catheterization attempt Certified Nurse Assistant (CNA) 1 informed him that Resident 1 was bleeding from his penis. RN 1 stated that when he went to check Resident 1, he found Resident 1's bed sheet was soaked with a large amount of blood around Resident 1's buttocks area.
During an interview with CNA 1 on 2/3/17 at 2:55 p.m., CNA 1 stated she cleaned up Resident 1. However, blood continued to flow out from Resident 1's penis.
A review of Resident 1's, "Change in Condition Assessment" dated 1/31/17, 12:00 p.m. indicated Resident 1 had "no urine output at this time, was bleeding from penile area, assessed to have blood coming out of urethra, notified physician and received order to send Resident 1 to General Acute Care Hospital (GACH)."
A review of Resident 1's, "Physician Telephone Orders," dated 1/31/17 indicated to transfer Resident 1 to the GACH for evaluation d/t (due to) urethral bleeding s/p (status post) straight catheterization, fever unspecified.
During an interview with the Director of Nursing (DON) on 2/3/17 at 3:20 p.m., the DON stated that RN 1 should have called Resident 1's physician regarding the outcome of the first catheterization. The DON stated that if the physician order was not clear, RN 1 should have called the physician to clarify if catheterization could be done more than once.
During a concurrent telephone interview and record review with Resident 1's physician on 2/3/17 at 4:00 p.m. in the presence of the DON, Resident 1's telephone order dated 1/31/17 was reviewed with the physician. Resident 1's physician stated:
1. He gave orders for the following: CBC, Chem 7, Chest X-ray, UA C & S and Sputum C & S.
2. He did not give an order to catheterize Resident 1.
3. He was not informed that there was resistance during the first catheterization attempt.
4. He did not order the second catheterization and was not informed that Resident 1 had been catheterized twice.
Resident 1's physician stated that he ordered Resident 1 to be transferred to the GACH when he was informed that Resident 1 was bleeding due to the catheterization.
On 4/14/17 at 4:00 p.m., a second record review of Resident 1's clinical record was conducted with the Assistant Director of Nursing. Resident 1's Physician telephone order dated 1/31/17 was still not signed by Resident 1's physician.
On 4/19/17, at 3:00 p.m. an in-person interview was conducted with Resident 1's physician. Resident 1's physician again stated that he did not give an order to catheterize Resident 1. Resident 1's physician provided a signed declaration that he did not order Resident 1 to be catheterized.
A review of Resident 1's GACH, "Emergency Department Report," dated 1/31/17 indicated Resident 1 had hypotension (abnormally low blood pressure (BP)), Resident 1 was brought in with persistent urethral bleeding after straight cath (catheterized) today. Resident 1's vital signs were: Temperature 98.2 degrees F, BP of 79/41 (prior BP 119/80) and pulse of 115 (prior pulse 98), was actively bleeding from tip of penis.
Review of GACH notes titled, "Death Summary," dated 2/3/17 indicated Resident 1 expired in the early morning of 2/1/17 with final diagnoses that included, but not limited to urinary tract infection (an infection in any part of the urinary tract characterized by pain with urination, frequent urination, and feeling the need to urinate despite having an empty bladder), septic shock (condition that occurs when infection leads to dangerously low blood pressure), hematuria (presence of blood in urine) and anemia (lowered ability of the blood to carry oxygen characterized by feeling tired, weak or short of breath).
A review of Resident 1's "Certificate of Death" dated 2/1/17 signed by Resident 1's attending physician indicated that Resident 1's immediate cause of death was cardiopulmonary arrest (absence of heart and lung function) and underlying cause was atherosclerotic heart disease (blockage of the blood vessels of the heart).
A review of the facility's policy and procedure titled "Catheter Insertion" dated 1/1/12 indicated that under Purpose, catheterization is ?[t]o relieve bladder distention, to obtain a urine specimen for diagnosis testing? and under Policy, ?Catheterization is provided under the direction of a physician?s order, utilizing sterile technique. Indwelling catheters will be used only when medically indicated.?
A review of the facility?s policy and procedure titled ?Indwelling Catheter? dated 11/1/14 indicated under Policy, ?Catheterization is provided under the direction of a physician?s order, utilizing sterile technique. Indwelling catheters will be used only when medically indicated.? Under Procedure, I. Insertion:
A. ?Obtain a physician order for catheter insertion which will include documentation of medical necessity for indicated use, and the size of the catheter and balloon.
B. The attending Physician?s decision to use an indwelling catheter will be based on valid clinical indicators including:
i. urinary retention that cannot be treated or corrected medically or surgically for which alternative therapy is not feasible;
ii. Stage II or IV pressure ulcers with exposure to urine which has impeded healing, despite appropriate personal care for the incontinence; and
iii. Terminal illness or severe impairment, which makes positioning or clothing changes uncomfortable or is associated with intractable pain.?
IV. Discontinuation, C. The licensed Nurse will notify the physician if the assessment indicates the need to discontinue catheter use.
A review of the facility's policy and procedure titled "Physician Orders" dated 1/1/12 indicated that the purpose is to ensure that all physician orders are complete and accurate. Orders will include a description complete enough to ensure clarity of the physician's plan of care.
Therefore, the facility failed to:
1. Ensure that Resident 1 was catheterized (insertion of a flexible tube into the urinary system to obtain a urine sample) in accordance with the facility's policies and professional standards.
2. Ensure that there was a valid physician's order to catheterize Resident 1 in accordance with the facility?s policy and professional standards.
3. Ensure that Resident 1's physician was notified of the unsuccessful catheterization attempt due to resistance when inserting the catheter in accordance with professional standards.
4. Ensure that there was a valid physician's order to attempt a second catheterization to Resident 1 in accordance with the facility?s policy and professional standards.
These deficient practices resulted in injury to Resident 1's urethra [part of the urinary system that drains the urine from the urinary bladder (part of the urinary system that collects the urine from the kidneys) to outside the body] and bleeding from Resident 1's penis.
These violations presented either an imminent danger that death or physical harm would result or a substantial probability that death or serious physical harm would result. |
| 950000081 |
PARK AVENUE HEALTHCARE & WELLNESS CENTER |
950013203 |
A |
17-May-17 |
WYW711 |
9589 |
F323 - 483.25(D) - Free of Accident Hazards/Supervision/Devices
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
On 3/13/17, an unannounced recertification survey was conducted.
Based on observation, interview, and record review, the facility failed to provide Resident 8 adequate supervision and assistance to prevent a fall during a transfer to bed.
(a) Revise the plan of care in accordance with the Minimum Data Set assessment (MDS a standardized assessment and care planning tool) to provide Resident 8 with two person physical support during transfer.
(b) Follow the staff in service training for the proper removal of a sling when Resident 8 was transferred to bed using a mechanical lift (an assistive device to transfer the resident between a bed and a chair).
(c) Implement safety precautions when transferring a resident using a mechanical lift as indicated in the Operator's Instruction Manual.
These failures resulted in Resident 8 sustaining a fractured fifth rib from a fall during transfer to bed.
The admission record (Face Sheet) indicated Resident 8 was a 78 year old male who was readmitted to the facility on XXXXXXX16, with diagnoses that included diabetes mellitus (high blood sugar), dementia (a progressive deterioration of intellectual functions including memory loss) and renal dialysis (filtering waste products from the blood when the kidneys no longer work adequately).
A review of the initial and quarterly Fall Risk Evaluation (a nursing tool which uses a scoring system to evaluate resident's risk of fall), dated 6/27/16 and 10/4/16, indicated Resident 8 scored 16. The Fall Risk Evaluation indicated a total score of 16 or above represented a high risk for fall.
A review of the initial and quarterly Minimum Data Set assessment dated 7/5/16, 10/4/16 and 1/3/17, indicated Resident 8 had short term memory recall ability, and was totally dependent (full staff performance every time during entire seven day period) in bed mobility with one person physical assistance and two persons physical assistance with transfers.
A review of the Licensed Personnel Weekly Progress Notes indicated on 1/20/17 at 4:30 a.m., CNA 3 (Certified Nursing Assistant) had reported to the licensed staff that Resident 8 slid off from his bed when she pulled the wet bed sheet. The licensed staff found the resident lying on his back on the floor next to his bed. The resident sustained a bruise on his right ear lobe and an abrasion on his right lower back. The physician was notified of the fall incident on 1/20/17. The physician's treatment order on 1/20/17, indicated that Resident 8's abrasion on his right lower back was to be cleansed with Normal Saline (sterile mixture of salt and water) and to apply triple antibiotic ointment (combination of antibiotic medicines used as a first aid to prevent infections in minor cuts, scrapes, or burns on the skin) once a day for 14 days. The resident did not complain of pain, until 1/21/17 at 7:30 a.m., to his right side of the head, right shoulder, right side of ribs, and right hip. The physician was made aware of the resident's complaint of pain on 1/21/17, and ordered an X-ray (a test that produces images of the bone structures inside the body) of the above pain locations.
A review of the X-ray report, dated 1/22/17, indicated Resident 8 had a fractured right fifth rib with minimal displacement. The report also indicated the resident had osteopenia (bone density [amount of bone mineral in bone tissue] that is lower than normal peak but not low enough to be classified as osteoporosis [weak and brittle bone]).
A review of the Physician Orders Sheet indicated the following:
1. On 1/22/17, apply chest binder and schedule orthopedic consult.
2. On 1/23/17, Tramadol (pain reliever) 50 milligram (mg) by mouth twice a day routinely for pain management.
3. On 1/24/17, apply chest binder only when the resident goes to dialysis center.
4. On 2/18/17, Tramadol 50 mg by mouth whenever necessary for moderate to severe pain.
5. On 2/27/17, no additional appointment and treatment for fractured rib.
During an interview on 3/8/17 at 9:26 a.m., Resident 8 was observed lying in bed. He was alert and Spanish speaking. Evaluator 2 acted as an interpreter for Resident 8. Resident 8 stated he had a fractured rib to his right side after he fell from the bed approximately two months ago. Resident 8 stated that a female CNA (CNA3) took him to the shower room by herself using a mechanical lift. CNA 3 told him that he is too heavy and could not transfer him by herself. CNA 3 did not ask for another staff to assist Resident 8 during transfer using the mechanical lift. After the shower, CNA 3 transferred him to the edge of his bed. CNA 3 turned his body towards the right side (facing the CNA), pulled out the wet sheet and sling underneath his body too hard, and he fell hitting the right side of his head and the right side of his shoulder on the floor. Resident 8 further stated sometimes he was unable to sleep due to pain from his fractured right rib which was radiating (spreading) to his left leg.
During an interview on 3/8/17 at 3:40 p.m., CNA3 stated she was not the regular caregiver of Resident 8. She had no permanent assignment and floats around mostly for Nurse Station 2. CNA 3 stated she put back Resident 8 to his bed after shower using a mechanical lift. CNA 3 transferred the resident by herself without asking for assistance from another staff. CNA 3 turned the resident's body to his right side at the edge of bed while she was trying to pull out the wet sheet and the sling underneath when the resident slid off the bed. The resident fell to the floor on the right side of his body. CNA 3 stated she was aware Resident 8 needed two persons physical assist in transfer because the resident was heavy. CNA 3 stated, "I thought I could transfer him and remove the wet sheet and sling by myself." CNA 3 stated removal of the wet sheet and sling should be done by two staff for Resident 8 to prevent him from rolling down the bed. CNA 3 stated she used the EZ Way Smart Lift (mechanical lift) to transfer Resident 8. CNA 3 stated the fall incident happened in the afternoon of January 2017.
During an interview on 3/9/17 at 3:20 p.m., the Staff Developer stated Resident 8 was assessed as totally dependent in bed mobility and transfer. The resident was heavy and required two persons physical assist in transfer. She stated CNA3 attended the in-service about the use of the EZ Way Smart Lift on 12/16/16. She in-serviced all the CNAs regarding proper removal of the sling for a resident who required two persons physical assist during a transfer in bed. She stated the resident was to be rolled to one side and the CNA will tuck in the sling underneath the resident. The CNA on the back of the resident will tuck half of the sling underneath the resident while the other CNA in front will hold the resident's body for support then the resident will be log rolled to the opposite direction to pull the rest of the sling out. The Staff Developer stated CNA 3 did not follow the in-service training for the proper removal of the sling for Resident 8 who required two persons physical assist in transfer to prevent a fall from bed.
A review of the Competency Checklist for the use of EZ Way Smart lift dated 12/16/16, indicated CNA 3's signature that she had the proper training for the sling removal during transfer of a resident in bed.
A review of the EZ Way Smart brochure safety notes indicated "The EZ Way Smart Lift was designed to be operated safely by one caregiver. However, depending on the situation, facility policy, and the patient's condition, two caregivers may be necessary."
On 3/10/17 at 3:30 p.m., the medical record of Resident 8 was reviewed with the DON (Director of Nursing) and MDS 3 (Minimum Data Set Nurse). The Plan of Care dated 6/27/16, indicated Resident 8 had self-care deficit and required assistance in transfer related to general weakness, dementia and dialysis. The Plan of Care interventions indicated to transfer Resident 8 with one to two persons physical assist. The MDS assessment dated 7/5/16, 10/4/16 and 1/3/17, indicated Resident 8 needed two persons physical assist due to total dependence in transfer. The Plan of Care was not revised to reflect two persons physical assistance was needed for Resident 8 during transfer. MDS 3 stated the Plan of Care was not revised because it was overlooked.
The facility failed to provide Resident 8 adequate supervision and assistance to prevent a fall during a transfer to bed.
(a) Revise the plan of care in accordance with the Minimum Data Set assessment (MDS a standardized assessment and care planning tool) to provide Resident 8 with two person physical support during transfer.
(b) Follow the staff in service training for the proper removal of a sling when Resident 8 was transferred to bed using a mechanical lift (an Assistive device to transfer the resident between a bed and a chair).
(c) Implement safety precautions when transferring a resident using a mechanical lift as indicated in the Operator's Instruction Manual.
These failures resulted in Resident 8 sustaining a fractured fifth rib from a fall during a transfer to bed.
These violations presented a substantial probability that death or serious physical harm would result. |
| 960001096 |
PURE JOY #1 |
960009394 |
B |
13-Jul-12 |
FQMP11 |
7094 |
H&S Code 1418.91 (a) (b) 1418.91 Reports of incidents of alleged abuse or suspected abuse of residents (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident to the department immediately, or within 24 hours. On September 17, 2011 at 8 a.m., an unannounced visit was made to the facility to investigate a complaint regarding an incident of alleged client abuse. The complainant indicated Staff A grabbed Client 1 by the neck, forced her face towards a trash can and ordered the client to spit out whatever was in the client?s mouth. Based on interview and record review, the facility?s administrative staff failed to: 1. Report an allegation of abuse to the Department of Public Health (DPH) within 24 hours. The facility?s QMRP stated the facility did not report the allegation of abuse because she had suspected the abuse did not happen.A review of Client 1?s medical record indicated the client was non-verbal and admitted to the facility on April 18, 1997 with diagnoses that included severe mental retardation (cognitive ability that is markedly below average level- one fifth to one third of chronological age- and a decreased ability to adapt to one's environment), non-psychotic unspecified mental disorder, non- specific vitamin deficiency and depended on staff for activities of daily living.On September 17, 2011 at 9:30 a.m., the surveyor reviewed the incident report log and during an interview, the lead staff stated, the allegation of abuse incident was not documented in the incident report logs. The lead staff stated, in August 2011, Staff A and Staff B were present when the event occurred.On September 17, 2011 at 10 a.m., during a telephone interview, Staff A stated on August 31, 2011, Client 1 took a banana from Client 2, then Staff A took Client 1 by the arm to the trash can, held her wrist at the trash can and told her ?open your hand (Client 1) and drop it?, which the client did. Staff A stated the other staff in the house did not like Staff A, Client 1 was fond of her, not afraid of her and the client grabs her hand when she begins to leave the facility. She stated she was not surprised the client grabbed the other client?s banana.On September 17, 2011 at 11:25 a.m., during an interview, Staff B gave an account of what had occurred on August 31, 2011. She stated Client 2 was standing eating her banana and Client 1, who had already eaten her banana, ran over to Client 2 and took a piece of her banana, then Staff A left the kitchen area to Client 1, grabbed the client, made her go to the trash can and yelled at her to spit out the banana she had in her mouth. Staff B stated the QMRP had called her in and was questioning her about Staff A?s demeanor which led to her informing the QMRP of what happened that day. She further stated, she thinks Staff A was a good person, but did not agree with how she treated the clients. She stated she had to speak for the clients because they could not speak for themselves. Staff B stated she had no abuse prevention training since August 31, 2011, but did have training when she began working for the facility.On September 17, 2011 at 12:05 p.m., during an interview, the QMRP stated both, she and the licensee/ administrator decided the incident on August 31, 2011 was an opinion and therefore, they did not report it to the department. The QMRP stated Client 3 said Staff A did not touch Client 1. The QMRP further stated she did not give formal abuse training with the staff since the incident. During the course of the interview, Staff A called the facility and resigned. On September 17, 2011 at 9:20 a.m., during an interview, when Client 3 was asked what she witnessed, she stated, ?she (Client 1) had a banana and she choke?. Client 3 stated Staff A was nice to the other clients. Client 3 appeared to have Down syndrome (a set of mental and physical symptoms that result from having an extra copy of chromosome 21) and was able to speak when spoken to with minimal comprehension. She was able to express her needs, likes and dislikes on occasion. Client 3 presented with the most independence in the household.A review of the facility?s incident report indicated on August 31, 2011 at 7:30 p.m. the QMRP conducted an interview with Staff B. Staff B informed the QMRP, Staff A was a little rough with the non-verbal clients. She stated if the clients are in Staff A?s way, while walking, Staff A pushes them with her body and if the client?s will not raise up from the sofa when asked, Staff A grabs their hands and arms and pulls them up.Staff B reported at 3 p.m. earlier that day, Client 2 was eating a banana and Client 1 ran over to Client 2 and snatched a piece of the banana. Staff B and Client 3 watched as Staff A walked to Client 1, put her hands on the back of the client?s neck and took her to the trash can raising her voice to spit it out which the client did (a signed written statement by Staff B indicated the same occurrences). According to the report, the client?s neck was checked and found to be free of redness or bruising. The QMRP asked Staff B why she did not report past aggressive behaviors of Staff A; she stated because Staff A was good friends with the house manager. The report further indicated Staff A was suspended for the investigation. Staff A denied touching the client or yelling at the client and admitted she took the client to the trash can and verbalized while motioning with hands to spit out the banana. The report indicated the QMRP advised Staff A she should have allowed the client to swallow the banana and inform her that it was inappropriate to take someone?s food from them. According to the incident report, the QMRP and the licensee/ administrator concluded the alleged abuse was unsubstantiated.A review of the facility?s undated policy and procedure titled, Client Abuse, indicated all supervisors (administrator, qualified mental retardation professional, registered nurse and house manager) should be notified immediately of all alleged abuse. Any employee who hears or thinks that a client has suffered abuse must immediately tell the house manager or the qualified mental retardation professional (QMRP) and as care providers are required by law to report abuse.The QMRP or another supervisor should notify the Department of Health Services Intermediate Care Facilities (DHS ICF) Unit as soon as possible of the alleged abuse within 24 hours. The QMRP should send a written report to the DHS ICF within 48 hours. There was not supportive documentation provided by the facility that this procedure was carried out or implemented.The facility?s administration staff failed to: 1. Report an allegation of abuse to the Department of Public Health (DPH) within 24 hours. The facility?s QMRP stated the facility did not report the allegation of abuse because she had suspected the abuse did not happen.The above violation had a direct relationship to the health, safety, or security of patients. |
| 960001096 |
PURE JOY #1 |
960012644 |
B |
12-Oct-16 |
1DGN11 |
8052 |
Title 22, Division 5, Chapter 8.5, Article 4, 76918 (a) Client?s Rights. Each Client shall have those rights as specified in Sections 4502 through 4505 of the Welfare and Institutions Code and Sections 50500 through 50550, Title 17, California Administrative Code. Welfare and Institution Code 4502 (b) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. (b) It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (2) A right to dignity, privacy, and habilitation services and supports in the least restrictive environment. Treatment and habilitation services and supports shall be provided in natural community settings. On August 5, 2016, an unannounced visit was made to the facility to conduct a fundamental survey. Based on observation, interview and record review, the facility staff failed to: 1. Ensure the right to privacy for Clients 1, 4, 5 and 6 while providing morning care and assisting the clients in the bathroom. Clients 1, 4 and 6 were sitting on the toilet, with the bathroom door open. Client 5 was dressing with the bedroom door open. a- During an observation, in the bathroom, on August 5, 2016, at 6:11 a.m., Client 4 was sitting on the toilet, with the bathroom door partially open, leaving Client 4 in view of any passersby. During a review of the clinical record for Client 4, on August 7, 2016, at 3:10 p.m., Client 4 was admitted to the facility January 1, 2011, with diagnoses that included severe intellectual disability (cognitive ability that is markedly below average level and a decreased ability to adapt to one's environment) and seizure disorder (epilepsy, a brain disorder involving repeated, spontaneous convulsions). Client 4 was dependent on staff in meeting his needs in activities of daily living. A review of Client 4?s individual program plan (IPP), dated July 13, 2016, indicated Client 4 required a walker at home with close supervision, a wheelchair for long distance and a helmet for safety in case of seizure activity. Client 4 needed to be reminded to always indicate needs, wants and feelings to minimize any negative change in mood and needed guidance towards the right path of social skills. b- During an observation, in Client 5's bedroom, on August 5, 2016, at 6:40 a.m., Staff D was assisting Client 5 to pull up her pants with the client's bedroom door open. Client 5 was in full view of any passersby. During a review of the clinical record for Client 5, on August 5, 2016 at 9 a.m., the face sheet indicated, Client 5 was admitted to the facility May 6, 2008 with diagnoses that included mild intellectual disability (developmentally functions below chronological age, is slow in all areas, but can acquire practical and vocational skills). Client 5 was dependent on staff in meeting her needs in activities of daily living. A review of the human rights committee meeting minutes dated June 8, 2016, indicated Client 5 required a front wheel walker and gait belt with staff assistance for ambulation and a wheelchair for long distance. c- During an observation, in the bathroom, on August 5, 2016, at 8:05 a.m., Client 6 was sitting on the toilet with her pants down and the bathroom door wide open exposing Client 6. Client 4 and staff ambulated down the hallway and had full view of Client 6. Staff D, who was with Client 6 for assistance, was standing in the hallway. During a review of the clinical record for Client 6, on August 5, 2016, at 9:00 a.m., Client 6 was admitted to the facility January 1, 2011, with diagnoses that included severe intellectual disability (cognitive ability that is markedly below average level and a decreased ability to adapt to one's environment) and seizure disorder (epilepsy, a brain disorder involving repeated, spontaneous convulsions). Client 6 was dependent on staff in meeting her needs in activities of daily living. d- During an observation, in the bathroom, on August 5, 2016, at 8:21 a.m., Client 1 was sitting on the toilet; with her pants down and the bathroom door wide open exposing Client 1 to Client 6 as she ambulated down the hallway. Staff D, who was assisting Client 1, was outside of the bathroom standing in the hallway. During a review of the clinical record for Client 1, on August 7, 2016, at 4:48 p.m., the face sheet indicated, Client 1 was admitted to the facility April 18, 1997 with diagnoses that included moderate intellectual disability (Developmentally functions below chronological age and can learn elementary health and safety habits) and Attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity and impulsiveness). Client 1 was dependent on staff in meeting her needs in activities of daily living. A review of Client 1?s IPP, dated May 11, 2016, indicated Client 1 moved around the facility freely and needed encouraging indicating her needs, wants and feelings for accurate intervention. During an interview with Staff D regarding the client?s rights to privacy, on August 8, 2016, at 8:48 a.m., she stated she was supposed to close the doors for privacy when she showers or changes the clients. She stated she left the door open when Client 1 was on the toilet because she would get off the toilet. She stated for Client 6, she leaves the door open because she has seizures. Staff D stated Client 5 only wanted her bedroom door closed when she was being changed. Staff D stated she had been an employee at the facility for three years and six months and had privacy training when she started working at the facility. During an interview with the qualified intellectual disability professional (QIDP) regarding privacy, on August 5, 2016, at 8:55 a.m., he stated the staff have been trained and tested on privacy. He stated client personal care was to be done behind closed doors. He later stated once the client was in the restroom, the door should have been closed. The QIDP went on to say staff should encourage the client's privacy and privacy was important for the client's respect and dignity. The QIDP stated he trains the staff the same way they would want privacy for themselves and they need to do that for the clients. A review of the in-service titled "Understanding the Importance of Privacy," dated March 2, 2016; indicated staff must always show unlimited respect to all clients regardless of their level of understanding. The in-service also indicated a client that resided in the facility had reported some infringement on her privacy due to staff knocking on her bedroom door and entering without permission. Staff D had not signed (participated) in the training. The undated facility policy and procedure titled "Policy on Privacy," stipulated privacy is the act of rendering appropriate respect and dignity to individuals. Privacy requires that all services must be delivered behind closed doors. Staff should close the door behind them whenever entering a client's bedroom or bathroom when in use. Never allow the naked body parts of a client to be exposed for viewing. The facility staff failed to ensure privacy for Clients 1, 4, 5 and 6 while providing morning care and assisting the clients in the bathroom. Clients 1, 4 and 6 were sitting on the toilet, with the bathroom door open. Client 5 was dressing with the bedroom door open. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Clients 1, 4, 5 and 6. |
| 250000072 |
PALM TERRACE CARE CENTER |
250013495 |
B |
14-Sep-17 |
D41W11 |
9202 |
Title 22 72527 (a) (6)
(a) The facility shall ensure that these rights are not violated. Patient shall have the right:
(6) To be transferred or discharged only for medical reasons, or the patient?s welfare or that of other patients or nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such action shall be documented in the patient?s health record.
During an unannounced complaint investigation visit on June 12, 2017, at 9:25 a.m., it was determined the facility failed to ensure Patient 1 was not transferred to another facility without appropriate medical reasons and consent from Patient 1?s family member.
As a result of this failure, Patient 1 and the responsible party were not provided the opportunity to stay in a familiar environment which was Patient 1?s home for four years.
Patient 1?s record was reviewed. Patient 1, a 90 year old female resident, was readmitted to the facility on April 24, 2017, with diagnoses which included muscle weakness and dementia (decline mental ability severe enough to interfere with daily life). Patient 1?s history and physical indicated the patient did not have the capacity to understand and make decisions.
Patient 1?s physician?s progress notes dated May 27, 2017, indicated, ?Pt (patient) was seen today talked c (with) facility administrator I (physician in charge) explained to (name of the administrator) it could be detrimental to move pt (patient) from (Facility 1) which has been her (Patient 1) home in last 4 years??
Patient 1?s elopement/ wandering risk assessments since readmission dated April 24 and June 2, 2017, indicated Patient 1 had attempted to exit doors. The documents further indicated Patient 1 was high risk for elopement and wandering. The facility plan on June 2, 2017, indicated a 1:1 monitoring at the Director of Nursing?s (DON) office and nursing station pending discharge to a locked facility.
Patient 1?s care plan related to alteration in cognitive patterns which was dated April 24, 2017, indicated Patient 1 had episodes of opening main doors/propelling outside of facility, drinking from other patient?s rooms, and was seen with personal belonging from another patient. The care plan indicated frequent monitoring for whereabouts, and redirection.
Documents provided by the facility Licensed Nursing Home Administrator (LNHA) indicated the following:
a. May 26, 2017, the facility LNHA had requested a meeting with Patient 1?s family member. The purpose of the request was due to many complaints and concerns of employees which included: Patient 1 inappropriately touching employees, visitors, and nurses; aggressive behavior towards other patients; had recently attempted to isolate and lock herself in the LNHA?s office. The meeting concluded with Patient 1?s family member refusing for Patient 1 to transfer to another facility. The document further indicated Patient 1?s family member stating the facility had to do their job and provide the necessary supervision in response to the facility LNHA?s concern regarding Facility 1 no longer being able to provide a safe environment for Patient 1 due to progressive dementia.
b. May 27, 2017, the facility LNHA had a meeting with Patient 1?s physician. The LNHA attempted to explain Patient 1 being better served and protected at a memory or dementia facility. Patient 1?s physician stated no difference between the current (Facility 1) to dementia facilities. Patient 1?s physician stated watching Patient 1 on a one on one basis was the facility staff?s job, in response to Patient 1?s behavior of attempting to lock herself in offices. Patient 1?s physician refused to voluntarily recommend the transfer of Patient 1 to an appropriate facility.
c. June 8, 2017, the physician was notified by the facility LNHA of the intent to transfer Patient 1. Patient 1?s physician requested that the facility assist the responsible party with placement, preferably Orange County.
d. June 8, 2017, at approximately 5 p.m., the LNHA called the responsible party and was advised regarding the intent to transfer. The document further indicated Patient 1?s family member was hostile and stated, ?The state says you can?t do this.?
There was no documented evidence indicating Patient 1?s responsible party provided consent with the transfer to the locked facility (Facility 2).
The DON was interviewed on June 12, 2017, at 11:19 a.m. She stated Patient 1 was on a 1:1 monitoring. The DON stated the facility had been arranging for a transfer since last year due to Patient 1?s behaviors which included: locking herself in a closet, going to different patients? rooms, drinking water of another patient, taking belongings from other patients. The DON stated she would have Patient 1 in her office or at times would be at the nursing station being monitored by the nurses. She stated Patient 1 started having the same behaviors this year. The DON stated Patient 1 was able to get out of the facility towards the slope (at the back of the facility) when she left her to assist another patient. The DON further stated Patient 1 kicked the back of the wheelchair of a patient which resulted in the patient?s request to get discharged a day early.
The facility LNHA was interviewed on June 13, 2017, at 11:01 a.m., and stated he had several conversations with Patient 1?s responsible party prior to Patient 1?s transfer to the locked facility (Facility 2). The administrator was asked during the conversation if Patient 1?s responsible party consented on the transfer, he stated ?NO?.
Patient 1?s responsible party was interviewed on June 14, 2017, at 12:53 p.m. She stated the facility called her last May 26 and June 2, 2017, to discuss the plan of transferring Patient 1. Patient 1?s responsible party stated she did not want the patient to leave since the patient had been at the facility for a long time (4 « years). She stated she never consented to the transfer of Patient 1 to the other facility (Facility 2). Patient 1?s responsible party stated she did not receive a 30 day notice prior to Patient 1?s transfer on June 8, 2017.
The DON at the locked unit (Facility 2) was interviewed on June 14, 2017, at 1:34 p.m. She stated Patient 1 did not show any behavior while at the locked unit (Facility 2) from June 8 to June 14, 2017 (7 days). She stated Patient 1 was transferred to a different skilled nursing facility (not a locked facility) as requested by the family member.
The Social worker (SW) at Facility 1 was interviewed on June 19, 2017, at 2:29 p.m., and stated she was not able to talk to Patient 1?s family member the day of the transfer to the other facility. The SW stated she told the receiving facility (Facility 2) Patient 1?s responsible party was notified. She did not know whether the responsible party had consented to the transfer.
The facility policy and procedure was reviewed. The policy titled,? Discharge, Transfer, Re-admission Rights,? revised November 28, 2016, indicated, ?Policy 1. Appropriate arrangements for post facility Care, including but not limited to, care at?another skilled/nursing facility?are made upon and prior to a Resident?s discharge from the facility to assure the most appropriate discharge for the resident. Guidelines. Facility will?Develop a discharge plan for each resident that is included in the Comprehensive Care Plan and evaluated/updated?Notify in writing the resident and if known, the resident representative of the transfer or discharge and reasons for the move? The notice will be made, at least thirty (30) days before the resident is transferred or discharge unless the transfer is made for medical, health, and safety reasons?Upon discharge to a non-acute care setting, the resident and the representative?will a. Review and receive a copy of the thirty (30) day discharge/transfer notice??
On July 6, 2017, a discharge transfer hearing was conducted at the facility with a hearing officer from the Office of Administrative Hearings and Appeals. The hearing officer determined the facility failed to:
(1) Support its reason for transfer since Patient 1?s elopement risk could have been greatly mitigated through the alarmed doors and close supervision, and to specify the difference between Facility 2 that Facility 1 thought would better address Patient 1?s problematic behaviors;
(2) Provide adequate notice advance written notice for the move. The Notice for Transfer was issued on June 8, 2017, and
(3) Provide adequate physician?s documentation for the move. There was no documentation from the physician recommending Patient 1 to be placed in a facility that would better address the behavior.
Therefore it was determined that that facility failed to ensure rights of Patient 1 and Patient 1?s responsible party were not violated when Patient 1 was transferred to another facility without adequate medical reason and consent to ensure an orderly transfer and discharge.
The failure of the facility to ensure rights were not violated would likely to cause indignity, anxiety, or other emotional trauma to patients. |
| 910000069 |
PLAYA DEL REY CENTER |
910013451 |
A |
14-Sep-17 |
5B1I11 |
19926 |
F 309
? 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, including but not limited to:
1. Failure to follow its policy on change of condition and oxygen use.
2. Failure to notify Resident 4's physician regarding abnormal laboratory results twice and monitor the resident's change in condition.
3. Failure to monitor Resident 5's urinary output and report abnormal findings.
4. Failure to follow the physician's orders in providing the necessary care and services.
Theses failures of not monitoring, reporting, and following physician's orders for both Residents 4 and 5, resulted in changes in condition, requiring a transfer to a general acute care hospital ([GACH] 1 and 2), receiving intravenous fluids ([IVF] into the vein), antibiotics (medication to fight infections), being intubated (placement of a flexible plastic tube into the trachea [windpipe] to maintain an open airway for breathing), and admitted into intensive care (ICU).
a. A review of Resident 5's Admission Record Face Sheet indicated the resident was an 82 year-old male who was admitted to the facility on 4/19/17. Resident 5's admission diagnoses included adult failure to thrive (a progressive deterioration of a loss of willingness to eat and drink), lack of coordination with generalized muscle weakness, dystonia (abnormal muscle tone resulting in muscular spasm and abnormal posture), and cerebrovascular accident ([CVA] stroke) and had an indwelling urinary catheter (soft rubber inserted in the bladder to drain urine).
A review of Resident 5's Minimum Data Set (MDS) a comprehensive assessment and care-screening tool, dated 4/26/17, indicated the resident had severe cognitive impairment (ability to think, reason, or remember) and required an extensive assistance from the staff with eating and drinking.
A review of Resident 5's History and Physical (H&P), dated 4/17/17, indicated Resident 5's baseline blood creatinine ([SCr] kidney function test) was elevated at 1.3 to 1.4 milligrams [mg] (normal reference range (NRR) is 0.6 to 1.2 mg).
A review of an online article by BioMed Nephrology, titled "Elevation Serum Creatinine in Primary Care," indicated residents with an elevated SCr had an increase in mortality (death). https;//www-ncbi-nlm-nih-gov.wgu.idm.oclc.org/pmc/articles/PMC4289548/
A review of Resident 5's "Activities of Daily Living form," ([ADL]-routine activities that people do every day ) such as eating, bathing, dressing, toileting, transferring and walking), dated 4/20/17 and timed 3 p.m. to 11 p.m., 4/21/17 and timed at 11 p.m. to 7 a.m., and 3 p.m. to 11 p.m., the entire day on 4/22/17 and 4/24/17 timed at 3 p.m. to 11 p.m., there was no documentation of Resident 5's urine output.
A review of Resident 5's plan of care, dated 4/20/17, and titled "Resident/Patient at Risk for Decreased Ability to Perform ADLS," bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting, the staff's listed interventions included to monitor Resident 5's laboratory test results and report abnormal results to the physician or mid-level practitioner. Monitor for complications of immobility (e.g., pressure ulcers (a bedsore), muscular atrophy (wasting or shrinking), contractures (muscle tightening that prevent normal movement), incontinence (loss of bladder control), urinary or respiratory infections; and monitor for shortness of breath and/or change of condition.
A review of Resident 5's laboratory results, dated 4/24/17, and timed at 3:50 a.m., indicated Resident 5's blood creatinine level had increased to 1.51 mg.
A review of a nurses' note, dated 4/26/17, and timed at 8:21 a.m., indicated Resident 5 was warm to touch, sweaty, and sleepy. The nurses' note further indicated Resident 5 was transferred to GACH 1 for an elevated body temperature of 101.4 degrees Fahrenheit [F] (NRR is 98.6§F), an elevated heart rate (HR) of 155 (NRR is 60 to 100 beats per minute) and an elevated blood sugar of 414 milligrams per deciliter ([mg/dl] NRR is 70-99 mg/dl).
A review of the facility's "Transfer Form," dated 4/26/17, and timed at 10:04 a.m., indicated Resident 5's blood pressure (BP) was recorded as 148/60 millimeters of mercury [mHg] (NRR is 120/80 mHg), HR was 88, respirations [breaths] was 18/min (NRR is 12-16 breaths per min), and the resident's temperature was 98.1 F.
A review of GACH's "Emergency Department (ED) Service Report," dated 4/26/17 and timed at 10:38 a.m., indicated Resident 5's vital signs (measurements of body temperature, blood pressure, pulse (heart rate), and respiratory rate) were: temperature 101.2 degrees F, BP 102/46 mmHg, HR 168, and respirations elevated at 30/min. According to the report, Resident 5 presented with an altered mental status ([AMS] a range from slight confusion to total memory loss), had dry mucus membranes (line many tracts and structures of the body, including the mouth, nose, eyelids, trachea [windpipe] and lungs etc.).
Resident 5's laboratory results were abnormal in the ED as follow:
a. Blood creatinine level was high at 3.36
b. Potassium was elevated high at 6.0 (NRR 3.5-5.0) milliquivalent (mEq/L).
c. White blood cells ([WBC] elevated in the presence of an infection) count was 30.72 (NRR 4,500 to 11,000).
d. Red cell distribution width ([RBC], NRR standard size of about 6-8 æm in diameter) was elevated at 50.5.
e. Neutrophils (type of WBC that ingests bacteria) count was elevated at 28.7 (NRR 1.5 to 8.0 [when elevated is indicative of an infection].
On 4/26/17, at 11:30 a.m., while in the ED, Resident 5 received 2,070 milliliters (ml) of sodium chloride (salt) 0.9 percent (%) intravenous bolus (relatively large volume of fluid or dose at one time).
A review of Resident 5's GACH's H&P, dated 4/26/17, and timed at 6:12 p.m., indicated Resident 5's fluid intake was 3,412 ml, but the resident's urine output was ten (10) ml gross (total) for 24 hours. The H&P indicated Resident 5 was in septic shock (an infection that spreads throughout the blood and tissues that can result in organ failure). The urine in Resident 5's indwelling urinary catheter was purulent (containing pus) on admission and the H&P indicated the resident required critical care (ICU), intubation, and received vasoactive medications (to increase blood pressure due to septic shock) to treat or prevent life threatening deterioration of circulatory (the movement of blood through the body) failure and shock (sudden drop in blood flow through the body).
A review of Resident 5's progress note, dated 5/2/17, and timed at 2:53 p.m., indicated Resident 5's family member (FM) contacted the facility and was very upset about the resident's condition of being extremely dehydrated and requiring an admission in the ICU.
On 6/2/17, at 4:23 p.m., during an interview, Licensed Vocational Nurse 6 (LVN 6) stated on 4/26/17, Resident 5 had only 10 and 20 ml of urine in the urinary indwelling catheter.
During an interview on 6/2/17, at 4:43 p.m., Certified Nurse Assistant 1 (CNA 1) stated Resident 5 would not eat his food and only took sips of fluids throughout the day. CNA 5 stated she could not recall the color of Resident 5's urine, but stated the catheter did not have more than 300 ml of urine after eight hours.
On 8/16/17, at 7:25 a.m., during a telephone interview, Resident 5's FM 1 stated the facility had contacted the resident's other family member and stated the resident was very sick, had a high fever, and was being transferred to the hospital. FM1 stated the ED physician informed the family that Resident 5 was severely dehydration and had an infection. FM1 stated Resident 5 had to received IVF upon admission to the ED. FM 1 stated Resident 5 was not able to hold a cup or a bottle to feed himself and on several occasions when she visited the resident at the facility, the resident's food tray would be at the bedside untouched.
On 8/17/17 at 2:43 p.m., during a telephone interview and concurrent record review, the Director of Nursing (DON) stated for the entire day on 4/22/17, there was no documentation to indicate Resident 5's meal/fluid intake and urine output were recorded and should have been. The DON stated Resident 5 had a physician's order for UA (a urinalysis ([UA] test to check urine for signs of disease and for clues about overall health) to be obtained, but was not collected on 4/25/17 nor 4/26/17. The DON stated on 4/26/17 at 8:21 a.m., LVN 6 discovered Resident 5's COC and notified the physician. The DON further stated Resident 5 did not have a care plan for a failure to thrive or at risk for dehydration, but should have had a plan of care for the risk of dehydration.
b. A review of Resident 4's Admission Record Face Sheet indicated the resident was a 79 year-old male who was admitted to the facility on 4/26/17. Resident 4's diagnoses included acute kidney failure (occurs when the kidneys are unable to filter waste products from the blood), acute respiratory failure (not enough oxygen passes from the lungs into the blood), pneumonia (lung infection), and dementia (decreased ability to think and remember).
A review of Resident 4's physician's order, dated 4/26/17, and timed at 8:50 p.m., indicated an order for a complete blood count (CBC), to be done on May 1, 2017 for one time only, in the morning. The order was confirmed and noted by Registered Nurse 1 (RN 1).
A review of Resident 4's H & P, dated 4/27/17, indicated the resident was non-ambulatory (unable to walk on his own), dependent on staff for activities of daily living (ADL) and was incontinent of bowel and bladder (unable to control urination and defecation). The resident was assessed not having the capacity to understand and make his own decisions due to dementia.
A review Resident 4's physician's orders, dated 4/27/17, indicated an order for complete blood count (CBC), comprehensive metabolic panel (CMP), and vitamin D level to be done the following day (4/28/17). The order was noted and signed by RN 1 on 4/27/17 at 4:50 p.m.
A review of Resident 4's plan of care titled, "Resident Experiences or is at Risk for Urinary Retention related to Other," dated 4/27/17, indicated the staff to assess for bladder distention and pre-existing history of urinary tract problems (stress incontinence, frequent UTIs, urge incontinence, etc.), assist with perineal care as needed, monitor for signs and symptoms of pain and report to the physician as needed.
Another plan of care for Resident 4 titled, "Indwelling Foley (catheter), dated 5/3/17, indicated for the staff to monitor for signs and symptoms of infection and report to the physician; monitor urine for sediment (gritty particles found in urine) cloudy, odor, blood, and amount. The plan of care included for the staff to report to the physician promptly if the urine contains any sediment or blood, or was cloudy, or odorous, or if the resident has a fever.
A review of Resident 4's nurse's note, dated 5/8/17, and timed at 4:28 a.m., indicated the resident was very congested throughout the night. Another nurses' note, dated 5/8/17, and timed at 9 a.m., indicated the resident had an unplanned transfer to the hospital. The note did not indicate the reason for Resident 4's transfer or where the resident was being transferred to. However, a review of Resident 4's Nursing Home to Hospital Transfer form, dated 5/8/17, indicated Resident 4 was transferred to a GACH due to respiratory distress.
A review of the facility's Prehospital Care Report Summary, dated 5/8/17, indicated that the Fire Department arrived at the facility at 8:26 a.m. on 5/8/17 for Resident 4. The assessment records for the resident when the paramedics arrived indicated the resident had rales (clicking, rattling, or crackling sounds in the lungs) and skin temperature was hot. The paramedics assessed the resident's heart via a 12-lead EKG (electrocardiogram used to monitor the electrical activity of the heart) to be in atrial fibrillation (an irregular and often rapid heart rate). Resident 4's vital signs taken at 8:34 a.m. on 5/8/17 by the paramedics were abnormal with a low blood pressure at 78/40 (NRR 120/80), and the pulse [heart rate] high at 123 beats per minute (bpm). The report further indicated the resident had shortness of breath with tripoding (position is a physical stance often assumed by people experiencing respiratory distress), while using accessory muscle (any of the muscles of the neck, back, and abdomen that may assist the diaphragm and the internal and external intercostal muscles in breathing) and had a productive cough.
A review of Resident 4's GACH Discharge Summary, dated 5/25/17, indicated the resident was brought to GACH (2) for acute respiratory distress and required intubation. The summary indicated the resident was febrile (elevated fever [body temperature] of 101.3 (NRR 98.6 F) had bilateral infiltrates (a substance denser than air, such as pus, blood, or protein, which lingers within the lungs [usually associated with pneumonia]) consistent with the diagnosis of bilateral pneumonia (both lungs); was dehydrated, in an acute renal failure with a BUN (blood, urea, and nitrogen [test used to evaluate kidney function]) of 39 (NRR 10 to 20 mg/dL) and an elevated creatinine level of 2.2 and sodium of 153 mEq/L (NRR 135-145 mEq/L).
On 6/2/17 at 4:05 p.m., during an interview and a concurrent record review, LVN 6 verified that the printed laboratory results were not found in Resident 4's medical records. LVN 6 stated two (2) laboratory reports, one dated on 4/28/17, and the other, on 5/1/17 were observed in Resident 4's electronic medical records (EMR). LVN 6 verified that there was no documentation that indicated the results were received, noted, and communicated to the physician. A further review of Resident 4's EMRs indicated there were no entries on 4/28/17 and 5/1/17 to indicate the physician was informed about Resident 4's abnormal lab results. LVN 6 stated that when abnormal labs are received, nurses are supposed to call the physician, then document on EMR.
The laboratory results for Resident 4 were as follows on 4/28/17:
a. White blood cell were elevated at 15.9 per micro liter (uL), higher than NRR of 4-10 uL
b. Red blood cell (RBC, type of blood cell that delivers oxygen (O2) to the body tissues) was low at 4.0, lower than NRR of 4.63-6.08
c. Hemoglobin (the molecule in red blood cells that carries oxygen) was low at 11.5, lower than NRR of 13.7-17.5
d. Hematocrit (the volume percentage of red blood cells in the blood) was low at 39.7, lower than NRR of 40.1-51
e. Absolute Neutrophils (neutrophils are a type of white blood cell that fights against infection) was elevated at 13.4, higher than NRR of 1.56-6.13
f. BUN was elevated at 27 mg/dl higher than NRR of 7-25 mg/dl
g. Albumin (human protein found in the blood) was low at 2.4 g/dl lower than NRR of 3.5-5.7 g/dl
The laboratory results for Resident 4 on 5/1/17 were as follows:
a. WBC was elevated at 20.13 per micro liter (uL), higher than NRR of 4-10 uL
b. RBC was low at 4.07, lower than NRR of 4.63-6.08
c. Hemoglobin was 11.9, lower than NRR of 13.7-17.5
d. Hematocrit was 41.1, lower than NRR of 40.1-51
e. Absolute Neutrophils was 17.52, higher than NRR of 1.56-6.13
On 6/2/17, at 4:20 p.m., during an interview, LVN 7 stated that a WBC of 20.13 was "very high" and she would have called the physician immediately and ask if he wanted to transfer the resident out to the hospital.
On 6/2/17, at 5:15 p.m., during an interview, LVN 9 confirmed working on 4/28/17, and was asked to verify Resident 4's lab results, dated 4/28/17; LVN 9 stated she could not find it in Resident 4's chart. LVN 9 further stated, "Sometimes we don't receive the labs."
During a concurrent interview and record review with LVN 10 on 6/2/17 at 5:50 p.m., he stated that Resident 4 was confused, but verbally responsive. LVN 10 stated that on assessment, the resident "sounded congested" and was sent out to the hospital because he had a low blood pressure and decreased oxygen saturation (O2 sat). LVN 10 confirmed he worked on 5/1/17 and stated, "Honestly I cannot remember any labs on the days I worked." During further review of the resident's chart with LVN 10 indicated there was no progress notes were written on the lab results, dated 5/1/17. LVN 10 stated that no notes would probably mean that no one reported the abnormal results to the physician. LVN 10 stated that if the labs were received, the nurse should document "reported to physician with a date and time."
During an interview with the Registered Nurse Supervisor (RN 1) on 6/2/17 at 6:10 p.m., she verified that she reviewed and signed the physician's order, dated 4/27/17, to draw Resident 4's CBC and CMP the following morning. RN 1 stated that pending labs are endorsed to the next shift for follow-up. RN 1 verified she worked on 4/27/17 on the 3 p.m. -11 p.m. shift and that she verbally endorsed the physician's order to the next shift, but could not remember who she endorsed to.
During an interview with the DON on 6/2/17 at 7:45 p.m., she stated that when a physician order was received for a lab draw, the nurse who received the order writes on the lab request form and when the order was carried out, the nurse writes on the communication book for the DON and the unit managers to monitor the labs. The DON stated that the nurses did not communicate with each other and failed to endorse with each other, which was the reason for failure to report the abnormal labs to the physician.
A review of the facility's undated policy titled, "Change of Condition" indicated the facility must immediately inform the patient, consult with the patient's physician, and notify, consistent with his/her authority, the patient's Health Care Decision Maker (HCDM), where there is a significant change in the patient's physical, mental or psychosocial status in either life-threatening conditions or clinical complications.
A review of the facility's job description for licensed vocational nurses, revised on 10/22/12, indicated that the nurse was responsible for provision of direct care, which included; to administer medications, perform treatment per physician's orders, communicate pertinent data to registered nurse or physician, and document accurately and thoroughly.
The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, including but not limited to:
1. Failure to follow its policy on change of condition and oxygen use.
2. Failure to notify Resident 4's physician regarding abnormal laboratory results twice and monitor the resident's change in condition.
3. Failure to monitor Resident 5's urinary output and report abnormal findings.
4. Failure to follow the physician's orders in providing the necessary care and services.
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 020000090 |
Parkview Healthcare Center |
020013456 |
B |
6-Sep-17 |
CFKC11 |
3275 |
483.12(a)(1) FREE FROM ABUSE/INVOLUNTARY SECLUSION
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms.
(a) The facility must-
(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
The facility failed to follow the aforementioned regulation by failing to protect Resident 1 from abuse when Certified Nursing Assistant 2 (CNA 2) shoved a spoon far back into Resident 1's mouth and slapped him on the cheek while feeding him breakfast.
According to the undated Face Sheet, Resident 1 was admitted to the facility on 7/21/14 with multiple diagnoses that included quadriplegia (paralysis of both arms and legs).
Review of Resident 1's annual Minimum Data Set (MDS, an assessment tool used to guide care) dated 9/8/16; indicated Resident 1 had a BIMS (brief interview for mental status) score of 15 (cognitively intact). The staff assessed Resident 1 on the 9/8/16 MDS as having the ability to recall events.
During an interview with Resident 1 on 7/25/17, at 1:20 p.m., Resident 1 stated CNA 2 was feeding him and shoved the plastic spoon so far into his mouth it hit "the hanging thingy, uvula in my throat" Resident 1 stated he then began gagging and screamed out repeatedly for someone to help. Resident 1 stated CNA 2 then slapped him on his right cheek. He said "I felt mad and scared enough to have physically hurt him if I wasn't paralyzed." Resident 1 stated he asked to speak to the manager of the day, but "no one ever came to talk to me." Resident 1 further stated although CNA 2 does not come into his room anymore, he still hears his voice in the hall and it frightens him because he is paralyzed and would not be able to defend himself if he needed to.
During a phone interview with CNA 2 on 7/26/17 at 9:14 a.m., CNA 2 admitted to feeding Resident 1's breakfast, but denied slapping Resident 1 or causing him to gag or yell out.
Review of a form titled "Grievance/Complaint Report", dated 5/24/17 (no time), indicated "CNA slap him on his right cheek. Then supervisor talk to the resident he [Resident 1] said...CNA was feeding him and spoon stuck to his throat...then CNA slap him on his Rt [right] cheek..."
Review of the employee file showed a "Disciplinary Action Record" dated 5/24/17, it indicated CNA 2 was suspended on 5/24/17 and returned to work on 5/27/17. The record further indicated CNA 2 had received in-service on abuse prevention and reporting and was warned to stay away from Resident 1.
The facility's Abuse & Neglect Prohibition policy, last revised October 2004 indicated each resident has the right to be free from mistreatment, neglect, and abuse.
Therefore the facility failed to protect Resident 1 from abuse when CNA 2 shoved a spoon far back into Resident 1's mouth and slapped him on the cheek while feeding him breakfast.
The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity anxiety or other emotional trauma to patients. |
| 240000094 |
Providence Ontario |
240013536 |
B |
10-Oct-17 |
None |
5945 |
REGULATION VIOLATION:
Title 22 72311 (a)(3)(b) Nursing Service ? General
(a) Nursing service shall include, but not be limited to, the following:
(3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of:
(B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.
The facility failed to ensure that their policy and procedure, ?Patients Right, Physician Notification,? was followed for one of three sampled patients (Patient 1) when:
The facility failed to notify the doctor of abnormal laboratory values and document the notification of the physician for the abnormal laboratory values.
This failure caused a delay in the necessary treatment for Patient 1 and resulted in hospitalization.
During a record review, the face sheet (a form that includes birth date, diagnoses, date of admission, etc.) indicated Patient 1 was admitted to the facility on February 24, 2017, with diagnoses that included hyperosmolality (increase in body fluids), hypernatremia (high sodium level in the blood), and type 2 diabetes (high sugar in the blood).
During a review of the physician's orders, dated June 20, 2017, a telephone order dated June 20, 2017 at 1:51 PM, was obtained by the licensed vocational nurse (LVN) for Patient 1 to have STAT (immediately) labs to be drawn to include a complete blood count (CBC- used to rule out infections, anemia (low red blood cell count), and leukemia - a cancer of the blood), and a basic metabolic panel (BMP- used to monitor blood glucose levels and electrolytes which keep body fluids in balance). A second telephone order was obtained dated June 20, 2017 at 2:03 PM, for Patient 1 to be started on intravenous (IV- into the blood stream via a vein) hydration of normal saline at 80 cc (cubic centimeters a unit of measure)/ hour for 2 liters every shift until June 22, 2017.
During a review of the nurses' notes dated June 20, 2017 at 8:35 PM, the licensed nurse documented Patient 1 had a change of condition (lethargy ? lack of energy).
During a review of Patient 1?s laboratory results report dated June 20, 2017, the report revealed the blood sample was collected on June 20, 2017 at 6:35 PM. The laboratory results were reported to the facility on June 20, 2017 at 11:43 PM. The laboratory results showed the BMP was abnormal as follows:
Glucose 132 mg (milligrams)/dl (deciliter- units of measurement) (high) 65-99 normal range (can indicate diabetes where the body cannot produce or utilize insulin)
BUN (Blood Urea Nitrogen-waste product of the liver)148 mg/dl (high) 7-25 normal range (indicates kidney function, dehydration or heart failure)
Creatinine (measures kidney functions in the blood) 6.39 mg/dl (high) .70-1.25 normal range (indicates impaired kidney function)
Sodium serum (salt in the blood) > (greater than)165 (high) 135-146 normal range ( indicates dehydration, and can increase blood pressure)
The CBC (complete blood count) was also abnormal as follows:
White blood cells (WBC) 21.5 thousand/unit (high) 3.8-10.8 normal range (indicates infectious process)
During a review of the nursing notes for June 20, 2017 and June 21, 2017, there was no documented evidence to show the physician was notified about the abnormal labs for Patient 1.
During a review of the nursing care plans for Patient 1, a care plan for being at risk for dehydration dated February 24, 2017, under the interventions, included that staff were to report abnormal labs to the MD (medical doctor).
During a review of the nursing notes dated June 21, 2017 at 3:37 PM, the note revealed Patient 1 continued to be lethargic and had an altered level of consciousness, and a desaturation of oxygen levels (the oxygen levels in the blood are low and cannot nourish the body cells causing respiratory distress), at which time Patient 1 was transferred to the acute care hospital via the paramedics ambulance.
During a review of the general acute care hospital history and physical form dated June 21, 2017, the history and physical revealed Patient 1 was admitted with a diagnosis of pneumonia (lung infection), acute renal failure (kidney failure), hyperkalemia (high potassium), and respiratory failure (very low blood oxygen levels). Patient 1 had to be intubated (breathing tube inserted to maintain his airway) and placed on a respirator (a machine used to breathe for a person) while in the emergency room.
During an interview with the Assistant Director of Nursing (ADON), conducted on August 15, 2017 at 10:40 AM, the ADON verified the MD had not been notified of Patient 1's abnormal labs drawn on June 20, 2017. The ADON stated, "The documentation wasn't specific to state the MD was notified of abnormal labs."
During a telephone interview with the Director of Nursing (DON), conducted on August 23, 2017 at 9:30 AM, the DON stated, "The nurses should be documenting in the progress notes, or it should be written on the lab results that the MD was notified of abnormal labs. We are not doing a good job on that."
During a review of the facility policy and procedure, undated, and titled, "Patient Rights: Notification, Physician," the policy indicated:
"It is the policy of this facility to notify the Patient's Physician of changes in the Patient's condition and/or status:
1. Licensed Nurses may notify the attending Physician for the following:
B. There is a significant change in the Patient's physical, mental, or psychosocial status."
The facility?s failure to follow their policy and procedure to notify the physician and document that notification of the abnormal laboratory results for Patient 1, caused a delay in treatment and hospitalization for Patient 1.
The facility failure had a direct or immediate relationship to the health, safety or security of long term health care facility patients. |
| 080000062 |
Parkway Hills Nursing & Rehabilitation |
080013660 |
B |
5-Dec-17 |
50BH11 |
10098 |
F 309 483.25
The facility failed to ensure emergency medical attention was provided for 1 of 2 sampled residents (1) during an episode of respiratory distress.
As a result, Resident 1's attending physician was not promptly notified of Resident 1's health condition, emergency responders (911) were not called, and Resident 1 died.
Resident 1 was admitted to the facility on 6/2/17 with diagnoses which included chronic pain, hypertension (abnormally high blood pressure), pressure ulcer (skin lesion) and quadriplegia (paralysis of the all limbs).
On 6/22/17 at 3:20 P.M., the Director of Nursing (DON) stated Resident 1 was admitted from the hospital to the facility for rehabilitation, and the plan was to discharge Resident 1 back to home. The DON stated Resident 1 was admitted on Friday evening and died on Sunday morning. The DON further stated the Charge Nurse (CN) informed her about Resident 1's change of condition and Resident 1 had a do not resuscitate (DNR) order. The DON stated she advised the CN to keep Resident 1 comfortable.
Per the Nursing Note, dated 6/4/17 at 12:50 A.M., Resident 1's vital signs were stable. Resident 1's respirations were even and unlabored.
Per the Physical Therapy (PT) Note, dated 6/4/17, "... Patient found to have labored breathing on 2 LPM O2 via NC (liters per minute oxygen via nasal cannula)...Charge nurse notified..."
According to the Nursing Note, created by Licensed Nurse (LN 1), dated 6/4/17, PT informed LN 1 about Resident 1's condition. Resident 1 had difficulty breathing. LN 1 went to Resident 1's room and found Resident 1 had, "shallow fast labored breathing". LN 1 checked Resident 1's oxygen saturation and it was documented as "54%," and respiration rate was "119."
Per the facility's policy and procedure, dated 10/10, titled Pulse Oximetry (Assessing Oxygen Saturation) a normal oxygen saturation was between 90 and 100 percent (%), oxygen saturation below 70 % was life threatening. In addition the facility's policy and procedure stated if the oxygen saturation was less than an acceptable level for the resident's condition, notify the physician.
Per the Nursing Note created by the CN, dated 6/4/17, "Med nurse came to CN at 1000 and made aware that resident is declining rapidly. Upon entering room resident HOB (head of bed) was up and had yellowish-white fluids running out of nose and mouth. Assessed for pulse and breathing ... unable to obtain ... CN left the room to ... let the DON and administrator know what was going on ..." Both nurses went back to Resident 1's room and confirmed Resident 1 was dead (there was no exact time of death). The CN further document the Medical Director and family member made aware Resident 1 was dead.
On 7/19/17 at 2:47 P.M., an interview was conducted with LN 1. LN 1 stated Resident 1 was expected to die, because Resident 1 did not look good. LN 1 stated he was the med nurse during the incident. LN 1 stated Resident 1 had difficulty breathing. LN 1 further stated emergency response (911) was not called because Resident 1 had a DNR - POLST (Physician Orders for Life-Sustaining Treatment). LN 1 further stated DNR means no hospitalization. LN 1 stated he documented 119 respiration was a "typo."
An interview was conducted with the PT, on 7/19/17 at 3:15 P.M. The PT stated he observed Resident 1 had oxygen but still had labored breathing. The PT stated he left the room and told the nurse. The PT stated, he recalled the nurse and he read Resident 1's POLST, and was told Resident 1 had a DNR - POLST which indicated no hospitalization.
A joint interview and record review was conducted with the CN on 7/24/17 at 12 P.M. The CN stated she admitted Resident 1, and during admission, Resident 1 looked "ok" and was able to communicate. The CN stated during the incident, the PT and LN 1 told her Resident 1's saturation was declining. The CN stated when she entered the room, Resident 1 looked pale. The CN notified the DON of the event and the DON said "keep the resident comfortable." The CN further stated Resident 1 had a DNR order, and her understanding of DNR was no hospitalization. The CN stated she was unsure of Resident 1's exact time of death because she did not document the time.
An interview was conducted with the MD, on 8/9/17 at 3:45 P.M. The MD stated DNR meant do not resuscitate. The MD further stated when the resident's heart stopped, DNR meant not to apply compression on the resident's chest. The MD stated DNR did not mean no hospitalization.
A record review was conducted on 6/22/17.
Per the (POLST), dated 6/2/17:
Under Section A titled Cardiopulmonary Resuscitation (CPR)
Resident 1 chose "Do not Attempt Resuscitation /DNR",
Under Section B, titled Medical Intervention there were 3 options.
(1) Full Treatment - primary goal of prolonging life by all medically effective means...
(2) Selective Treatment - goal of treating medical conditions while avoiding burdensome measures...
(3) Comfort-Focused Treatment - primary goal of maximizing comfort...
Section B was blank.
Under Section D, titled Information and Signatures, the attending physician had not signed the POLST.
Per the POLST form, revised on 10/1/14 "...To be valid a POLST form must be signed by the (1) physician, or by a nurse practitioner or a physician assistant ... Any section not completed implies full treatment for that section..."
An interview was conducted with the DON, on 9/11/17 at 4:30 P.M. The DON stated when there was a change of condition, her expectation was to assess the resident and provide treatment as needed. The DON further stated DNR residents could be transferred to the hospital. The DON stated there was no facility policy and procedure related to POLST.
Per the facility policy and procedure, revised on 12/11, titled Change in a Resident's Condition or Status, "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status..."
The above violation had a direct relationship to the health, safety or security of patients.
Based on interview and record review, the facility failed to ensure the licensed nurse (LN) accurately document:
1. The exact time of death, when the licensed nurses confirmed Resident 1 was dead for 1 of 2 sampled residents (1).
2. The saturation (blood oxygen level in the body) for 1 of 2 sampled residents (1), when Resident 1 was confirmed dead.
As a result, Resident 1's exact time of dead was not recorded and there was inaccurate documentation of Resident 1's medical record when Resident 1 was pronounced dead in the morning, and the LN documented Resident 1 had a good saturation in the afternoon.
Findings:
1. Resident 1 was admitted to the facility on 6/2/17 with diagnosis which included chronic pain, hypertension (abnormally high blood pressure), pressure ulcer and quadriplegia (paralysis of all limbs), per the Admission Record.
On 11/28/16 a record review was conducted.
Per the Nursing Note created by the Charged Nurse (CN), dated 6/4/17, "Med nurse came to CN at 1000 and made aware that resident is declining rapidly. Upon entering room resident HOB (head of bed) was up and had yellowish-white fluids running out of nose and mouth. Assessed for pulse and breathing ... unable to obtain ... CN left the room to ... let the DON and administrator know what was going on ..." Both nurses went back to Resident 1's confirmed Resident 1 was dead (there was no exact time of death).
Per the Administration Note dated 6/4/17 at 12:15 P.M., License Nurse (LN 1), documented Resident 1 died at 10:20 A.M.
Per the Administration Note dated 6/4/17 at 2:36 P.M., License Nurse (LN 1), documented Resident 1 died at 10:30 A.M.
A joint interview and record review was conducted with CN, on 7/24/17 at 12 N.N. The CN stated unaware the exact time Resident 1 died. The CN stated everything happened fast, and she should have documented the time of death.
An interview was conducted with the Director of Nursing (DON), on 9/11/17 at 4:30 P.M. The DON stated her expectation was for LNs to include the exact date and time of death.
Per the facility's policy and procedure, undated, titled Death of a Resident, "...All information pertaining to a resident's death (i.e., date, time of death....) must be recorded on the nurses' notes..."
2. Resident 1 was admitted to the facility on 6/2/17 with diagnosis which included chronic pain, hypertension (abnormally high blood pressure), pressure ulcer and quadriplegia (paralysis of all limbs), per the Admission Record.
On 11/28/16 a record review was conducted.
Per the Nursing Note created by the Charged Nurse (CN), dated 6/4/17, "Med nurse came to CN at 1000 and made aware that resident is declining rapidly. Upon entering room resident HOB (head of bed) was up and had yellowish-white fluids running out of nose and mouth. Assessed for pulse and breathing ... unable to obtain ... CN left the room to ... let the DON and administrator know what was going on ..." Both nurses went back to Resident 1's confirmed Resident 1 was dead (there was no exact time of death).
Per the Treatment Administration Record (TAR), dated 6/4/17, Resident 1 had an order to "Monitor oxygen saturation every shift." The documented indicated Resident 1 had a saturation of 97% during day shift and also 97 % in the evening shift (Resident 1 died in the morning).
An interview was conducted with the LN 5 on 9/11/17 at 3 P.M. LN 5 stated oxygen saturation was performed within their shift. LN 5 further stated evening shift was from 2:30 P.M. until 11 P.M. LN 5 stated she documented 97 % on Resident 1 had not realized Resident 1 no longer at the facility because she just copied the previous documentation.
An interview was conducted with the DON, on 9/11/17 at 4:30 P.M. The DON stated her expectation was for LNs to always document accurately. |
| 960002393 |
Pacific Home Care |
960013493 |
B |
13-Sep-17 |
LC9J11 |
5216 |
Code of Federal Regulation (CFR)
(W429) The facility must maintain the temperature and humidity within a normal comfort range by heating, air conditioning or other means.
August 2, 2017 a Fundamental Re-Certification survey was initiated.
The facility staff failed to:
1. Ensure the facility's temperature remained in a normal comfort range for 3 of 3 sampled clients (Clients 1, 2, and 3) and 3 of 3 non-sampled clients (Clients 4, 5, and 6). On August 2, 2017 at 6:02 a.m., the temperature of the facility was 91 Fahrenheit (F) degrees. On August 3, 2017 at 1:45 p.m., the temperature of the facility was 93 (F) degrees.
2. Follow their policy ?Mechanical Systems," which indicated the temperature shall be maintained within a normal comfort range by air conditioning or other means.
During an observation on August 2, 2017 at 6:02 a.m., upon entering the facility to conduct an annual survey the facility?s temperature was hot. According to the thermostat the temperature inside of the facility measured 91 degrees (F) ; there were 4 fans in the kitchen and living room on at the time. On August 3, 2017 at 1:45 p.m., the temperature inside of the facility measured 93 degrees on the thermostat; there were 5 fans on at the time in the living room and in the kitchen.
During an interview with Client 1, on August 2, 2017 at 6:23 a.m., he stated it was hot in the facility.
During an interview with Client 4, on August 2, 2017 at 6:55 a.m., she stated it was hot in the facility.
During an interview with the Administrator, on August 2, 2017 at 7:40 a.m., she stated the licensee/owner was aware of the heat and made mention of the facility being extremely hot and was planning on purchasing an air conditioning unit but had not purchased one yet.
A review of Client 1's clinical record on August 4, 2017, indicated Client 1 was admitted to the facility May, 10, 1999 with diagnoses of mild intellectual disability (developmentally functions below chronological age, slow in all areas, but can acquire practical and vocational skills), seizure disorder (epilepsy, a brain disorder involving repeated, spontaneous convulsions), and diabetes (uncontrolled blood sugars).
A review of Client 2's clinical record on August 4, 2017, indicated Client 2 was admitted to the facility March 1, 1999 with diagnoses of mild intellectual disability, hypertension (elevated blood pressure), and diabetes.
A review of Client 3's clinical record on August 4, 2017, indicated Client 3 was admitted to the facility August 26, 2015 with diagnoses of profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care), breast cancer, and cerebral palsy (disorders that include: poor coordination, stiff muscles, weak muscles, trouble swallowing or speaking, tremors, problems with sensation, vision, and hearing. Also difficulty with the ability to think or reason, and the symptoms worsen over time).
A review of the registered nurses (RN) body check form, dated August 1, 2017 at 7:00 p.m., August 2, 2017 at 6:30 a.m., and again at 6:45 p.m., and on August 3, 2017 at 6:45 a.m., indicated Client 3 had scattered heat rashes (skin condition that often affects children and adults in hot, humid weather conditions. You can develop heat rash when your pores become blocked and sweat can?t escape) over the body.
A review of Client 4's clinical record on August 4, 2017, indicated Client 4 was admitted to the facility January 18, 2002 with diagnoses of mild intellectual disability and spina bifida (congenital defect of the spine in which part of the spinal cord and its meninges are exposed through a gap in the backbone that often causes paralysis of the lower limbs, and sometimes mental handicap).
A review of Client 5's clinical record on August 4, 2017, indicated Client 5 was admitted to the facility December 22, 2004 with diagnoses of mild intellectual disability, Downs syndrome (a set of mental and physical symptoms that result from having an extra copy of chromosome 21), and schizophrenia (a severe brain disorder in which people interpret reality abnormally).
A review of Client 6's clinical record on August 4, 2017, indicated Client 6 was admitted to the facility November 29, 2010 with diagnoses of mild intellectual disability, cerebral palsy, and diabetes.
The facility's policy and procedure dated 1993 titled ?Mechanical Systems," indicated the facility?s temperature shall be maintained within a normal comfort range by air conditioning or other means.
The facility staff failed to:
1. Ensure the facility's temperature remained in a normal comfort range for 3 of 3 sampled clients (Clients 1, 2, and 3) and 3 of 3 non-sampled clients (Clients 4, 5, and 6). On August 2, 2017 at 6:02 a.m., the temperature of the facility was 91 degrees. On August 3, 2017 at 1:45 p.m., the temperature of the facility was 93 degrees.
2. Follow their policy ?Mechanical Systems," which indicated the temperature shall be maintained within a normal comfort range by air conditioning or other means.
The above violation presented had a direct relationship to the health, safety, and security of the clients. |
| 930000773 |
PROVIDENCE LITTLE COMPANY OF MARY TRANSITIONAL CARE CENTER |
930013505 |
B |
19-Sep-17 |
63XO11 |
14709 |
CFR 483.15(c)(3) Notice before transfer
Before a facility transfers or discharges a resident, the facility must?
(i) Notify the resident and the resident?s representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident?s medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.
CFR 483.15(c)(5) Contents of the notice.
The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident?s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
CFR 483.15 (c)(7) Orientation for transfer or discharge.
A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.
On 5/18/17, the Department received a complaint, alleging that the facility was discharging Resident 1 to a shelter on 5/17/17. According to the complaint, on 5/17/17 (five days after admission), the licensed clinical social worker 1 (LCSW 1) stated to Resident 1 that he needed to leave the facility because they needed the bed. LCSW 1 called the facility?s security and intimidated Resident 1 to sign discharge paperwork.
The facility did not follow its policy and procedure and Resident 1?s plan of care to ensure the resident was adequately prepared for the pending transfer/discharge by failing to:
1. Notify Resident 1 in writing of the pending discharge to a shelter and the reasons for it.
2. Ensure Resident 1 exercised his rights to determine what resources and living arrangements he will accept, includes the right to refuse going to a shelter following discharge.
3. Provide the notice of the proposed transfer and discharge to the Long-Term Care Ombudsman (stated advocacy program for residents).
This deficient practice resulted in Resident 1 being ill-prepared for the transfer resulting in the resident experiencing anxiety (a feeling of worry, nervousness, typically about an imminent event with an uncertain outcome), accompanied by elevated blood pressure of 190/101 (normal reference range is more than 120/80 and less than 140/90) and exacerbated his primary illness symptoms, which led to Resident 1?s transfer to the general acute care hospital (GACH) emergency department (ED). Resident 1 felt threatened by the security guards that showed up to his room to physically escort him out of the facility.
On 5/19/17 at 1:21 p.m., during a telephone interview, Resident 1 stated that on the morning of 5/17/17, he was provided with bus token and was being discharged against his will to a homeless shelter. Resident 1 stated he had never felt so threatened in his life, because he could not care for himself, not even to wipe his backside. Resident 1 stated the facility?s security guards were called to his room to physically throw him out on the streets, which gave him an anxiety attack that led to his transfer to the Emergency Department (ED).
A review of Resident 1?s admission record, indicated Resident 1 was admitted to the facility on 5/12/17, with a diagnosis that included neuromyelitis optica (a disorder in where the body's own cells attack the nerves and the spinal cord resulting in swelling, inflammation, pain, loss of vision, weakness or paralysis in the legs or arms, and problems with bladder and bowel function).
A review of Interdisciplinary Team (IDT) care conference note, dated 5/15/17, indicated Resident 1 was assessed as oriented to person, place, time, and situation, as being a high risk for falls, required set up and stand by assistance for feeding, dressing and toileting, but was independent in bed mobility and transfer between bed to chair with the ability to walk the distance of 50 feet. The IDT note indicated Resident 1 was from a foreign country and was currently visiting a friend.
A review of LCSW 1's Discharge Planning note, dated 5/15/17, at 4:40 p.m., indicated the goal for Resident 1 was to have a safe discharge with durable medical equipment (DME - items such as hospital beds, wheelchairs, walkers, canes), and home health agency to be arranged and provided, if indicated. LCSW 1's note indicated LCSW 1 met with Resident 1 to review discharge planning and that discharge may be as soon as two to three days. Resident 1 indicated to LCSW 1 that he will most likely to go home with his friend and then work on his plane ticket to get home from there. The note indicated that LCSW 1 encouraged Resident 1 to reach out to his friend and make an alternate plan in case the plan did not work.
A review of LCSW 1's Discharge Planning note, dated 5/16/17 and timed at 3:12 p.m., indicated the discharge goal for Resident 1 was to have a safe discharge, with DME and home health agency arrangement, if indicated. LCSW 1's note indicated that she had offered resources such as shelter information.
A review of an Occupational Therapist's ([OT] a health care professional who helps patients recover or develop skills needed for the activities of daily living) note, dated 5/16/17, 3:59 p.m. indicated Resident 1 required set up assistance during feeding and stand by assistance with grooming and dressing.
A review of a physician's order, dated 5/17/17, at 9:49 a.m., indicated to discharge Resident 1 on 5/17/17, however there was no documentation to where the resident was to be discharged.
A review of medical social worker 1( MSW 1)'s Plan of Care note, dated 5/17/17, at 10:09 a.m., indicated MSW 1 informed Resident 1 he was being discharged the same day and that there were several options/resources available to him upon discharge. According to the note, MSW 1 discussed options of providing the resident with bus tokens or to provide with shelter placement.
According to the licensed vocational nurse case manager?s (LVN-CM) progress note, dated 5/17/17, at 10:50 a.m., the facility offered Resident 1 to be discharged to a shelter and Resident 1 had refused to go.
A review of MSW 1's Plan of Care note, dated 5/17/17, at 2:30 p.m., indicated MSW 1 met with Resident 1 again and attempted to discuss discharge plan. According to the note, MSW 1 attempted to discuss the following options with Resident 1 again: providing bus tokens, clothing, and resources (clinic, shelter, etc.) versus shelter placement with clothing.
During a telephone interview with the Ombudsman on 5/19/17 at 2:41 p.m., and a review of a follow up e-mailed letter from the Ombudsman, dated 5/26/17 and timed at 1:47 p.m., indicated on 5/17/17, the Ombudsman saw the facility's social worker (MSW 1) with sweat pants in her hand and two security guards in Resident 1's room at the facility. According to the email and the interview, the Ombudsman stated the situation appeared that the security guards were physically going to remove Resident 1 off of the facility's property. The Ombudsman stated she informed MSW 1 and the security guards that Resident 1 had rights and that he should not be removed from the facility. The Ombudsman informed the facility?s staff that Resident 1 must be given a 30-day discharge/transfer notice, which contained information about the resident?s rights to appeal the facility's decision before he can be discharged. In addition, the Ombudsman informed the Licensed Clinical Social Worker 1 (LCSW 1) and the Administrator about Resident 1's right for appeal and the new notification process regarding the discharge notice requirement sent to the Ombudsman when a resident was being discharged and a discharge notice had not been provided to Resident 1.
On 5/20/17 at 4:13 p.m., during an interview, MSW 1 verified there was no written notice given to Resident 1 prior to his discharge. MSW 1 stated the only notice she was familiar with was similar to a discharge summary and it was given to residents after discharge.
On 5/21/17 at 12:15 p.m., during an interview, LCSW 1 acknowledged that Resident 1 was not provided any written documentation in preparation for discharge.
At 2:15 p.m., on 5/21/17, during an interview, the facility?s Medical Director (MD) acknowledged that Resident 1 was not given any paperwork regarding his discharge.
A review of MSW 1 progress note, dated 5/17/17, and timed at 12:01 p.m., the day the facility was attempting to discharge Resident 1 to a shelter, indicated MSW 1 told Resident 1 that since he had the discharge order, and was not willing to discuss the discharge, she was going to contact the facility's security. The note indicated MSW 1 documented she contacted the facility's Risk Management, who agreed to have the security staff to escort Resident 1 out of the facility.
During Resident 1's stay at the facility, he shared a room with another resident, Resident 2, who had a family member (FM 1) present, when the facility was attempting to physically remove Resident 1 from the facility on 5/17/17.
A review of a letter, written by FM 1, dated 5/21/17 and timed at 7:45 p.m., on the day of Resident 1 discharge, MSW 1 entered his room and informed Resident 1 that she had worked with Resident 1 by calling shelters on his behalf, arranged transportation, and that Resident 1 simply had to go. Resident 1 informed MSW 1 he would not be leaving and in turn MSW 1 told Resident 1 that she would have to call security. According to FM 1's letter, a nurse, three security guards, and someone from administration entered Resident 1's room sometime later that day.
On 5/19/17 at 4:36 p.m., during an interview, the facility?s security guard 1 (SG 1) stated she received a call from MSW 1 and was instructed to escort Resident 1 out of the facility. SG 1 stated the physician had discharged Resident 1 and Resident 1 was giving them a hard time about leaving the facility. SG 1 indicated that Resident 1 was only dressed in a gown and had no other form of clothing and she and another security guard went to Resident 1?s room to remove him from the facility.
A review of the registered nurse 1 (RN 1) note, dated 5/17/17, at 11 a.m., indicated during Resident 1's discharge, the resident complained to RN 1 that he was feeling hot and diaphoretic (sweating heavily). On the same day at 3 p.m., RN 1?s note indicated Resident 1 stated his arms became more contracted, painful, and he was unable to hold the telephone during a call, so RN 1 had to assist him. RN 1 documented an order was received from the physician to transfer Resident 1 to the Emergency Department (ED).
A review of Resident 1?s physician discharge summary, dated 5/17/17, at 3:38 p.m., indicated Resident 1 was experiencing increased stiffness and pain to his upper extremities.
A review of the emergency medical technician [(EMT) a person who is specially trained and certified to administer basic emergency services] note, dated 5/17/17, Resident 1's blood pressure was 190/101 when the ambulance arrived at the facility to transport Resident 1 to the ED.
A review of Resident 1's History and Physical (H & P) from the general acute care hospital (GACH), dated 5/18/17, at 7:54 a.m., indicated that on 5/17/17, Resident 1 experienced increased anxiety due to the plan to be discharged to a shelter instead of back to his friend's home, which Resident 1 felt exacerbated his baseline paresthesia (a pricking, burning, tingling, or numbing sensation that is usually felt in the arms, legs, hands, and feet). The H & P further indicated that Resident 1 reported intermittent (not continuous or steady) right-sided chest tightness without any shortness of breath, nausea, or vomiting over the past three days when he was informed of his discharge.
A review of a physician's progress note, from the GACH, dated 5/19/17, at 1:45 p.m., indicated Resident 1 presented from the facility to the ED with progressively worsening bilateral upper and lower extremity paresthesia as evidenced by stiffness and tightness and contractures (a permanent shortening of a muscle or joint) as well as vibratory sensation of the left upper extremity for approximately three days due to the anxiety over pending discharge to a shelter against his will.
A review of the facility's policy and procedure titled, "Coordinating Care for Patients Who are Without a Residence," dated 10/1/09, indicated in keeping with the philosophy and mission of the facility, the policy provides care and discharge planning for patients who are without a residence in a manner that respects their rights and needs. The designated health care provider will make every attempt to assist a resident in understanding and accepting his/her current medical condition, the impact of not having a residence on health, and available residence options. Any patient with decision-making capacity retains the right to determine what resources and living arrangements he/she will accept. This includes the right to refuse going to a shelter following discharge. At the time of discharge to a non-healthcare related location, the health care provider will complete the Community Shelter Discharge Referral form and request patient to sign either acceptance or refusal of referrals.
The facility did not follow its policy and procedure and Resident 1?s plan of care to ensure the resident was adequately prepared for the pending transfer/discharge by failing to:
1. Notify Resident 1 in writing of the pending discharge to a shelter and the reasons for it.
2. Ensure Resident 1 exercised his rights to determine what resources and living arrangements he will accept, includes the right to refuse going to a shelter following discharge.
3. Provide the notice of the proposed transfer and discharge to the Ombudsman advocacy program.
The above violation had a direct relationship to the health, safety, or security of Resident 1. |
| 100000084 |
Pioneer House |
030013512 |
B |
19-Oct-17 |
GYVJ11 |
7183 |
F 206 Policy to Permit Readmission Beyond Bed-Hold483.15
(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.
(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.
The following citation was written as a result of complaints ## CA00531892, CA00538219, and CA00541837. An unannounced visit was made to the facility on 7/11/17 to investigate an allegation of refusal to readmit.
The Department determined the facility failed to:
Readmit Resident 1 to the first available bed in the facility following Resident 1's hospitalization. This failure had the potential to delay Resident 1's readmission to skilled nursing care.
Review of Resident 1's clinical record revealed Resident 1 was admitted to the facility on 11/17/16, with diagnoses including early onset of Alzheimer's Disease (a disease that involves memory impairment). An interdisciplinary progress note, dated 3/24/17, indicated on 3/23/17 Resident 1 displayed a behavioral episode which included throwing silverware during lunch time in the facility's dining room. On 3/23/17 at 12:45 p.m., Resident 1 was transferred to the General Acute Care Hospital (GACH) with the assistance of the police department and ambulance staff.
Review of Resident 1's clinical record revealed:
A Hospitalist H&P (History and Physical) written by Physician 1 and dated 3/23/17, which indicated, "Expected time of Hospitalization is about 1 day."
A Hospitalist Progress note, written by Physician 2 and dated 5/5/17, which indicated, "Discharge Plan: Waiting for skilled nursing facility. Clear for DC [discharge] from medical standpoint".
A Hospitalist Progress note, written by Physician 3 and dated 5/5/17, which indicated, "Discharge Plan: Waiting for skilled nursing facility".
A Hospitalist Progress note, written by Physician 2 and dated 5/6/17, which indicated, "Discharge Plan: Waiting for skilled nursing facility. Clear for DC from medical standpoint".
An "Update Care Coordination Note" written by Registered Nurse 1 (RN1) and dated 5/18/17, which indicated, "Expected Discharge Date: 05/26/17 . . . received phone call from [administrator name], Administrator at [skilled nursing facility], regarding pt [patient]. [Administrator name] is requesting all medical records from 04/20/17 to present. [Administrator name] instructed to send request for medical records on company letter head to [ten digit number]. [Administrator name] states understanding of instruction. [Administrator name] states that he 'would like to make this work' and will review records with DON [director of nursing]. CM [case manager] will continue to follow and await decision of placement from [skilled nursing facility name].
An "Update Care Coordination Note" written by RN 1 and dated 5/30/17, which indicated, "Expected discharge Date: 05/31/17 . . . spoke with [administrator name], Administrator at [skilled nursing facility name], regarding transfer. Per [administrator name], there is no MD [medical doctor] willing to write admission orders for pt. [Administrator name] also states that he has requested all medical records from 04/20 to present on May 25 but has yet to receive anything. . . . This CM contacted medical records to ascertain if request for records was filed by [skilled nursing facility name]. No requests for records has been received [by the GACH] since 4/22."
An "Update Care Coordination Note" written by RN 1 and dated 6/16/17, which indicated, "Expected discharge Date: 06/26/17. . . [skilled nursing facility name] continues to refuse transfer back."
A Hospitalist Progress note, written by Physician 4 and dated 7/11/17, indicated, "[Resident 1's name] . . . was admitted on 3/23/2017 with confusion and behavioral disturbance. . . her medications were adjusted. She has since then been doing well and has remained medically stable . . . She has been awaiting placement since. By court order [skilled nursing facility name] is supposed to take patient back, however they have instead chose (sic) to pay the fine, and has (sic) refused to take her back."
Further review of Resident 1's clinical record revealed, a physician's discharge order, written by Physician 5 and dated 8/4/17, for Resident 1's discharge.
A Hospitalist Discharge Summary, written by Physician 5 and dated 8/4/17, indicated, "Brief hospital course: Psychiatry was consulted, for which (sic) her medications were adjusted. . . By court order [skilled nursing facility name] is supposed to take patient back, however they instead chose to pay the fine, and refused to take her back. Finally seen and accepted by [alternate skilled nursing facility name]. She was discharged to [alternate skilled nursing facility name] in stable condition."
An interview was conducted with the skilled nursing facility administrator on 8/9/17. The administrator was asked to provide documentation of how often he attempted to get information from the GACH to review for Resident 1's readmission. As of 8/15/17 no documented evidence of the skilled nursing facility's attempts to request information from the GACH were provided.
The facility's undated Bed Hold Policy And Procedure indicated, "If the resident exceeds the number of days allowed, he/she will be readmitted to this facility on a priority basis for the first available semi-private bed, if their care needs are appropriate to the services of the facility and if they are eligible for Medi-Cal to reimburse for the services."
Therefore, the Department determined the facility failed to:
Readmit Resident 1 to the first available bed in the facility following Resident 1's hospitalization. This failure had the potential to delay Resident 1's readmission to skilled nursing care.
This violation had a direct or immediate relationship to the health, safety or security of Long Term Care patients or residents. |